Borderline personality disorder criteria associated with prospectively observed suicidal behavior

OBJECTIVE: The authors prospectively examined associations between each DSM-IV borderline personality disorder criterion and suicidal behaviors. METHOD: Borderline personality disorder diagnosis and criteria, major depressive disorder, substance use disorders, and history of childhood sexual abuse were assessed with semistructured interviews. Participants (N=621) were followed for 2 years with repeated structured evaluations that included assessments of suicidality. RESULTS: With the self-injury criterion excluded, the borderline personality disorder criteria of affective instability, identity disturbance, and impulsivity significantly predicted suicidal behaviors. Only affective instability and childhood sexual abuse were significantly associated with suicide attempts (i.e., behavior with some intent to die). CONCLUSIONS: Affective instability is the borderline personality disorder criterion (excluding self-injury) most strongly associated with suicidal behaviors. Since major depressive disorder did not significantly predict suicidal behaviors, the reactivity associated with affective instability (more so than negative mood states) appears to be a critical element in predicting suicidal behaviors.     

Dialectical Behavior Therapy for Multiple Treatment Targets: A Case Study of a Male with Comorbid Personality and Substance Use Disorders

Dialectical behavior therapy has accrued substantial evidence as a treatment for individuals with borderline personality disorder. However, there are only two randomized clinical trials with individuals with comorbid substance use disorders. This case study presents Michael, a male client who sought treatment for his alcohol use, difficulties at work, and struggles with making and maintaining relationships. Michael engaged in dialectical behavior therapy that simultaneously addressed his substance use with comorbid borderline personality disorder. With this approach, the client exhibited reductions in substance use, suicidal ideation, self-harm, and increases in skillful behaviors. Results highlight the importance of continuing assessments with clients and using this information to inform therapy as well as provide an example of how trainees, with close supervision, can implement dialectical behavior therapy with a client with comorbid borderline personality and substance use disorders.     

Non-Suicidal Self-Injury and Suicidal Behavior in a Diverse Sample: The Moderating Role of Social Problem-Solving Ability

Non-suicidal self-injury and suicidal behavior are prevalent in young adults, and often constitute a continuum of self-destructiveness. Not all those who self-injure, however, engage in suicidal behaviors with intent to die, perhaps due to protective intrapersonal characteristics. We examined the role of one such potential buffer, social problem-solving ability, as a moderator of the association between non-suicidal self-injury and suicidal thoughts and attempts, hypothesizing that individuals with greater social problem-solving ability would report fewer suicidal behaviors in relation to self-harm. An ethnically diverse sample was recruited from a large, Northeastern urban university, and completed self-report questionnaires assessing non-suicidal self-injury, suicidal behaviors, and social problem-solving ability. Multivariate hierarchical regression analyses were conducted. For the entire sample, individuals with higher social problem-solving abilities reported fewer suicidal behaviors associated with non-suicidal self-injury. In ethnically stratified analyses, social problem-solving significantly moderated the relationship between self-injury and suicidal behaviors for Whites and Hispanics only. Promotion of problem-solving skills may weaken the linkage between self-injury and potential for future suicidal behaviors for some individuals; however, culture-specific differences in this effect may exist.     

Suicide and deliberate self-harm in personality disorders

PURPOSE OF REVIEW: This article reviews literature published over the period January 2004-May 2005 on suicidal behaviour and self-harm in personality disorders. RECENT FINDINGS: Studies have confirmed that personality disorders and their co-morbidity with other psychiatric conditions are risk factors for both fatal and nonfatal suicidal behaviours, and self-mutilation. Negative life events, childhood sexual abuse, difficulties in social functioning, deficits in future-directed thinking and time perception, as well as familial and neurocognitive factors may be related to increased suicide risk in individuals with borderline and other personality disorders. Findings seem to confirm that suicidality and self-injurious behaviour are efficient DSM-IV diagnostic criteria for borderline personality disorder. Out of several psychosocial and pharmacological interventions for treating suicidality in personality disorders, only one randomized, controlled study has recently been published. Medico-legal concerns related to the clinical management of chronically suicidal patients, including hospitalization and alternative treatment approaches, are also discussed. SUMMARY: Although recent studies have contributed to the theoretical knowledge and clinical practice, there are unsettled questions that should be addressed in the future. More randomized, controlled trials evaluating the efficacy of interventions in suicidal individuals with personality disorders should be conducted. As the majority of studies conducted to date have concentrated on borderline personality disorder and antisocial personality disorder, the prevalence and risk factors for suicidal behaviours and self-mutilation in other personality disorders require further clarification. The introduction of unified nomenclature related to suicidal behaviours and self-mutilation would facilitate comparability of results across studies.     

