Criteria for Borderline Personality Disorder Associated with Suicide Attempts

Borderline personality disorder (BPD) and its specific diagnostic criteria of identity disturbance, chronic feelings of emptiness, and frantic efforts to avoid abandonment are associated with prospectively observed suicide attempts, researchers found in a multisite, longitudinal study of 10 years of follow-ups of adults with personality disorders. The study was published in JAMA Psychiatry.

The researchers recruited 733 participants aged 18 to 45 years who had received or were currently receiving treatment at clinics affiliated with Brown University, Harvard University, Columbia University, and Yale University. The participants met diagnostic criteria for schizotypal (STPD), BPD, avoidant (AVPD) or obsessive compulsive (OCPD) behaviors.

A comparison group of participants each had been diagnosed with major depressive disorder (MDD) with 2 or fewer criteria met for any personality disorder (PD). The participants were interviewed and assessed for personality disorder criteria using the Diagnostic Interview for DSM-IV Personality Disorders (DIPD) at baseline, 6 months, 1 year and annually through 10 years of follow-up.

The researchers assessed suicidal behavior with the Longitudinal Interview Follow-up Evaluation (LIFE) and recorded suicide attempts, defined as suicidal behaviors with nonzero intent to die, in each month of follow-up.

The 701 participants (447 women, 488 White, 512 who had attended at least some college, and 433 who reported being unemployed at baseline) who completed at least 1 follow-up had a mean age of 33 years at baseline.

At some point over the 10 years of prospective follow-up, 148 of these participants (105 women, 109 White, 50 with high school or less education experience, 102 unemployed) reported experiencing suicidal behavior with nonzero intent.

When the researchers used a hierarchical multiple logistic regression model to determine baseline factors associated with suicide attempts over the follow-up period, including demographic factors, axis I and clinical factors, and PD diagnoses, they found that their final model showed that only BPD without self-injurious behavior criterion (Wald χ² = 39.58, odds ratio (OR): 4.18 (2.68-6.52), P < .001) and sexual abuse (Wald χ² = 10.11, OR: 2.12 (1.33-3.36), P < .01) were significant baseline factors associated with the suicide attempt.

When they conducted logistic regression analysis of each of the BPD criteria assessed at baseline and controlled for significant demographic and clinical covariates, they found that identity disturbance (80 of the 148 participants who reported the suicidal behavior and 212 of the 701 overall group had this BPD criteria, Wald χ² = 10.59, OR: 2.21 (1.37-3.56), P <.01), frantic efforts to avoid abandonment (69 of the 148, 190 of the 701, Wald χ² = 6.71, OR: 1.93 (1.17-3.16), P  <.05) and chronic feelings of emptiness (93 of the 148, 292 of the 701, Wald χ² = 4.36,  OR: 1.63 (1.03-2.57), P < .05) were the significant independent prospective factors associated with suicide attempts over the follow-up period.

Limitations of the study include potential recall biases due to basing assessments primarily on interviewer ratings of participants’ self-report back to the time of each prior assessment. Participants were predominantly White and women, and the decision not to assess the effect of treatment were additional limitations.

“Overall, the results of this study show the importance of assessing and targeting identity disturbance, abandonment, and emptiness in patients with BPD when considering suicide prevention, symptoms that may often be overshadowed by affective or behavioral features of BPD,” the researchers said. “These other features that may confer risk of suicidal behavior may help to inform or elaborate contemporary theories of suicidal behavior.”

Disclosure: Multiple authors declared affiliations with industry. Please refer to the original article for a full list of authors’ disclosures.

Reference

Yen S, Peters JR, Nishar S, et al. Association of borderline personality disorder criteria with suicide attempts findings from the collaborative longitudinal study of personality disorders over 10 years of follow-up. JAMA Psychiatry. [published online November 18, 2020]. doi: 10.1001/jamapsychiatry.2020.3598