Suicidality in borderline personality disorder

The Role of Negative Affect and Self-Concept Clarity in Predicting Self-Injurious Urges in Borderline Personality Disorder Using Ecological Momentary Assessment

Deficits in identity as well as negative affect have been shown to predict self-injurious and suicidal behaviors in individuals with borderline personality disorder (BPD). However, less is known about the interactive effects of these two predictors. We examined the moderating effect of a particular component of identity, self-concept, on the relationship between negative affect and self-injurious urges utilizing ecological momentary assessments. Outpatients diagnosed with either BPD (n = 36) or any anxiety disorder but no BPD (n = 18) completed surveys throughout the day over a 21-day period. Higher levels of momentary negative affect predicted greater subsequent urges to self-injure, but only when self-concept clarity was low (z = -3.60, p < .01). This effect did not differ between diagnostic groups. The results suggest that self-concept clarity has a protective effect against self-injurious urges in light of high negative affect, and that this effect may be transdiagnostic.

Hunter DBT project: randomized controlled trial of dialectical behaviour therapy in women with borderline personality disorder

OBJECTIVE

Deliberate self-harm (DSH), general hospital admission and psychiatric hospital admission are common in women meeting criteria for borderline personality disorder (BPD). Dialectical behaviour therapy (DBT) has been reported to be effective in reducing DSH and hospitalization.

METHOD

A randomized controlled trial of 73 female subjects meeting criteria for BPD was carried out with intention-to-treat analyses and per-protocol analyses. The intervention was DBT and the control condition was treatment as usual plus waiting list for DBT (TAU+WL), with outcomes measured after 6 months. Primary outcomes were differences in proportions and event rates of: any DSH; general hospital admission for DSH and any psychiatric admission; and mean difference in length of stay for any hospitalization. Secondary outcomes were disability and quality of life measures.

RESULTS

Both groups showed a reduction in DSH and hospitalizations, but there were no significant differences in DSH, hospital admissions or length of stay in hospital between groups. Disability (days spent in bed) and quality of life (Physical, Psychological and Environmental domains) were significantly improved for the DBT group.

CONCLUSION

DBT produced non-significant reductions in DSH and hospitalization when compared to the TAU+WL control, due in part to the lower than expected rates of hospitalization in the control condition. Nevertheless, DBT showed significant benefits for the secondary outcomes of improved disability and quality of life scores, a clinically useful result that is also in keeping with the theoretical constructs of the benefits of DBT.

Epidemiology, risk factors, and psychopharmacological management of suicidal behavior in borderline personality disorder

Borderline personality disorder (BPD) is a chronic psychiatric condition characterized by a pervasive pattern of instability in affect regulation and impulse control. These maladaptive coping strategies predispose individuals with BPD to suicidal behavior, and this diagnosis increases the risk for completed suicide. Empirical data indicate that adverse life events; a history of childhood trauma; and the presence of comorbid psychiatric conditions, in particular major depressive disorder and substance use disorders; confer an elevated risk of suicidal behavior in patients with BPD. Psychopharmacological interventions, including the use of antidepressants, anti-psychotics, and mood stabilizers, are considered in this review in terms of the evidence for their utility in reducing the risk of suicidal behavior in BPD.

Borderline personality disorder, stigma, and treatment implications

Borderline personality disorder (BPD) is often viewed in negative terms by mental health practitioners and the public. The disorder may have a stigma associated with it that goes beyond those associated with other mental illnesses. The stigma associated with BPD may affect how practitioners tolerate the actions, thoughts, and emotional reactions of these individuals. It may also lead to minimizing symptoms and overlooking strengths. In society, people tend to distance themselves from stigmatized populations, and there is evidence that some clinicians may emotionally distance themselves from individuals with BPD. This distancing may be especially problematic in treating patients with BPD; in addition to being unusually sensitive to rejection and abandonment, they may react negatively (e.g., by harming themselves or withdrawing from treatment) if they perceive such distancing and rejection. Clinicians' reactivity may be self-protective in response to actual behavior associated with the pathology. As a consequence, however, the very behaviors that make it difficult to work with these individuals contribute to the stigma of BPD. In a dialectical relationship, that stigma can influence the clinician's reactivity, thereby exacerbating those same negative behaviors. The result is a self-fulfilling prophecy and a cycle of stigmatization to which both patient and therapist contribute. The extent to which therapist distancing is influenced by stigma is an important question that highlights the possibility that the stigma associated with BPD can have an independent contribution to poor outcome with this population. A final issue concerns the available means for identifying and limiting the impact of stigmatization on the treatment of individuals with BPD.

