BPE and Suicidality
BPE and Suicidality
BPE and Suicidality
Because of the frequency of self-injurious behavior in pa- derline personality disorder with major depressive disor-
tients with borderline personality disorder and because der (28, 30, 32–34) and with substance abuse (28, 30, 35,
such behavior is often viewed as an effort to elicit a desired 36). In a study of inpatients with borderline personality dis-
response from another person, self-injurious behavior can order, Soloff and colleagues (37) reported that the comor-
be mistakenly thought of as willful, deliberate, and under bidity of borderline personality disorder and major depres-
the patient’s control. However, self-injurious behavior in pa- sive episode increased the number and seriousness of
tients with borderline personality disorder is incompletely suicide attempts. They also identified impulsivity and
understood, and it may be associated with different motiva- hopelessness as independent risk factors for suicidal be-
tions, meanings, or goals from one patient to another or at havior in patients with comorbid borderline personality
various times in the same patient. It may produce relief of disorder and major depressive episode. In a patient with
acute dysphoria (23) and may be accompanied by analgesia, borderline personality disorder only, the symptoms of de-
perhaps suggesting the release of endogenous opiates dur- pression and suicidality are usually reactive to interper-
ing acute intensification of dysphoric states (24). sonal or other real or perceived stresses and are usually of
brief duration. If such a patient makes a
Comorbidity suicide attempt, the attempt is often im-
Numerous studies have identified
“Develop, with the pulsive in nature. In contrast, in a pa-
high rates of comorbidity in patients patient, a mutual plan tient with comorbid borderline person-
ality disorder and axis I major
with borderline personality disorder.
Intra-axis-II comorbidity is common
that protects the depressive episode, symptoms of de-
pression and suicidality develop and
(25, 26), but little is known about patient’s life and the deepen gradually and may persist for
whether particular combinations of
disorders correlate with predictable
integrity of the weeks (or much longer if not treated).
treatment.” Such patients may show loss of appetite,
patterns of suicidal behavior. Among
sleep disturbances, loss of interest in or-
personality disorders, antisocial per-
dinarily pleasurable activities, and other
sonality disorder, like borderline per-
persistent signs and symptoms of depression.
sonality disorder, is associated with suicide risk. The esti-
The well-documented comorbidity of substance abuse
mated lifetime suicide risk for patients with antisocial
with borderline personality disorder (28, 30, 35, 36) in-
personality disorder is 5% (27, 28). However, this estimate
creases patients’ risk for impulsive suicidal behavior and
may be low, because patients with antisocial personality
for impaired judgment. Because of the impaired judgment,
disorder have a high rate of risk-taking behavior, and it is
a suicidal act made with a low level of intent to die could
difficult to differentiate suicide from accidental death. The
have lethal results in such patients. The APA Practice Guide-
relative rates of suicide in patients with comorbid border-
line for the Treatment of Patients With Borderline Person-
line personality disorder and antisocial personality disor-
ality Disorder (21) specified that patients with comorbid
der, compared to patients with either condition alone, are
borderline personality disorder and substance abuse prob-
unclear, although Soloff et al. (29) found a higher level of
lems have a more guarded prognosis and are at greater risk
lethality of suicide attempts in patients with the comor-
for suicide or death from injury or accident, a heightened
bidity, compared to patients with borderline personality
risk also noted by others (28, 34–36).
disorder alone. In clinical populations, borderline person-
ality disorder occurs predominantly in female patients (7),
but it is more evenly distributed among males and females Treatment and Management
in the general population (30). One possible explanation
for this difference in gender ratio in clinical versus non- Risk Factors and Prediction of Suicide
clinical populations is that the comorbidity of borderline Risk factors for suicidal behavior in patients with bor-
personality disorder and antisocial personality disorder derline personality disorder are summarized in Table 2.
occurs most often in non-treatment-seeking males. The risk factors most readily recognized by clinicians in-
Instead of approaching the question of comorbidity by clude a history of multiple suicide attempts, especially
using the DSM-IV-TR categorical system, many experts in those with high potential lethality, and the presence of sig-
personality studies prefer a dimensional approach. Using nificant, persistent substance use. Despite the ability to
a dimensional framework, Links and Kolla (28) identified identify meaningful risk factors in patients with borderline
three personality characteristics as relevant for suicidal personality disorder, we cannot with certainty predict fu-
behavior in psychiatric patients—impulsive aggression, ture suicidal behavior in an individual patient (39, 43)—a
perfectionism, and emotional dysregulation. Of these, problem that confronts clinicians in the treatment of all
impulsive aggression and emotional, or affective, dysreg- patient populations with potential suicide risk.