Assessment Tools for Self-Harm Behavior Among Those with Eating Disorders

There appears to be a substantial minority of eating disorder patients who report self-harm behaviors. This paper reviews the available assessment tools relating to individuals with eating disorders and self-harm behaviors. Current eating disorder assessments do not contain any items relating to self-harm behaviors. Several of the self-harm measures contain some eating disorder items, but not a sufficient number to provide an eating disorder diagnosis. Among the self-harm measures, only three offer items relating to eating pathology as well as overt self-harm and high-lethal behaviors. One of the three has an established scoring that predicts borderline personality disorder. In summary, there are no currently available assessment tools that are able to simultaneously diagnose eating disorder pathology as well as measure self-harm behaviors.     

Assessment tools for self-harm behavior among those with eating disorders

There appears to be a substantial minority of eating disorder patients who report self-harm behaviors. This paper reviews the available assessment tools relating to individuals with eating disorders and self-harm behaviors. Current eating disorder assessments do not contain any items relating to self-harm behaviors. Several of the self-harm measures contain some eating disorder items, but not a sufficient number to provide an eating disorder diagnosis. Among the self-harm measures, only three offer items relating to eating pathology as well as overt self-harm and high-lethal behaviors. One of the three has an established scoring that predicts borderline personality disorder. In summary, there are no currently available assessment tools that are able to simultaneously diagnose eating disorder pathology as well as measure self-harm behaviors.     

Lecture des troubles de personnalité limite à travers la théorie de l’attachement

Borderline personality disorders concern clinicians and caregivers because of the violent and impulsive nature of their behavioral and affective reactions, which often confronts them to a feeling of helplessness and incomprehension. Indeed, it may be difficult to deal with self-harm, massive anxiety, intense affects and interpersonal ruptures, which are often present in the life course of the borderline patients. Their distress is particularly difficult to accept as it takes place in the therapeutic link, which reveals the core of the patient's attachment problematic. This paper aims to draw up an overview of borderline personality disorders, in light of attachment theory, which could help to clarify the involved mechanisms and gather the described behaviors in a coherent unit. Many studies relating to borderline personality disorder and attachment theory highlight what constitutes the specificity of these disorders through an integrative approach. Thus, the combination of an insecure attachment style, biological vulnerabilities and environmental stressors like traumatisms may induce the establishment of many defensive mechanisms, such as attachment system hyperactivation, emotional dysregulation or mentalization's failure. People suffering of borderline personality disorder activate these mechanisms as soon as they have to deal with real or imagined abandonments related to one of their attachment figures. However, in view of the massive anxiety and the severe disruption, those inefficient mechanisms cannot enable a good resolution of stressful situations. Consequently, borderline patients are likely to resort to new kind of emotional regulation such as suicidal, destructive and impulsive behaviors. Attachment based theories focus on these defensive mechanisms and inadequate attempts of emotional regulation, in order to propose an appropriate treatment for borderline personality disorder.     

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.     

Clinical aspects of suicidal behavior relevant to genetics

A major hindrance to determining the underlying biology of suicide is the heterogeneity of the phenotype. Not only are there various forms of self-harm and suicidal behaviors but even the finite act of dying by suicide can occur in multiple psychosocial contexts. Of all the different forms of fatal and non-fatal suicidal behaviors, the one that received the most attention is the aggressive impulsive type, which seems to occur in younger people and to cut across nosological entities, although its most classical expression occurs in borderline personality disorder. This focus should not obscure the fact that other forms of suicidal behavior such as those related to demoralization or wounded honor (narcissism) may well have different underlying genetic diatheses.     