The implications of attachment theory and research for understanding borderline personality disorder

Borderline personality disorder (BPD) is a highly prevalent, chronic, and debilitating psychiatric problem characterized by a pattern of chaotic and self-defeating interpersonal relationships, emotional lability, poor impulse control, angry outbursts, frequent suicidality, and self-mutilation. Recently, psychopathology researchers and theorists have begun to understand fundamental aspects of BPD such as unstable, intense interpersonal relationships, feelings of emptiness, bursts of rage, chronic fears of abandonment and intolerance for aloneness, and lack of a stable sense of self as stemming from impairments in the underlying attachment organization. These investigators have noted that the impulsivity, affective lability, and self-damaging actions that are the hallmark of borderline personality occur in an interpersonal context and are often precipitated by real or imagined events in relationships. This article reviews attachment theory and research as a means of providing a developmental psychopathology perspective on BPD. Following a brief review of Bowlby's theory of attachment, and an overview of the evidence with respect to the major claims of attachment theory, I discuss individual differences, the evidence that these differences are rooted in patterns of interaction with caregivers, and how these patterns have important implications for evolving adaptations and development. Following this discussion, I present recent work linking attachment theory and BPD, focusing on the implications for understanding the etiology and treatment of BPD. In conclusion, I address some of the salient issues that point to the direction for future research efforts.

[Crisis interventions with patients with borderline personality disorder. Part 1: Preventive and resolving approaches in individual psychodynamic therapy]

Patients suffering from borderline personality disorder have by definition a poorly functional personality which is readily reacting to changes and psychosocial stressors with recurrent crises. A personality disorder is necessarily fraught with interpersonal difficulties, and it is often within the individual psychotherapeutic encounter that such clashes develop. This article discusses basic principles offering clinicians ways to prevent or structure crisis intervention adapted to borderline personality disorder within the individual psychotherapy context. It thus reviews various clinical issues such as suicidal or homicidal threats, conflicts related to requests expressed by the patient, the absence of the therapist or attempts at breaking the therapeutic framework in order to offer intervention modalities for the resolution of these crises.

Clinical management for hospital-treated deliberate self-poisoning: comparisons between patients with major depression and borderline personality disorder

OBJECTIVE

To compare the initial clinical management of hospital-treated deliberate self-poisoning patients with major depressive disorder (MDD) or borderline personality disorder (BPD) after controlling for demographic factors and level of suicide ideation.

METHOD

This study compared sequential hospital treated deliberate self-poisoning patients (n = 570) with either MDD or BPD (but no major comorbid psychopathology) on four outcomes modelled using logistic regression: (i) length of stay in the general hospital; (ii) discharge to a psychiatric hospital; (iii) psychiatric follow-up; and (iv) general practitioner (GP) follow-up.

RESULTS

BPD and MDD patients were discharged to psychiatric inpatient care at very similar rates (33%-35%) and almost all subjects with high levels of suicidal ideation were discharged to psychiatric hospital. However, for mild to moderate levels of suicidal ideation BPD patients were more likely to be discharged to psychiatric hospital than MDD patients. After controlling for demographics and suicidal ideation, BPD patients were more likely to be referred for psychiatric hospitalization on discharge (adjusted OR = 1.79, 95% CI = 1.01-3.18) and less likely to be referred to GPs if discharged to home (adjusted OR = 0.44, 95% CI = 0.24-0.81). There were no differences in general hospital length of stay or arrangements made for psychiatric follow-up for those discharged to home.

CONCLUSIONS

This suggests that for mild to moderate suicidal ideation levels clinicians are more likely to choose to send BPD patients, after deliberate self-poisoning, to inpatient psychiatric care than MDD patients. Clinicians are also apparently more likely to choose to manage MDD patients in primary care settings, for those patients discharged to home. This has implications for service planning and clinical guidelines.

Life events, motives, and precipitating factors in parasuicide among borderline patients

The high prevalence of borderline personality disorder in parasuicide raises the question whether there are differences in motives, precipitating factors, and life events as compared to other clinical groups. Consecutive hospital admitted parasuicide patients were therefore investigated for personality disorders by a structured clinical interview (SCID-II), a structured interview concerning precipitating factors and a self-report questionnaire on motives and life events. Out of a total of 64 patients, 55% met the criteria for a borderline personality disorder. While the parasuicidal motives and precipitating factors did not differ between the borderline group and the others, the borderline group reported significantly more adverse life events. Our findings suggest that the overrepresentation of borderline personality disorder in parasuicide might be related to accumulated adverse life events rather than to manipulative motives.

