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Original Investigation
November 18, 2020

Association of Borderline Personality Disorder Criteria With Suicide Attempts: Findings From the Collaborative Longitudinal Study of Personality Disorders Over 10 Years of Follow-up

Author Affiliations
  • 1Beth Israel Deaconess Medical Center, Massachusetts Mental Health Center, Harvard Medical School, Boston, Massachusetts
  • 2Alpert Medical School, Brown University, Providence, Rhode Island
  • 3Yale Medical School, New Haven, Connecticut
  • 4Wesleyan University, Middletown, Connecticut
  • 5Providence Veterans Affairs Medical Center, Providence, Rhode Island
  • 6McLean Hospital, Harvard Medical School, Belmont, Massachusetts
  • 7Texas A&M University, Phoenix, Arizona
  • 8University of Arizona College of Medicine, Phoenix
JAMA Psychiatry. 2021;78(2):187-194. doi:10.1001/jamapsychiatry.2020.3598
Key Points

Question  Are borderline personality disorder (BPD) and its specific diagnostic criteria associated with who reports a suicide attempt(s) over 10 years of prospective follow-up?

Findings  In this longitudinal study of adults with personality disorders, after controlling for significant demographic and other clinical risk factors, BPD and the specific criteria of identity disturbance, chronic feelings of emptiness, and frantic efforts to avoid abandonment emerged as significant factors associated with prospectively observed suicide attempt status.

Meaning  Identity disturbance, chronic feelings of emptiness, and frantic efforts to avoid abandonment may be clinically overlooked features of BPD in context of suicide risk assessment.

Abstract

Importance  Borderline personality disorder (BPD) has been identified as a strong risk factor for suicidal behavior, including suicide attempts. Delineating specific features that increase risk could inform interventions.

Objective  To examine factors associated with prospectively observed suicide attempts among participants in the Collaborative Longitudinal Study of Personality Disorders (CLPS), over 10 years of follow-up, with a focus on BPD and BPD criteria.

Design, Setting, and Participants  The CLPS is a multisite, naturalistic, prospective study of adult participants with 4 personality disorders (PDs) and a comparison group of adults with major depressive disorder and minimal PD features. Participants were all treatment-seeking and recruited from inpatient, partial, and outpatient treatment settings across New York, New York, Boston, Massachusetts, New Haven, Connecticut, and Providence, Rhode Island. A total of 733 participants were recruited at baseline, with 701 completing at least 1 follow-up assessment. The cohorts were recruited from September 1996 through April 1998 and September 2001 through August 2002. Data for this study using this follow-up sample (N = 701) were analyzed between March 2019 and August 2020.

Main Outcomes and Measures  Participants were assessed annually using semistructured diagnostic interviews and a variety of self-report measures for up to 10 years. Multiple logistic regression analyses were used to examine baseline demographic and clinical risk factors, including BPD and individual BPD criteria, of suicide attempt assessed over 10 years of prospective follow-up.

Results  Of the 701 participants, 447 (64%) identified as female, 488 (70%) as White, 527 (75%) as single, 433 (62%) were unemployed, and 512 (73%) reported at least some college education. Of all disorders, BPD emerged as the most robust factor associated with prospectively observed suicide attempt(s) (odds ratio [OR], 4.18; 95% CI, 2.68-6.52), even after controlling for significant demographic (sex, employment, and education) and clinical (childhood sexual abuse, alcohol use disorder, substance use disorder, and posttraumatic stress disorder) factors. Among BPD criteria, identity disturbance (OR, 2.21; 95% CI, 1.37-3.56), chronic feelings of emptiness (OR, 1.63; 95% CI, 1.03-2.57), and frantic efforts to avoid abandonment (OR, 1.93; 95% CI, 1.17-3.16) emerged as significant independent factors associated with suicide attempt(s) over follow-up, when covarying for other significant factors and BPD criteria.

Conclusions and Relevance  In the multisite, longitudinal study of adults with personality disorders, identity disturbance, chronic feelings of emptiness, and frantic efforts to avoid abandonment were significantly associated with suicide attempts. Identity disturbance, chronic feelings of emptiness, and frantic efforts to avoid abandonment may be clinically overlooked features of BPD in context of suicide risk assessment. In light of the high rates of BPD diagnostic remission, our findings suggest that these criteria should be independently assessed and targeted for further study as suicide risk factors.

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    1 Comment for this article
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    RE: Association of Borderline Personality Disorder Criteria With Suicide Attempts
    Tomoyuki Kawada, MD | Nippon Medical School
    Yen et al. conducted a prospective study to examine factors associated with suicide attempts among participants with borderline personality disorder (BPD) (1). The adjusted odds ratio (OR) (95% confidence interval [CI]) of BPD for suicide attempts was 4.18 (2.68-6.52). Among BPD criteria, the adjusted ORs (95% CIs) of identity disturbance, chronic feelings of emptiness, and frantic efforts to avoid abandonment for suicide attempts were 2.21 (1.37-3.56), 1.63 (1.03-2.57), and 1.93 (1.17-3.16), respectively. The authors concluded that these three criteria should be paid attention as suicide risk factors. I present information about this study.

    Grilo and Udo conducted a cross-sectional
    study to examine the association of BPD and specific BPD criteria with suicide attempts in US adults (2). The adjusted ORs (95% CIs) of a lifetime diagnosis of BPD for lifetime and past-year suicide attempts were 8.40 (7.53-9.37) and 11.77 (7.86-17.62), respectively. In addition, the adjusted ORs (95% CIs) of BPD diagnosis, self-injurious behaviors, and chronic feelings of emptiness for lifetime suicide attempts were 2.10 (1.79-2.45), 24.28 (16.83-32.03), and 1.58 (1.16-2.14), respectively. Furthermore, the adjusted ORs (95% CIs) of BPD diagnosis, self-injurious behaviors, and chronic feelings of emptiness for past-year suicide attempts were 11.42 (7.71-16.91), 19.32 (5.22-71.58), and 1.99 (1.08-3.66), respectively. They concluded that self-injurious behaviors and chronic feelings of emptiness should be considered as suicide risk. Although there were some wide ranges of 95% confidence interval in this cross-sectional study, ORs of chronic feelings of emptiness for lifetime and past-year suicide attempts were stable.

    Taken together, chronic feelings of emptiness was a common risk factor for suicide attempt in two studies. Intervention trial of improving emptiness feelings in patients with BPD should be conducted to prevent suicide.

    References
    1. 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 2021;78(2):187-194.
    2. Grilo CM, Udo T. Association of Borderline Personality Disorder Criteria With Suicide Attempts Among US Adults. JAMA Netw Open 2021;4(5):e219389.
    CONFLICT OF INTEREST: None Reported
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