Dialectical behavior therapy for personality disorders

Interest in dialectical behavior therapy (DBT) as a treatment for personality disorders has increased dramatically in recent years. Although originally designed for the outpatient treatment of suicidal individuals with borderline personality disorder (BPD), DBT has been applied to many more diverse populations including comorbid substance dependence and BPD, inpatient treatment for BPD, as well as antisocial behaviors in juveniles and adults. This paper provides a brief overview of DBT, presents and evaluates the most recent literature on the application of DBT to the treatment of personality disorders, and highlights some of the current controversies surrounding the use of DBT.     

Direct and indirect forms of non-suicidal self-injury: evidence for a distinction

Non-suicidal self-injury (NSSI) involves deliberate acts (such as cutting) that directly damage the body but occur without suicidal intent. However, other non-suicidal behaviors that involve people mistreating or abusing themselves but that do not deliberately and directly damage bodily tissue may have much in common with NSSI. Such 'indirect' methods of self-injury might include involvement in abusive relationships, substance abuse, risky or reckless behavior, or eating disordered behavior. Using a community sample (N=156) we compared individuals engaging in NSSI (n=50), indirect (non-suicidal) self-injurers (n=38), and healthy controls (n=68) on a range of clinical and personality characteristics. As predicted, non-suicidal self-injurers and indirect self-injurers showed more pathology than healthy controls on all measures. Comparisons of the NSSI and the Indirect self-injury groups revealed no significant differences on measures of dissociation, aggression, impulsivity, self-esteem, negative temperament, depressive symptoms, and borderline personality disorder. However, compared to people who engaged only in indirect forms of self-injury, those who engaged in NSSI were more self-critical, had higher scores on a measure of suicide proneness, and had a history of more suicide attempts. The findings suggest that NSSI and indirect self-injury are best viewed as separate and distinct clinical phenomena.     

Comparison of the suicidal behavior of adolescent inpatients with borderline personality disorder and major depression

The objective of the study was to examine the hypothesis that some forms of suicidal behavior among adolescents are related to helplessness and depression, whereas others are related to anger and impulsivity. Sixty-five adolescents were studied. Thirty-three had borderline personality disorder (BPD), of whom 17 had made a recent suicide attempt. Thirty-two had major depressive disorder (MDD), of whom 16 had made a recent suicide attempt. Assessments were made with the Child Suicide Potential Scale, the Beck Depression Inventory, the Beck Hopelessness Scale, the Multidimensional Anger Inventory, the Overt Aggression Scale, the Impulsiveness-Control Scale, and the Suicide Intent Scale. Adolescents with BPD had more anger, aggression, and impulsiveness than those with MDD, but similar levels of depression and hopelessness. Suicidal versus nonsuicidal adolescents were more depressed, hopeless, and aggressive, but not more angry or impulsive. There were no significant differences in impulsiveness for the MDD suicidal group versus the MDD nonsuicidal group, but the suicidal BPD adolescents were significantly more impulsive than the nonsuicidal BPD adolescents. In the subjects with BPD, impulsiveness and aggression correlated significantly and positively with suicidal behavior. In the subjects with MDD, no such correlations were seen. In both diagnostic groups, depression and hopelessness correlated positively and significantly with suicidal behavior. Anger did not correlate with suicidal behavior in either of the groups. The suicidal subjects with MDD had significantly higher suicidal intent scores than the suicidal adolescents with BPD. We conclude that the nature of suicidal behavior in adolescents with BPD differs from that seen in MDD with respect to the role of anger and aggression.     

Two-year prevalence and stability of individual DSM-IV criteria for schizotypal, borderline, avoidant, and obsessive-compulsive personality disorders: toward a hybrid model of axis II disorders

