Borderline personality disorder in youth: The prospective impact of child abuse on non-suicidal self-injury and suicidality

BackgroundBorderline personality disorder (BPD) is characterized by greater engagement in non-suicidal self-injury (NSSI) and suicidality. The aim of the study is to test whether the occurrence of child abuse contributes to these high-risk behaviors in BPD youth.Materials and methodsBPD female youth aged 13–21 years with (n = 29) and without (n = 29) a history of child abuse were administered clinical interviews assessing diagnostic history, child abuse, NSSI and suicidality (i.e., ideation, plans, and attempts). NSSI and suicidality were subsequently reevaluated at the 1- and 2-month follow-up assessments.ResultsSeveral findings emerged. First, relative to BPD youth without abuse, the abuse group reported greater past NSSI; however, no significant differences emerged in the follow-up period. Second, the occurrence of child abuse was associated with a 5-fold increase in the rate of lifetime suicide attempts relative to the no abuse group and additionally, prospectively predicted suicide ideation (but not attempts). Last, exploratory analyses indicated that the co-occurrence of physical and sexual abuse was associated with greater past NSSI and suicidality as compared to the no abuse and sexual abuse only participants.ConclusionAs a whole, child abuse – particularly co-occurring physical and sexual abuse – increases risk for NSSI and suicidality among BPD youth, which may have important treatment implications in this high-risk population.     

Chronic suicidality among patients with borderline personality disorder

OBJECTIVE: This paper reviews research on chronic suicidality among patients with borderline personality disorder. METHODS: MEDLINE and PsycINFO databases were searched for all English-language articles published between 1984 and 2000 containing the keywords "borderline personality disorder" and "suicide" or "suicidality." A total of 170 articles located through this search and additional key articles published before 1990 were reviewed. The most relevant articles were selected of review. RESULTS AND CONCLUSIONS: One in ten patients with borderline personality disorder completes suicide, but this outcome is not readily preventable and does not necessarily occur during the course of treatment. In outpatient psychotherapy, chronic suicidal behavior by patients with borderline personality disorder can be best understood as a way of communicating distress. Hospitalization is of unproven value in preventing suicide by these patients and can sometimes have negative effects. Clinicians' fear of potential litigation resulting from a completed suicide should not be the basis for admission. With no evidence that full hospitalization prevents suicide completion by patients with borderline personality, suicidal risk is not a contraindication for day hospital treatment.     

Predictors of dropout from inpatient dialectical behavior therapy among women with borderline personality disorder

Inpatient dialectical behavior therapy (DBT) is an effective treatment for borderline personality disorder (BPD), but often treatment is ended prematurely and predictors of dropout are poorly understood. We, therefore, studied predictors of dropout among 60 women with BPD during inpatient DBT. Non-completers had higher experiential avoidance and trait anxiety at baseline, but fewer life-time suicide attempts than completers. There was a trend for more anger–hostility and perceived stigma among non-completers. Experiential avoidance and anxiety may be associated with dropout in inpatient DBT. Low life-time suicidality and high anger could reflect a subtype at risk for discontinuation of inpatient treatment.     

Characteristics of recent suicide attempters with and without Borderline Personality Disorder.

The present research compared recent suicide attempters with and without a diagnosis of Borderline Personality Disorder (BPD). One hundred and eighty recent suicide attempters, recruited in the Emergency Department, participated in extensive research interviews. Results showed that suicide attempters with BPD displayed greater severity of overall psychopathology, depression, hopelessness, suicidal ideation, past suicide attempts, and had poorer social problem solving skills than those without a BPD diagnosis. No differences were found between the groups regarding the intent to die or lethality associated with the index suicide attempt. These findings highlight the seriousness of BPD and the risk that individuals diagnosed with this disorder will attempt suicide.     

