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Three Key Factors Tied to Higher Suicide Risk in BPD

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Three specific symptoms may help clinicians identify patients with borderline personality disorders (BPD) at highest risk for suicide.

Results of a large longitudinal study show patients with BPD are at considerably higher risk of suicide attempts compared to patients with other personality disorders including schizotypal, avoidant, and obsessive compulsive personality disorder (OCPD).

Furthermore, among DSM-5 diagnostic criteria for BPD, the study identified three as the most significant independent risk factors for suicide attempts in this patient population. They included identity disturbance, chronic feelings of emptiness, and frantic efforts to avoid abandonment.

The take-home message for clinicians is they should screen for these three factors in patients with BPD when assessing suicide risk, study investigator Shirley Yen, PhD, associate professor, Harvard Medical School, Boston, Massachusetts, told Medscape Medical News.

The study was published online November 18 in JAMA Psychiatry.

Unique Features

Individuals with psychiatric disorders are at increased risk of suicide. However, the risk is higher in patients with BPD versus those with other disorders and occurs independently of common psychiatric comorbidities associated with BPD.

To understand the reason suicide risk is so strong in patients with BPD, the investigators analyzed data from the Collaborative Longitudinal Study of Personality Disorders, which included adults with one of four personality disorders and a comparison group of match controls with major depressive disorder (MDD).

Earlier findings from this study showed that affective instability and negative affectivity at 2 and 7 years, respectively, were associated with suicide attempts.

“Up until this point, most of the attention with respect to BPD and suicide risk has been focused on affective instability and impulsivity. Therefore, we wanted to examine all the features of BPD, particularly those that are unique to this disorder,” said Yen.

A total of 701 participants were recruited from inpatient and partial or outpatient treatment settings. The cohort was a mean age of 33 years, 64% were women, 70% were White, 73% had completed at least some college, and 62% were unemployed.

The comparison group consisted of participants who met criteria for MDD and had minimal to no PD (less than two criteria).

“The MDD group was analyzed with all PD groups, [but] our analyses for this did not do head-to-head comparison of BPD vs MDD. Rather, the analysis pools all groups together, as they all have some possibility of having any one criterion. This leads to a more variable distribution of the criteria,” said Yen.

6.5-Fold Increased Risk

Participants were assessed at baseline and then annually using the Diagnostic Interview for DSM-IV Personality Disorders (DIPD) and the self-report Schedule for Nonadaptive and Adaptive Personality. Suicidality was also assessed at each time point.   

Covariates included demographic and clinical factors, such as childhood sexual abuse, alcohol and substance use disorders, and posttraumatic stress disorder (PTSD).

Of the total sample, 21% of participants reported suicidal behavior, with some intent to die at some point during the 10-year follow-up. Female sex, lower level of education, and unemployment were significantly associated with suicide attempts, with each of these resulting in roughly a 1.5-fold greater risk of a suicide attempt.

Of all disorders, MDD was the most prevalent disorder experienced by the PD and MDD groups, but it did not turn out to be a significant risk factor for suicide attempts due to its prevalence across the entire sample.

After controlling for demographic covariates, a history of childhood sexual abuse, PTSD, alcohol use disorder, and substance use disorder were all significant risk factors for suicide attempts, with each increasing the odds of a suicide attempt by approximately 2.5 fold.

Of the four personality disorders, BPD was associated with the highest risk of suicide attempt, with approximately a 6.5-fold increased risk (Table 1). Even when self-injury criterion was excluded, the risk remained extremely high with almost a 5-fold increased risk of a suicide attempt. In contrast, OCPD was associated with the lowest risk.

Table 1. Risk of Suicide Attempt by Personality Disorder

Personality Disorder Odds Ratio (95% CI)
BPD6.53 (4.33 – 9.85)
BPD (without self-injury)4.99 (3.35 – 7.41)
OCPD0.47 (0.31 – 0.71)

BPD = borderline personality disorder

OCPD = obsessive-compulsive personality disorder

The researchers then used two different analyses to investigate which individual BPD criteria were associated with suicide attempts, with both models controlling for demographic and clinical covariates.

The first model examined each BPD criterion independently of the other criteria, while the second estimated all BPD criteria (except for self-injurious behavior) simultaneously. 

Each criterion, when examined separately, increased the odds of suicidal behavior approximately two to three times.

However, in the simultaneous model, only three criteria emerged as significant independent factors associated with suicide attempt over follow-up: identity disturbance (OR, 2.21; 95% CI, 1.37 – 3.56), frantic efforts to avoid abandonment (OR, 1.93; 95% CI, 1.17 – 3.16); and chronic feelings of emptiness (OR, 1.63; 95% CI, 1.03 – 2.57).

Yen said further research is necessary to examine why identity disturbance, chronic feelings of emptiness, and frantic efforts to avoid abandonment contribute to suicidality, but “we can put forth some hypotheses.”

These three criteria, which represent personality functioning disturbances in the DSM-5 Alternative Model of Personality Disorders, are “likely to have a significant chronic impact on an individual’s interpersonal functioning, which may manifest in a variety of ways including social rejection, alienation, [and] lack of belongingness,” she said.

Painful Symptoms

Commenting on the study for Medscape Medical News, Donald W. Black, MD, professor emeritus, University of Iowa Carver College of Medicine, Iowa City, said the study “confirms that BPD is a major contributor to suicide attempts and gives us new information about symptoms specifically linked to it.”

These symptoms are “painful” and “may underlie the person’s relationship difficulties and may interfere with self-direction and engagement in goals,” said Black who was not involved with the study.

Clinicians should inquire about BPD symptoms in patients who are suicidal or have attempted suicide “because specific BPD treatments are available,” Black advised. Moreover, “the clinician may wish to specifically inquire about these three symptoms and discuss their meaning with the patient.”

The study was funded by grants to various investigators from the National Institute of Mental Health; Columbia University and New York State Psychiatric Institute; McLean Hospital/HMS; Vanderbilt University; Yale University; and Brown University. Yen has reported receiving grants from the National Institute of Mental Health during the conduct of the study and support from Janssen outside the submitted work. Disclosures for the other authors are listed in the article. Black has reported no relevant financial relationships.

JAMA Psychiatry. Published online November 18, 2020. Abstract

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