OBJECTIVE: This study tracked the individual criteria of four DSM-IV personality disorders-borderline, schizotypal, avoidant, and obsessive-compulsive personality disorders-and how they change over 2 years. METHOD: This clinical sample of patients with personality disorders was derived from the Collaborative Longitudinal Personality Disorders Study and included all participants with borderline, schizotypal, avoidant, or obsessive-compulsive personality disorder for whom complete 24-month blind follow-up assessments were obtained (N=474). The authors identified and rank-ordered criteria for each of the four personality disorders by their variation in prevalence and changeability (remission) over time. RESULTS: The most prevalent and least changeable criteria over 2 years were paranoid ideation and unusual experiences for schizotypal personality disorder, affective instability and anger for borderline personality disorder, feeling inadequate and feeling socially inept for avoidant personality disorder, and rigidity and problems delegating for obsessive-compulsive personality disorder. The least prevalent and most changeable criteria were odd behavior and constricted affect for schizotypal personality disorder, self-injury and behaviors defending against abandonment for borderline personality disorder, avoiding jobs that are interpersonal and avoiding potentially embarrassing situations for avoidant personality disorder, and miserly behaviors and strict moral behaviors for obsessive-compulsive personality disorder. CONCLUSIONS: These patterns highlight that within personality disorders the relatively fixed criteria are more trait-like and attitudinal, whereas the relatively intermittent criteria are more behavioral and reactive. These patterns suggest that personality disorders are hybrids of traits and symptomatic behaviors and that the interaction of these elements over time helps determine diagnostic stability. These patterns may also inform criterion selection for DSM-V.     

Dialectical behavior therapy for suicidal adolescents with borderline personality disorder

Although research to date on dialectical behavior therapy (DBT) for adolescents has its limitations, growing evidence suggests that DBT is a promising treatment for adolescents with a range of problematic behaviors, including but not limited to suicidal and nonsuicidal self-injury. This article introduces dialectical behavior therapy's theoretical underpinnings, describes its adaptation for suicidal adolescents, and provides a brief review of the empirical literature evaluating DBT with adolescents.     

Characteristics of suicide attempts of patients with major depressive episode and borderline personality disorder: a comparative study

OBJECTIVE: Suicidal behavior is highly prevalent in borderline personality disorder and major depressive episode, although the characteristics of suicide attempts in the two disorders are believed to differ. Comorbidity of borderline personality disorder and major depressive episode may obscure characteristics of suicide attempts that are uniquely related to the psychopathology of each disorder. We compared suicidal behavior in patients with borderline personality disorder, major depressive episode, and borderline personality disorder plus major depressive episode to determine whether characteristics of suicide attempts differed between groups and if aspects of core psychopathology predicted specific attempt characteristics. METHOD: Eighty-one inpatients with borderline personality disorder, including 49 patients with borderline personality disorder plus major depressive episode, were compared to 77 inpatients with major depressive episode alone on measures of depressed mood, hopelessness, impulsive aggression, and suicidal behavior, including lifetime number of attempts, degree of lethal intent, objective planning, medical damage, and degree of violence of suicide methods. RESULTS: No significant differences were found in the characteristics of suicide attempts between patients with borderline personality disorder and those with major depressive episode. However, patients with both disorders had the greatest number of suicide attempts and the highest level of objective planning. An increase in either impulsive aggression or hopelessness or a diagnosis of borderline personality disorder predicted a greater number of attempts. Hopelessness predicted lethal intent in all three groups and predicted objective planning in the group with both disorders. Medical damage resulting from the most serious lifetime suicide attempt was predicted by number of attempts. CONCLUSIONS: Comorbidity of borderline personality disorder with major depressive episode increases the number and seriousness of suicide attempts. Hopelessness and impulsive aggression independently increase the risk of suicidal behavior in patients with borderline personality disorder and in patients with major depressive episode.     

Gender Patterns in Borderline Personality Disorder

Gender differences in patients with borderline personality disorder are potentially relevant because they may guide clinicians in assessment and treatment. To date, a number of clinical features in borderline personality disorder have been examined for gender differences. As for prevalence, earlier research concluded that a higher proportion of women than men suffer from borderline personality disorder, although more recent research has determined no differences in prevalence by gender. In addition, there may not be gender differences in borderline personality disorder with respect to specific types of self-harm behavior, such as self-cutting or levels of psychological distress at clinical presentation. However, current evidence indicates that there are notable gender differences in borderline personality disorder with regard to personality traits, Axis I and II comorbidity, and treatment utilization. With regard to personality traits, men with borderline personality disorder are more likely to demonstrate an explosive temperament and higher levels of novelty seeking than women with borderline personality disorder. As for Axis I comorbidity, men with borderline personality disorder are more likely to evidence substance use disorders whereas women with borderline personality disorder are more likely to evidence eating, mood, anxiety, and posttraumatic stress disorders. With regard to Axis II comorbidity, men with borderline personality disorder are more likely than women to evidence antisocial personality disorder. Finally, in terms of treatment utilization, men with borderline personality disorder are more likely to have treatment histories relating to substance abuse whereas women are more likely to have treatment histories characterized by more pharmacotherapy and psychotherapy.     