Characteristics of Recent Suicide Attempters with and without Borderline Personality Disorder

The present research compared recent suicide attempters with and without a diagnosis of Borderline Personality Disorder (BPD). One hundred and eighty recent suicide attempters, recruited in the Emergency Department, participated in extensive research interviews. Results showed that suicide attempters with BPD displayed greater severity of overall psychopathology, depression, hopelessness, suicidal ideation, past suicide attempts, and had poorer social problem solving skills than those without a BPD diagnosis. No differences were found between the groups regarding the intent to die or lethality associated with the index suicide attempt. These findings highlight the seriousness of BPD and the risk that individuals diagnosed with this disorder will attempt suicide.     

Suicide Risk in Primary Care: Identification and Management in Older Adults

The National Strategy for Suicide Prevention (2012) has set a goal to reduce suicides by 20 % within 5 years. Suicide rates are higher in older adults compared to most other age groups, and the majority of suicide completers have visited their primary care physician in the year before suicide. Primary care is an ideal setting to identify suicide risk and initiate mental health care. We review risk factors for late-life suicide; methods to assess for different levels of suicidality; and recent research developments regarding both effective assessment and management of suicide risk among older primary care patients. We highlight that broader scale screening of suicide risk may be considered in light of findings that suicidality can occur even in the absence of major risk factors like depression. We also highlight collaborative care models targeting suicide risk, and recent innovative interventions that aim to prevent the development of suicidal ideation and suicidal behavior.     

Sex differences in risk factors for suicidality among Japanese substance use disorder patients: Association with age, types of abused substances, and depression

Aim: The aim of this study was to identify risk factors for suicide in Japanese substance use disorder (SUD) patients, adjusting for age and sex, and to examine sex differences in suicide risk among these patients. Methods: A self-reporting questionnaire on age, sex, types of abused substances, current depression, and suicidality was administered to 1420 SUD patients who consecutively visited seven hospitals specializing in SUD treatment during the month of December 2009. Unadjusted/adjusted odds ratios of factors associated with suicidality were calculated for each sex. Results: The multivariate analysis using the total sample identified younger age, female sex, and current depression as risk factors for severe suicidality in SUD patients. The multivariate analysis by each sex demonstrated that younger age and current depression were associated with severe suicidality in male SUD patients. Only current depression was associated with severe suicidality in female patients. Conclusion: Current depression is a risk factor for suicide in SUD patients common in both Western countries and Japan, although in Japanese SUD patients both younger age and female sex were more closely associated with severe suicidality than aspects of SUD. Additionally, young male SUD patients are speculated to have psychosocial features associated with suicidality in common with female SUD patients.     

Temperament and character in persons with borderline personality disorder

High comorbidity, suicidal ideation, difficult temperament, and character are key symptoms of persons with borderline personality disorder (BPD). We investigated 478 persons, 40 of whom had a BPD according SCID-II, self-rating. Participants were examined with a semistructured interview and several self-rating questionnaires in their households. Taking the high comorbidity of persons with BPD into account, we compared the BPD group with four control groups with different axis 1 or personality disorders and one nonclinical group. Persons with BPD showed high comorbidity with affective, anxiety, and alcohol use disorders. With respect to suicidality, 75% reported that they wish to be dead at least sometimes, and about one-third said that they had already attempted suicide. Regarding temperament and character dimensions, our analyses revealed higher novelty seeking for persons with BPD compared to participants without BPD, although this difference was primarily attributable to males with BPD. Additionally, participants with BPD reported higher harm avoidance compared to control groups, while this was more distinctive for females. Finally, we found that persons with BPD had very low levels of self-directedness. This effect was independent from gender and was found in all group comparisons. Therapy of BPD should take into account high comorbidity and suicidality of patients. Moreover, our results show that low self-directedness seems to be specific for persons with BPD. Therefore, therapy must address those deficits by focusing on skills training as well as on aspects of maturation.     