ulation are the two most relevant factors for suicidal or
self-injurious behavior in patients with borderline per- Treatment of Borderline Personality Disorder
sonality disorder. The APA Practice Guideline for the Treatment of Patients
Axis I/axis II comorbidity is also common (26, 30, 31), With Borderline Personality Disorder (21) recommended
and there is particular interest in the comorbidity of bor- psychotherapy as the primary, or core, evidence-based
TABLE 2. Risk Factors for Suicidal Behavior in Patients With The APA practice guideline recommended symptom-tar-
Borderline Personality Disordera geted pharmacotherapy to be combined with psychother-
Risk Factor apy for adjunctive benefit in the treatment of borderline
Prior suicide attempts (20, 29, 37–39) personality disorder (21). The results of randomized, con-
Comorbid mood disorder (20, 29, 34, 37)
High levels of hopelessness (37) trolled trials of specific medications were presented in the
Family history of completed suicide or suicidal behavior (39) guideline, along with decision-tree algorithms based on
Comorbid substance abuse (20, 34, 40, 41) clinical judgment that were organized around the predom-
History of sexual abuse (42)
High levels of impulsivity and/or antisocial traits (29, 37, 39, 41)
inance of affective dysregulation, impulsive-behavioral
a dyscontrol, or cognitive-perceptual symptoms. Newer
Reference numbers for studies that examined each risk factor are
shown in parentheses. randomized, controlled trials, as well as a number of case
reports and noncontrolled medication trials, were sum-
treatment for the disorder, whether or not suicidality is marized in the Guideline Watch (46). Newer-generation
prominent in a given patient. The guideline did not en- atypical neuroleptics are recommended, generally in low
dorse a specific form of psychotherapy, but two forms of doses, to treat cognitive-perceptual symptoms, and the
selective serotonin reuptake inhibitors (SSRIs) are recom-
psychotherapy—dialectical behavior therapy (44) and
mended to stabilize impulsive aggression or affective dys-
psychodynamic psychotherapy (45)—were reported in
regulation (21, 46). If the prescribing physician is not also
published randomized, controlled trials to have shown
the psychotherapist, effective communication between
benefit in the treatment of borderline personality disorder.
the two is essential. The adjunctive medication may be
More recently, APA issued a Guideline Watch (46) that
needed only for relatively brief periods for patients with
summarized significant developments in the treatment of borderline personality disorder alone. If an axis I comor-
borderline personality disorder since the 2001 publication bidity such as major depressive disorder is present, other
of the complete guideline. In addition to a review of new evidence-based guidelines for the axis I condition should
published reports on dialectical behavior therapy, the be used to guide pharmacotherapy decisions.
Guideline Watch described other types of psychotherapy Figure 1 portrays hypothetical relative proportions of
that are being tried for the treatment of borderline person- psychotherapy and pharmacotherapy in treatment of the
ality disorder, including interpersonal therapy, cognitive different subtypes of borderline personality disorder that
therapy, cognitive analytic therapy, systems training for are described in Table 1. Gunderson (7, pp. 150–151) em-
emotional predictability and problem solving, and trans- phasized that these subtypes could also reflect different
ference-focused psychotherapy. Randomized, controlled phases of treatment or different levels of severity. Thus, a
trials of these treatments have not yet been reported, al- given patient’s predominant symptoms and corresponding
though several such studies are in process. need for medication could change in the course of therapy.
FIGURE 2. Treatment Priorities in Two Psychotherapeutic signed role is to understand and accept the importance of
Approaches for Patients With Borderline Personality this opportunity and to learn to choose alternative meth-
Disordera
ods to deal with the inevitable crises that arise. The stakes
can be high, and risk is certainly involved, but the capac-
Dialectical Psychoanalytic/ ity to tolerate risk is an important asset for both the pa-
Behavior Therapy Psychodynamic Therapy
tient and the therapist (56, 57).