Are suicide attempters who self-mutilate a unique population?

OBJECTIVE: Individuals who mutilate themselves are at greater risk for suicidal behavior. Clinically, however, there is a perception that the suicide attempts of self-mutilators are motivated by the desire for attention rather than by a genuine wish to die. The purpose of this study was to determine differences between suicide attempters with and without a history of self-mutilation. METHOD: The authors examined demographic characteristics, psychopathology, objective and perceived lethality of suicide attempts, and perceptions of their suicidal behavior in 30 suicide attempters with cluster B personality disorders who had a history of self-mutilation and a matched group of 23 suicide attempters with cluster B personality disorders who had no history of self-mutilation. RESULTS: The two groups did not differ in the objective lethality of their attempts, but their perceptions of the attempts differed. Self-mutilators perceived their suicide attempts as less lethal, with a greater likelihood of rescue and with less certainty of death. In addition, suicide attempters with a history of self-mutilation had significantly higher levels of depression, hopelessness, aggression, anxiety, impulsivity, and suicide ideation. They exhibited more behaviors consistent with borderline personality disorder and were more likely to have a history of childhood abuse. Self-mutilators had more persistent suicide ideation, and their pattern for suicide was similar to their pattern for self-mutilation, which was characterized by chronic urges to injure themselves. CONCLUSIONS: Suicide attempters with cluster B personality disorders who have a history of self-mutilation tend to be more depressed, anxious, and impulsive, and they also tend to underestimate the lethality of their suicide attempts. Therefore, clinicians may be unintentionally misled in assessing the suicide risk of self-mutilators as less serious than it is.     

Self-harm and bulimia nervosa: a complex connection

There is some evidence to suggest that eating disordered individuals are unusually likely to engage in self-harm behavior. However, the nature of the relationship among self-harm, bulimia nervosa, and related constructs such as borderline personality disorder and multi- impulsive bulimia nervosa remains unclear. This article briefly addresses the nature of this relationship and discusses two possible mechanisms for self-harm behavior in bulimia nervosa. Additionally, a protocol for managing such behavior in the treatment of eating disordered individuals is presented.     

Dilemmas in the management of suicidal behavior in individuals with borderline personality disorder

Managing suicidal behavior of individuals with borderline personality disorder presents both therapeutic and ethical/legal dilemmas. It is argued in this paper that clinicians treating borderline individuals need to carefully discriminate "acute" from "chronic" suicidal states. For "acute" suicidal situations, traditional management approaches are appropriate. However, for "chronic" situations, common among borderline individuals, traditional management approaches may be therapeutically counterproductive. A number of proposals for managing chronic suicidal behavior are reviewed. Unfortunately, current ethical standards and laws have evolved from considering suicide in an "acute" context and are insensitive to the "chronic" situation. Recommendations are made for clinicians to effectively manage chronic suicidal behaviors within present ethical and legal guidelines, and some suggestions for legal reform are offered.     

The psychopharmacology of borderline personality disorders

DSM-III borderline personality disorder defines a group of patients who are characterised by impulsivity and unpredictable behaviour, inappropriate aggression, intense and unstable relationships and are often associated with repeated suicidal behaviour. A substantial body of research has established an association between disturbance of serotonin and also dopamine and suicidal behaviour in depression. A similar relationship is also seen in studies of personality disorders which suggests the association is not specific to depression. A placebo controlled study of low dose flupenthixol has been shown to significantly reduce subsequent suicidal behaviour in patients with personality disorders without depression or schizophrenia. Evidence points to a biological basis for suicidal behaviour and borderline personality disorder and possibly of pharmacotherapy.