Borderline Personality Disorder: High Risk for Early Death

Batya Swift Yasgur, MA, LSW

February 08, 2019

Individuals with borderline personality disorder (BPD) are at high risk for premature death from suicide as well as other causes, although those who recover have less risk, new research suggests.

Investigators followed almost 300 patients with BPD and 72 comparison patients who had other personality disorders (PDs). The participants, who were recruited during an inpatient hospital admission, were followed for 24 years and were evaluated every other year.

During the follow-up period, almost 6% of BPD patients died by suicide, vs only 1.4% of comparison patients; 14% of BPD patients died by causes other than suicide, compared to only 5.5% of comparison participants.

The most common causes of nonsuicidal deaths were cardiovascular disease, followed by substance-related complications and accidents.

"Our findings suggest that patients with BPD are at an elevated risk of premature death due to all causes at rates similar to other forms of SMI [serious mental illness]," lead author Christina Temes, PhD, clinical and research fellow, McLean Hospital and Harvard Medical School, Boston, Massachusetts, told Medscape Medical News.

"Although preventing suicide is rightfully often a focus of treatment with these patients, our findings also highlight how other forms of premature mortality are important to consider as adverse outcomes of BPD," she said.

The study was published online January 22 in the Journal of Clinical Psychiatry.

Early, Nonsuicidal Death

BPD is associated with a higher risk for suicidality, but most studies of risk factors for suicide have focused on suicide attempts rather than completed suicides, the authors note.

The few studies that examined completed suicides in patients with BPD suggest several factors that are predictive of completed suicide: prior suicidal behavior, more/longer psychiatric hospitalizations, and psychiatric comorbidities.

These studies, however, were not prospective studies but rather utilized postmortem reports and/or chart reviews to assess predictors and other patient characteristics.

Additionally, there has been very little research on nonsuicide-related mortality in patients with BPD.

"I work on a longitudinal study of a cohort of patients with BPD and a cohort of comparison patients with other personality disorders who were psychiatrically hospitalized and then followed every 2 years for 24 years. When contacting people for the latter waves of follow-up, we began discovering that a number of participants had died, many due to nonsuicide causes," said Temes.

"We wanted to study this issue in a more systematic way to learn more about trends in mortality over time, causes of death in these patients, and whether we could predict who died prematurely, based on the data we had collected earlier in these patients' lives. We also wanted to examine how rates of premature mortality in BPD compare to rates observed in other forms of serious illness," she added.

The McLean Study of Adult Development (MSAD) includes all patients who were initially inpatients at McLean Hospital between June 1992 and December 1995. The patients were followed every 2 years for 24 years. The study is ongoing and is currently in its 26th year.

BPD was diagnosed on the basis of several instruments, including the Background Information Schedule, the Structured Clinical Interview for DSM-III-R Axis I disorders, and the Revised Diagnostic Interview for Borderlines.

Patients were required to be of ages 18 to 35 years, to have an IQ ≥71, and to have no current or past history of psychotic conditions (eg, schizophrenia, schizoaffective disorder, or bipolar I disorder).

Participant deaths were recorded when discovered. The recording of deaths was supplemented with death certificate claims, informant reports, news reports, or obituaries when available.

Participants were considered to have recovered if there was at least one 2-year follow-up period during which patients were concurrently in remission from their primary PD, had one or more emotionally sustaining relationships, and were be able to go to work or school "consistently, competently, and on a full-time basis."

Complicated Interplay

The study included 290 patients with BPD and 72 patients with other PDs. Other PDs included antisocial; narcissistic; paranoid; avoidant; dependent; self-defeating; and passive-aggressive; and PD not otherwise specified, which was the most common.

Of the participants, 77% were women and 87% were white. The mean (SD) age was 27 (6.3) years, and the mean global functioning store was 39.8 (7.8), indicating major impairment in several areas (eg, work/school, family relations, mood).

The mean socioeconomic status score was 3.3 (1.5), with 1 as the highest and 5 as the lowest measure.