In the patient described at the beginning of this article,
Suicidal or
homicidal threats
suicidal ideation had not been a prominent ongoing con-
cern. In such a case, it would be important to review poten-
Suicidal
tial risk factors for suicide, including the patient’s family
behaviors
Overt threats to history. The new appearance of suicidality in the context of
treatment community
ongoing treatment could represent the first time that the
borderline personality disorder symptom of reactive sui-
Dishonesty or cidality emerged during the treatment period, or it could
deliberate withholding herald the onset of comorbid major depression. In the pa-
tient described in the case vignette, the gradual develop-
Behaviors Contract ment of depression, hopelessness, and suicidal ideation (in
interfering breeches contrast to impulsive suicidal behavior) suggests the emer-
with therapy gence of comorbid axis I depression. Appropriate antide-
pressant medication might need to be started for such a
Acting out
in sessions patient, as the patient has already been effectively engaged
in psychotherapy. Brief hospitalization could be necessary,
if signs indicated an extremely high suicide risk and the pa-
Acting out tient’s hold on the lifeline of therapy seemed to be weaken-
Behaviors between sessions
ing. However, the therapist should have no expectation
interfering with
quality of life that accomplishing such a plan would be smooth sailing,
Nonaffective or because a depressive episode, superimposed on the pa-
other themes tient’s not-yet-resolved borderline intrapsychic world,
could challenge the tenuous trust being built between the
a
patient and the therapist.
Adapted with permission from the APA Practice Guideline for the
Treatment of Patients With Borderline Personality Disorder (21).
Received Oct. 4, 2005; accepted Oct. 6, 2005. From the Depart-
ment of Psychiatry and Behavioral Sciences, Medical University of
the patients’ personality pathology may persist, compli- South Carolina. Address correspondence and reprint requests to Dr.
cating the treatment of the axis I episode. Oldham, Department of Psychiatry and Behavioral Sciences, Medical
University of South Carolina, 67 President St., Charleston, SC 29425;
oldhamj@musc.edu (e-mail).
Summary and Recommendations
Suicide risk is a frequent companion in the treatment of References
patients with borderline personality disorder, and it rep-
resents a challenge for the patient and the therapist alike. 1. Clarkin JF, Widiger T, Frances A, Hunt SW, Gilmore M: Prototypic
typology and the borderline personality disorder. Abnorm Psy-
In the early stages of therapy—whether dialectical behav-
chol 1983; 92:263–275
ior therapy, cognitive behavior therapy, psychodynamic
2. Oldham JM: Integrated treatment planning for borderline per-
therapy, or another form of therapy—suicide risk is often
sonality disorder, in Integrated Treatment of Psychiatric Disor-
the number-one priority. Giving high priority to this con- ders. Edited by Kay J. Washington, DC, American Psychiatric
cern does not imply the wish to reinforce and perpetuate Publishing, 2001, pp 51–77
the patient’s periodic preoccupation with suicide. Rather, 3. Oldham JM: A 44-year-old woman with borderline personality
it conveys the need to come at this preoccupation head- disorder. JAMA 2002; 287:1029–1037
on, as a recognized risk, and to engage the patient’s moti- 4. Akiskal HS: Subaffective disorders: dysthymic, cyclothymic and
vation to join forces with the therapist and find a better bipolar II disorders in the “borderline” realm. Psychiatr Clin
road to travel. The preferred strategy to accomplish this North Am 1981; 4:25–46
goal is to develop, with the patient, a mutual plan that 5. Akiskal HS, Chen SE, Davis GC, Puzantian VR, Kashgarian M,
Bolinger JM: Borderline: an adjective in search of a noun. J Clin
protects the patient’s life, the patient’s bodily integrity,
Psychiatry 1985; 46:41–48
and the integrity of the treatment itself. In such a plan, the
6. Klein DF, Liebowitz MR: Hysteroid dysphoria (letter). Am J Psy-
therapist’s assigned role is not as a member of an emer- chiatry 1982; 139:1520–1521
gency medical services team but, rather, as the protector 7. Gunderson JG: Borderline Personality Disorder: A Clinical
of a valuable sanctuary—the therapy itself—as a place Guide. Washington, DC, American Psychiatric Press, 2001
where the patient’s confusion, fear, hopelessness, and 8. Zanarini MC: Borderline personality disorder as an impulse
distorted perceptions can be sorted out. The patient’s as- spectrum disorder, in Borderline Personality Disorder: Etiology
and Treatment. Edited by Paris J. Washington, DC, American 29. Soloff PH, Fabio A, Kelly TM, Malone KM, Mann JJ: High-lethal-
Psychiatric Press, 1993, pp 67–85 ity status in patients with borderline personality disorder. J Per-
9. Siever LJ: Relationship between impulsivity and compulsivity: a sonal Disord 2005; 19:386–399
synthesis, in Impulsivity and Compulsivity. Edited by Oldham 30. Torgersen S, Kringlen E, Cramer V: The prevalence of personal-
JM, Hollander E, Skodol AE. Washington, DC, American Psychi- ity disorders in a community sample. Arch Gen Psychiatry
atric Press, 1996, pp 261–272 2001; 58:590–596
10. Links PS, Heslegrave RJ: Prospective studies of outcome: un- 31. Oldham JM, Skodol AE, Kellman HD, Hyler SE, Doidge N, Ros-
derstanding the mechanisms of change in patients with bor- nick L, Gallaher PE: Comorbidity of axis I and axis II disorders.