Axis I and axis II disorders as predictors of prospective suicide attempts: findings from the collaborative longitudinal personality disorders study

This study examined diagnostic predictors of prospectively observed suicide attempts in a personality disorder (PD) sample. During 2 years of follow-up, 58 participants (9%) reported at least 1 definitive suicide attempt. Predictors that were examined include 4 PD diagnoses and selected Axis I diagnoses (baseline and course). Multivariate logistic regression analyses indicated that baseline borderline personality disorder (BPD) and drug use disorders significantly predicted prospective suicide attempts. Controlling for baseline BPD diagnosis, proportional hazards analyses showed that worsening in the course of major depressive disorder (MDD) and of substance use disorders in the month preceding the attempt were also significant predictors. Therefore, among individuals diagnosed with PDs. exacerbation of Axis I conditions, particularly MDD and substance use, heightens risk for a suicide attempt.

Assessing suicidal youth with antisocial, borderline, or narcissistic personality disorder

OBJECTIVE

This paper has 3 objectives. First, we review the epidemiologic evidence for the association between suicidal behaviour and suicide in individuals diagnosed with antisocial, borderline, or narcissistic personality disorder. Second, we examine whether any potentially modifiable risk factors are associated with these diagnoses, based on existing empirical evidence. Last, we discuss clinical approaches to assessing youth with antisocial, borderline, or narcissistic personality disorder presenting at risk for suicide.

METHOD

We reviewed the English-language literature for the last 12 years (from January 1, 1991, to December 31, 2002), using as search terms the names of the 3 disorders, as well as the key words suicide, suicidal behaviour, youth, and adolescents.

RESULTS

Patients with antisocial or borderline personality disorder are likely to be at increased risk for suicidal behaviour when they demonstrate such comorbid disorders as major depressive episodes or substance abuse disorders, when they experience recent negative life events, or when they have a history of childhood sexual abuse.

CONCLUSIONS

For patients with antisocial personality disorder, the risk of violence has to be judged in addition to the risk of suicide or self-harm. For patients with borderline personality disorder, interventions are determined by differentiating acute-on-chronic from chronic risk of suicidal behaviour. Finally, patients with narcissistic personality disorder can be at high risk for suicide during periods when they are not suffering from clinical depression. These episodes can seem to be unpredictable.

Suicidal and self-injurious behavior in personality disorder: controversies and treatment directions

Contrary to common clinical perceptions, individuals with personality disorders attempt and commit suicide at nearly the same rate as individuals with major depression. In particular, those with borderline personality disorder are at high risk for suicidal behavior and nonsuicidal self-injury. Yet there is significant controversy surrounding the diagnosis of borderline personality disorder in terms of its existence, its definition and symptom structure, its Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) axis location, and its importance as a contributing factor to suicidality and nonsuicidal self-injury. Furthermore, both suicidal and nonsuicidal self-harm is prominent in borderline personality disorder. There is often confusion between suicidal and nonsuicidal self-injury with one sometimes mistaken for the other. Nonsuicidal self-injury is sometimes met with hospitalization, because it is viewed as life threatening. Alternately, the potential lethality of suicidal behavior is underestimated, because it occurs in the context of multiple low lethality self-harm behaviors. It is possible to view these behaviors as distinct yet on a spectrum in borderline personality-disordered patients. With respect to treatment of self-injury in personality disorders, some recent pharmacotherapy trials have been conducted, though efficacy is often unclear. Findings with respect to psychotherapy, particularly dialectical behavior therapy, a form of cognitive behavioral treatment, are promising.

Suicidal Behavior in Patients with Adjustment Disorders

Summary: This retrospective study characterizes the suicidal behavior in 119 patients with Axis I adjustment disorders as assessed by psychiatrists at the University of Virginia Hospital. Results indicated that 72 patients (60.5%) had documented suicide attempts in the past, 96% had been suicidal during their admission to the hospital, and 50% had attempted suicide before their hospitalization. The most commonly used method of suicide attempts was overdosing. Of the sample group with suicide attempts in the past, 67% had Axis II diagnoses of borderline personality disorder and antisocial personality disorder. Adjustment disorder diagnosis in patients with the suicide attempts was associated with a high level of suicidality at admission, involuntary hospitalization and substance-abuse disorders. Axis II diagnoses in patients with adjustment disorders constituted risk factors for further suicidal behavior. Additional future prospective studies with reliability checks on diagnosis of adjustment disorders and suicidal behavior are needed.