Deep Brain Stimulation for Treatment Resistant Depression: Postoperative Feelings of Self-Estrangement, Suicide Attempt and Impulsive–Aggressive Behaviours

The goal of this article is to shed light on Deep Brain Stimulation (DBS) postoperative suicidality risk factors within Treatment Resistant Depression (TRD) patients, in particular by focusing on the ethical concern of enrolling patient with history of self-estrangement, suicide attempts and impulsive–aggressive inclinations. In order to illustrate these ethical issues we report and review a clinical case associated with postoperative feelings of self-estrangement, self-harm behaviours and suicide attempt leading to the removal of DBS devices. Could prospectively identifying and excluding patients with suicidality risk factors from DBS experimental trials—such as history of self-estrangement, suicide attempts and impulsive–aggressive inclinations—lead to minimizing the risk of suicidality harm?     

Suicide during clozapine treatment: a case report

The risk of suicide among patients with schizophrenia is greater than that in the general population. Although clozapine, along with its other significant features, has been reported to decrease suicidality and suicide rate among schizophrenia patients, physicians should remain vigilant for general risk factors of suicide in patients with schizophrenia during a treatment course and assess them carefully. Awareness of the effect of the illness, a sense of inadequacy to achieve goals, a change in the course of the illness, an improvement after relapse and a proposed discharge from the hospital in the near future are factors that should be noted especially within these general risk factors for suicide. In this case report, we presented a schizophrenia patient with several risk factors who committed suicide during clozapine treatment. Risk factors prominent in this case including increased awareness after improvement in chronic state, planned discharge in the near future, and the notion of reduced suicidality in schizophrenia patients during clozapine treatment are discussed in this article based on the literature and the case.     

Suicide prevention in first episode psychosis: the development of a randomised controlled trial of cognitive therapy for acutely suicidal patients with early psychosis

BACKGROUND: Young people with early psychosis are at particularly high risk of suicide. However, there is evidence that early intervention can reduce this risk. Despite these advances, first episode psychosis patients attending these new services still remain at risk. To address this concern, a program called LifeSPAN was established within the Early Psychosis Prevention and Intervention Centre (EPPIC). The program developed and evaluated a number of suicide prevention strategies within EPPIC and included a cognitively oriented therapy (LifeSPAN therapy) for acutely suicidal patients with psychosis. We describe the development of these interventions in this paper. METHOD: Clinical audit and surveys provided an indication of the prevalence of suicidality among first episode psychosis patients attending EPPIC. Second, staff focus groups and surveys identified gaps in service provision for suicidal young people attending the service. Third, a suicide risk monitoring system was introduced to identify those at highest risk. Finally, patients so identified were referred to and offered LifeSPAN therapy whose effectiveness was evaluated in a randomised controlled trial. RESULTS: Fifty-six suicidal patients with first episode psychosis were randomly assigned to standard clinical care or standard care plus LifeSPAN therapy. Forty-two patients completed the intervention. Clinical ratings and measures of suicidality and risk were assessed before, immediately after the intervention, and 6 months later. Benefits were noted in the treatment group on indirect measures of suicidality, e.g., hopelessness. The treatment group showed a greater average improvement (though not significant) on a measure of suicide ideation. CONCLUSIONS: Early intervention in psychosis for young people reduces the risk of suicide. Augmenting early intervention with a suicide preventative therapy may further reduce this risk.     

Two studies on suicidality in the postpartum

Objective: Research in the prevalence of and risk factors for suicidality in the postpartum is extremely limited. We present here data on the prevalence of and factors associated with suicidality from two postpartum samples. Method: The first sample (SC) comprised 317 women consecutively screened for a trial of psychotherapy for postpartum depression. The second sample was a population‐based (PB) sample of 386 women. We used the Mini‐International Neuropsychiatric Interview (MINI) to assess suicidality in the SC sample and the self‐harm question of the Beck Depression Inventory (BDI9) in the PB sample. Results: According to the MINI and the BDI9, prevalence of high suicide risk was 5.7% and 11.1%, respectively, in the SC sample. Previous suicide attempts and a positive BDI were retained as predictors of suicidality. The BDI9 indicated suicidality in 8.3% of the 386 women in the PB sample; a positive BDI was retained in the multivariate analysis as a risk of suicidality. Conclusion: Clinicians should enquire vigorously about suicidality in women presenting with depressive symptoms or previous suicide attempts in the postpartum.     