derline personality disorder. Psychiatr Clin North Am 2000; 23: Am J Psychiatry 1995; 152:571–578
137–150 32. Kelly TM, Soloff PH, Lynch KG, Haas GL, Mann JJ: Recent life
11. Kernberg OF: Borderline Conditions and Pathological Narcis- events, social adjustment, and suicide attempts in patients
sism. New York, Jason Aronson, 1975 with major depression and borderline personality disorder. J
12. Zanarini MC, Frankenburg FR: Pathways to the development of Personal Disord 2000; 14:316–326
borderline personality disorder. J Personal Disord 1997; 11:93– 33. Skodol AE, Stout RL, McGlashan TH, Grilo CM, Gunderson JG,
104 Shea MT, Morey LC, Zanarini MC, Dyck IR, Oldham JM: The co-
13. Masterson J: Treatment of the Borderline Adolescent: A Devel- occurrence of mood and personality disorders: a report from
opmental Approach. New York, John Wiley & Sons, 1972 the Collaborative Longitudinal Personality Disorders Study
(CLPS). Depress Anxiety 1999; 10:175–182
14. Masterson JF, Rinsley DB: The borderline syndrome: the role of
34. Yen S, Shea MT, Pagano M, Sanislow CA, Grilo CM, McGlashan
the mother in the genesis and psychic structure of the border-
TH, Skodol AE, Bender DS, Zanarini MC, Gunderson JG, Morey
line personality. Int J Psychoanal 1975; 56:163–177
LC: Axis I and axis II disorders as predictors of prospective sui-
15. Gunderson JG: The borderline patient’s intolerance of alone-
cide attempts: findings from the Collaborative Longitudinal
ness: insecure attachments and therapist availability. Am J Psy-
Personality Disorders Study. J Abnorm Psychol 2003; 112:375–
chiatry 1996; 153:752–758
381
16. Adler G: Borderline Psychopathology and Its Treatment. New
35. Skodol AE, Oldham JM, Gallaher PE: Axis II comorbidity of sub-
York, Jason Aronson, 1985
stance use disorders among patients referred for treatment of
17. Adler G, Buie D: Aloneness and borderline psychopathology: personality disorders. Am J Psychiatry 1999; 156:733–738
the possible relevance of child developmental issues. Int J Psy-
36. Zanarini MC, Frankenburg FR, Dubo ED, Sickel AE, Trikha A,
choanal 1979; 60:83–96
Levin A, Reynolds V: Axis I comorbidity of borderline personal-
18. American Psychiatric Association: Practice Guideline for the As- ity disorder. Am J Psychiatry 1998; 155:1733–1739
sessment and Treatment of Patients With Suicidal Behaviors. 37. Soloff PH, Lynch KG, Kelly TM, Malone KM, Mann JJ: Character-
Am J Psychiatry 2003; 160(Nov suppl) istics of suicide attempts of patients with major depressive ep-
19. Perry JC: Longitudinal studies of personality disorders. J Per- isode and borderline personality disorder: a comparative
sonal Disord 1993; 7(suppl):63–85 study. Am J Psychiatry 2000; 157:601–608
20. Black DW, Blum N, Pfohl B, Hale N: Suicidal behavior in border- 38. Kullgren G: Factors associated with completed suicide in bor-
line personality disorder: prevalence, risk factors, prediction, derline personality disorder. J Nerv Ment Dis 1988; 176:40–44
and prevention. J Personal Disord 2004; 18:226–239 39. Livesley WJ: Practical Management of Personality Disorder.