A total of 5.9% of borderline patients and 1.4% of comparison patients died by suicide.

Despite this significant difference, the between-group difference in time to suicide was not deemed significant; however, in contrast to comparison patients, whose suicide rates were "low and stable" over time, the suicide rates of BPD patients were "variable."

The most common methods of suicide were overdose (n = 8) and hanging (n = 6).

The number of prior hospitalizations significantly predicted completed suicide (hazard ratio [HR] = 1.62, P = .037).

Of the patients with BPD, 14.0% died of nonsuicidal causes; of comparison patients, 5.5% died by nonsuicidal causes.

In this category too, the between-group difference in incidence and time to death was not significant.

The most common causes of nonsuicidal deaths (aggregated across both categories) were myocardial infarction (n = 11), followed by substance-related complications (eg, liver cirrhosis) (n = 5), cancer (n = 4), and accidents (n = 4).

Male sex, lower socioeconomic status, being on government disability, a history of drug use disorder, the number of psychiatric hospitalizations prior to index hospitalization, the number of psychiatric medications, and body mass index (BMI) in the obese range were all significant predictors of premature nonsuicidal death (for all, P < .05).

Further multivariate analyses found that male sex (HR = 3.56, P = .003) and more prior psychiatric hospitalizations (HR = 2.93, P < .001) significantly predicted premature death.

A significantly higher proportion of patients with BPD who died either by suicide and or by nonsuicidal causes never achieved recovery, as reflected by good psychosocial functioning and full-time work.

High-risk behaviors likely played a role in the number of premature nonsuicidal deaths in patients with BPD, Temes suggested.

"For instance, a large portion of the deaths were caused by the consequences of long-term substance abuse, and substance abuse at baseline was also a predictor of premature death," she said.

Previous research has shown that BPD patients who do not achieve recovery are "likely to report a number of unhealthy lifestyle behaviors and/or other health-related risk factors, such as smoking, lack of exercise, regular alcohol use, and increased BMI — which are also related to outcomes like cardiovascular morbidities," she noted.

"The finding that a disproportionate number of those who died never achieved recovery likely reflects this complicated interplay between mental health, physical health, and health-related behaviors," she said.

Severe, Life Threatening

Commenting on the study for Medscape Medical News, Donald W. Black, MD, professor of psychiatry, Carver School of Medicine, University of Iowa, Iowa City, who was not involved with the study, said that BPD "has a well-known association with suicide, but this is the first demonstration that BPD is also associated with high death rates from nonsuicide causes."

He was not surprised by the rates of nonsuicidal premature deaths because people with BPD "are often obese, tend to have multiple medical problems, often don't get good care, and often ignore these medical problems, and these probably contribute to the excess mortality," he said.

He noted that this research has found that high death rates are common in other groups of psychiatric patients, including patients with schizophrenia and those with major depression.

Also commenting on the study for Medscape Medical News, Mark Zimmerman, MD, professor of psychiatry and human behavior, Brown University, Providence, Rhode Island, who was not involved with the study, described the MSAD as "a classic in the field, with a follow-up that has now reached nearly a quarter century."

He called the findings "eye-opening, but not surprising" and said that they "highlight the importance of considering BPD amongst the most severe and life-threatening psychiatric disorders."

The implications are important, said Zimmerman, who is also the director of the Outpatient Division at the Partial Hospital Program, Rhode Island Hospital.

"The findings call for improving the recognition of the disorder in clinical practice, greater funding into efforts to improve the outcome of the disorder, and its inclusion in the Global Burden of Disease study," he said.

"Targeting factors found to predict premature death in patients with BPD — eg, poor health behaviors, number of psychiatric medications, and substance abuse — in treatment may help prevent or delay this outcome [of premature mortality]," he added.

The study was supported by the National Institute of Mental Health. Temes and coauthors, Black, and Zimmerman have disclosed no relevant financial relationships.

J Clin Psychiatry. Published online January 22, 2019. Abstract

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