Impulsivity and borderline personality as risk factors for suicide attempts among opioid-dependent individuals

The study aimed to examine the association of impulsivity and screening positively for borderline personality disorder (BPD+) as risk factors for suicide attempts among opioid-dependent individuals. The study used a case-control design with 775 opioid-dependent cases and 306 non-opioid-dependent controls. Cases were more likely than controls to screen BPD+ and to be classed as highly impulsive. Significant risk for lifetime suicide attempt was associated with screening BPD+ and also with high impulsivity. A number of risk factors were identified for suicide attempts among those with either high impulsivity or among those who screened BPD+: being female, a diagnosis of an anxiety disorder and a diagnosis of illicit drug dependence (other than opioid dependence). Opioid dependence was not a unique risk factor for suicide attempts among either the BPD+ group or the high impulsivity group. Although opioid dependence was not a unique risk factor for suicide attempts among those who screened BPD+, cases presented with multiple risk factors at substantially higher rates than controls. This research also highlights the importance of assessing impulsivity, in both clinical settings and research, particularly among those with a history of suicidal behaviour.     

Executive function and suicidal risk in women with Borderline Personality Disorder

A range of executive function (EF) deficits have been associated with Borderline Personality (BPD), a disorder characterized by high rates of suicide. However, the role of EF and suicide risk in BPD has not been examined. This exploratory study compared working memory, Stroop interference, motor inhibition (SSRT) and Iowa Gambling Task (IGT) decision making performance in 42 women with BPD and 41 healthy controls. The sensitivity of EF to suicidal risk as assessed by the Suicide Behaviour Questionnaire-R (Osman et al., 2001) was also tested. Women with BPD performed similar to controls on all EF except decision making. Weaker Stroop interference control, however, was the only significant EF contributor to suicide risk, demonstrating near equivalent contributions to that of depression. EF and depression collectively explained 34% of the adjusted variance in total suicide risk. Contrary to expectations, IGT decision making and motor inhibition were not associated with overall suicide risk. Only Stroop interference control contributed significantly to lifetime suicide intent/attempt beyond depression or BPD severity. As prior suicide attempt remains the strongest predictor of future attempt (Soloff et al., 2003), the sensitivity of stroop performance to suicidal risk may be clinically important. Interference control may represent a "diathesis" for suicide that is independent of psychiatric diagnoses.     

Causes, diagnosis and treatment of suicidality

In Germany, each year more than 11,000 people commit suicide. Rates of attempted suicide are estimated to be tenfold higher. Psychosocial as well as biological causes play an important role in the etiology of suicidality. Patients suffering from affective disorders, alcohol and drug abuse, and psychotic disorders are considered to be the most important high-risk groups. Careful diagnosis of suicidality is a precondition for successful therapy. Acute treatment is based on psychopharmacological as well as on psychotherapeutic strategies. In the case of acute danger, short-term goals consist in gaining time and actively providing direct support. In the long run, treatment of the underlying psychiatric disorder and stabilisation of the daily life situation become more important. There is no scientific evidence for the hypothesis that selective serotonin reuptake inhibitors (SSRIs) increase the risk of suicide.     

PTSD,Depression, and Substance Use in Relation to Suicidality Risk among Traumatized Minority Lesbian,Gay, and Bisexual Youth

Youths who are lesbian, gay, or bisexual (LGB) are more likely than heterosexuals to commit suicide. Substance use, PTSD, and depression are independent risk factors for suicidality; however, the extent to which these factors interact to predict suicidality is unclear. The current study examined the association between substance use, PTSD symptoms (PTSS), depressive symptoms, and suicidality in a sample of 68 traumatized minority LGB youths. Participants were recruited from an LGBT community center and completed a packet of questionnaires. Substance use and depressive symptoms were positively associated with prior suicide attempts. A significant three-way interaction revealed that substance use interacted with both PTSS and depressive symptoms to increase the odds of attempted suicide. Results underscore the importance of integrating substance use components into PTSD/depression treatment to reduce suicide risk in LGB youth.     