21. American Psychiatric Association: Practice Guideline for the New York, Guilford, 2003
Treatment of Patients With Borderline Personality Disorder. 40. Shearer SL, Peters CP, Quaytman MS, Wadman BE: Intent and
Am J Psychiatry 2001; 158(Oct suppl) lethality of suicide attempts among female borderline inpa-
22. Gunderson JG, Ridolfi ME: Borderline personality disorder: sui- tients. Am J Psychiatry 1988; 145:1424–1427
cidality and self-mutilation. Ann NY Acad Sci 2001; 932:61–73 41. Brodsky BS, Malone KM, Ellis SP, Dulit RA, Mann JJ: Characteris-
23. Stanley B, Brodsky BS: Suicidal and self-injurious behavior in tics of borderline personality disorder associated with suicidal
borderline personality disorder: a self-regulation model, in Un- behavior. Am J Psychiatry 1997; 154:1715–1719
derstanding and Treating Borderline Personality Disorder: A 42. Soloff PH, Lynch KG, Kelly TM: Childhood abuse as a risk factor
Guide for Professionals and Families. Edited by Gunderson JG, for suicidal behavior in borderline personality disorder. J Per-
Hoffman PD. Washington, DC, American Psychiatric Publishing, sonal Disord 2002; 16:201–214
2005, pp 43–63 43. Paris J, Nowlis D, Brown R: Predictors of suicide in borderline
24. Leibenluft E, Gardner DL, Cowdry RW: The inner experience of personality disorder. Can J Psychiatry 1989; 34:8–9
the borderline self-mutilator. J Personal Disord 1987; 1:317– 44. Linehan M: Cognitive-Behavioral Treatment of Borderline Per-
324 sonality Disorder. New York, Guilford, 1993
25. Oldham JM, Skodol AE, Kellman HD, Hyler SE, Rosnick L, Davies 45. Bateman A, Fonagy P: Effectiveness of partial hospitalization in
M: Diagnosis of DSM-III-R personality disorders by two struc- the treatment of borderline personality disorder: a random-
tured interviews: patterns of comorbidity. Am J Psychiatry ized controlled trial. Am J Psychiatry 1999; 156:1563–1569
1992; 149:213–220 46. Oldham JM: Guideline Watch: Practice Guideline for the Treat-
26. Skodol AE: Manifestations, clinical diagnosis, and comorbidity, ment of Patients With Borderline Personality Disorder. Arling-
in American Psychiatric Publishing Textbook of Personality Dis- ton, Va, American Psychiatric Association, 2005. http://
orders. Edited by Oldham JM, Skodol AE, Bender DS. Washing- www.psych.org/psych_pract/treatg/pg/BPD_watch_031505.pdf
ton, DC, American Psychiatric Publishing, 2005, pp 57–87 47. Paris J: Chronic suicidality among patients with borderline per-
27. Links PS, Gould B, Ratnayake R: Assessing suicidal youth with sonality disorder. Psychiatr Serv 2002; 53:738–742
antisocial, borderline, or narcissistic personality disorder. Can J 48. Sansone RA: Chronic suicidality and borderline personality. J
Psychiatry 2003; 48:301–310 Personal Disord 2004; 18:215–225
28. Links PS, Kolla N: Assessing and managing suicide risk, in 49. Hopko DR, Sanchez L, Hopko SD, Dvir S, Lejuez CW: Behavioral
American Psychiatric Publishing Textbook of Personality Disor- activation and the prevention of suicidal behaviors in patients
ders. Edited by Oldham JM, Skodol AE, Bender DS. Washington, with borderline personality disorders. J Personal Disord 2003;
DC, American Psychiatric Publishing, 2005, pp 449–462 17:460–478
50. Stanley B, Brodsky BS: Dialectical behavior therapy, in Ameri- 54. Paris J: Half in love with easeful death: the meaning of chronic
can Psychiatric Publishing Textbook of Personality Disorders. suicidality in borderline personality disorder. Harv Rev Psychi-
Edited by Oldham JM, Skodol AE, Bender DS. Washington, DC, atry 2004; 12:42–48
American Psychiatric Publishing, 2005, pp 307–320 55. Gerson J, Stanley B: Suicidal and self-injurious behavior in per-
51. Koenigsberg HW, Kernberg OF, Stone MH, Appelbaum AH, Yeo- sonality disorder: controversies and treatment directions. Curr
mans FE, Diamond D: Borderline Patients: Extending the Lim-
Psychiatry Rep 2002; 4:30–38
its of Treatability. New York, Basic Books, 2000
56. Krawitz R, Jackson W, Allen R, Connell A, Argyle N, Bensemann
52. Brown MZ, Comtois KA, Linehan MM: Reasons for suicide at-
tempts and nonsuicidal self-injury in women with borderline C, Mileshkin C: Professionally indicated short-term risk-taking
personality disorder. J Abnorm Psychol 2002; 111:198–202 in the treatment of borderline personality disorder. Australas
53. Paris J: Is hospitalization useful for suicidal patients with bor- Psychiatry 2004; 12:11–17
derline personality disorder? J Personal Disord 2004; 18:240– 57. Gutheil TG: Suicide, suicide litigation, and borderline personal-
247 ity disorder. J Personal Disord 2004; 18:248–256