Maternal suicidality and risk of suicidality in offspring: findings from a community study

OBJECTIVE: This study evaluated the associations between suicidal ideation and suicide attempts in mothers and various aspects of suicidality in their offspring in a representative community sample. METHOD: Baseline and 4-year follow-up data were used from the Early Developmental Stages of Psychopathology study, a prospective, longitudinal community study of adolescents and young adults. Results are based on 933 adolescents who completed follow-up and for whom direct diagnostic information for the biological mother was available. Suicidal ideation and suicide attempts were assessed in adolescents and mothers with the Munich-Composite International Diagnostic Interview. RESULTS: Compared to offspring of mothers without suicidality, offspring of mothers reporting suicide attempts showed a remarkably higher risk for suicidal thoughts and suicide attempts and a tendency toward suicide attempts at an earlier age. Associations were comparable for male and female offspring. Transmission of maternal suicidality was roughly stable with control for maternal comorbid psychopathology. CONCLUSIONS: The offspring of mothers with suicide attempts are at a markedly increased risk for suicidality themselves and tend to manifest suicide attempts earlier than offspring of mothers without suicidality. Suicidality seems to run in families, independent of depression and other psychopathology.     

Social and interpersonal factors relating to adolescent suicidality: a review of the literature

This article reviews the empirical literature concerning social and interpersonal variables as risk factors for adolescent suicidality (suicidal ideation, suicidal behavior, death by suicide). It also describes major social constructs in theories of suicide and the extent to which studies support their importance to adolescent suicidality. PsychINFO and PubMed searches were conducted for empirical studies focused on family and friend support, social isolation, peer victimization, physical/sexual abuse, or emotional neglect as these relate to adolescent suicidality. Empirical findings converge in documenting the importance of multiple social and interpersonal factors to adolescent suicidality. Research support for the social constructs in several major theories of suicide is summarized and research challenges are discussed.     

Prediction of suicidality and violence in hospitalized adolescents: comparisons by sex.

OBJECTIVE: To examine psychological correlates of suicidality and violent behaviour in hospitalized adolescents and the extent to which these associations may be affected by their sex. METHOD: A sample of 487 psychiatric inpatients (207 male, 280 female), aged 12 to 19 years, completed a battery of psychometrically sound self-report measures of psychological functioning, substance abuse, suicidality, and violent behaviour. We conducted multiple regression analyses to determine the joint and independent predictors of suicide risk and violence risk. In subsequent analyses, we examined these associations separately by sex. RESULTS: Multiple regression analysis revealed that 9 variables (sex, age, hopelessness, self-esteem, depression, impulsivity, alcohol abuse, drug abuse, and violence risk) jointly predicted suicide risk and that an analogous model predicted violence risk. However, we found several differences with respect to which variables made significant independent contributions to these 2 predictive models. Female sex, low self-esteem, depression, drug abuse, and violence risk made independent contributions to suicide risk. Male sex, younger age, hopelessness, impulsivity, drug abuse, and suicide risk made independent contributions to violence risk. We observed a few additional differences when we considered male and female subjects separately. CONCLUSIONS: We found overlapping but distinctive patterns of prediction for suicide risk and violence risk, as well as some differences between male and female subjects. These results may reflect distinct psychological and behavioural pathways for suicidality and violence in adolescent psychiatric patients and differing risk factors for each sex. Such differences have potential implications for prevention and treatment programs.     

Social and Interpersonal Factors Relating to Adolescent Suicidality: A Review of the Literature

This article reviews the empirical literature concerning social and interpersonal variables as risk factors for adolescent suicidality (suicidal ideation, suicidal behavior, death by suicide). It also describes major social constructs in theories of suicide and the extent to which studies support their importance to adolescent suicidality. PsychINFO and PubMed searches were conducted for empirical studies focused on family and friend support, social isolation, peer victimization, physical/sexual abuse, or emotional neglect as these relate to adolescent suicidality. Empirical findings converge in documenting the importance of multiple social and interpersonal factors to adolescent suicidality. Research support for the social constructs in several major theories of suicide is summarized and research challenges are discussed.