Two Key Suicide Risk Factors Identified in Borderline Personality

Pauline Anderson

May 19, 2021

Dr Carlos M. Grilo

Feelings of chronic emptiness and self-injury have been identified as two key risk factors for suicide attempts (SAs) in patients with borderline personality disorder (BPD), a new cross-sectional, nationally representative study suggests.

The findings also show lifetime and past-year SAs are common among patients with BPD, even when excluding self-injurious behaviors.

The results suggest that in addition to asking patients about self-harm during suicide risk screenings and assessments, clinicians should query them about "longstanding" feelings of emptiness, study investigator Carlos M. Grilo, PhD, professor of psychiatry and psychology, Yale University School of Medicine, New Haven, Connecticut, told Medscape Medical News.

Although related, chronic emptiness "is distinct and goes beyond feelings of sadness, loneliness, and hopelessness," explained Grilo. Patients describe this emptiness as "a feeling that their life has no meaning or any real purpose," he said.

The study was published online May 11 in JAMA Network Open.

Filling a Research Gap

While BPD and other psychiatric disorders are associated with suicide, the authors note there is a "dearth of epidemiological research" examining the link between BPD and suicide.

Criteria for BPD diagnosis requires any five of nine possible criteria including unstable relationships, affective instability, abandonment fear, anger, identity disturbance, emptiness, disassociation/paranoia, self-injurious behavior, and impulsivity, along with social-occupation dysfunction.

To determine SA risk with specific BPD diagnostic criteria, the investigators examined data on 36,309 individuals who participated in the third wave of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC-III), conducted from 2012-2013.

During computer-assisted, face-to-face interviews, study participants answered questions based on the Alcohol Use Disorder and Associated Disabilities Interview Schedule-5 (AUDADIS-5) of the National Institute on Alcohol Abuse and Alcoholism.

This structured interview assesses a range of DSM-5–defined psychiatric disorders and their criteria. In addition to BPD, the AUDADIS-5 generates diagnoses for mood disorders, anxiety disorders, post-traumatic stress disorder, substance use disorders, antisocial personality disorder, schizotypal disorder, and conduct disorder.

During the interviews, respondents were asked if they had ever attempted suicide. For those who had, interviewers recorded the total number of lifetime attempts.

Participants also answered questions about childhood maltreatment including physical neglect, emotional neglect, physical abuse, emotional abuse, and sexual abuse by parents or caregivers and other adverse events occurring before the age of 18.

Childhood Trauma Common

Patients with BPD frequently report a history of childhood trauma, noted Grilo, adding that such trauma is associated with self-harm and suicide attempts. Sociodemographic information, including age, sex, and ethnicity/race, education level, and income, was also gathered.

Investigators examined data on suicide attempts using relatively stringent coding that required serious dysfunction in at least five BPD criteria.

Using this definition, investigators found the lifetime SA prevalence in patients with BPD was 30.4%, and 3.2% for past-year SAs. This compared with a rate of 3.7% for lifetime SAs and 0.2% for past-year SAs in those without a BPD diagnosis.

The authors also examined SA rates using diagnostic codes in the NESARC-III that required seriously impaired function in only 1 or 2 BPD criteria. Rates were higher using the 5-criteria definition.

When excluding the BPD criterion of self-injurious behavior, the prevalence was 28.1% for lifetime and 3.0% for past-year SAs among the BPD group, with corresponding rates of 3.8% and 0.2% in those without a BPD diagnosis.

It's important to look at this, said Grilo, as some patients with BPD who engage in self-harm have suicidal intent while others don't.

"We tested whether BPD had heightened risk for suicide attempts if we eliminated the self-injurious criterion and we found that heightened risk was still there," he explained.

Looking at individual criteria for BPD, a model that adjusted for sociodemographic characteristics, other psychiatric disorders, age at BPD onset, and history of childhood adverse events uncovered two criteria that were significantly associated with increased odds of SAs.

One was emptiness. For lifetime suicide attempts, the adjusted odds ratio (aOR) was 1.58 (95% CI, 1.16 - 2.14) and for past-year attempts, the aOR was 1.99 (95% CI, 1.08 - 3.66).

The second was self-injurious behavior. For lifetime attempts, the aOR was 24.28 (95% CI, 16.83 - 32.03) and for past-year attempts, the aOR was 19.32 (95% CI, 5.22 - 71.58).

In a model in which all BPD-specific criteria were entered while excluding self-injurious behavior, the aORs for emptiness were 1.66 (95% CI, 1.23 - 2.24) for lifetime suicide attempts and 2.45 (95% CI, 1.18 - 5.08) for past year attempts.

Unlike another recent study that included more than 700 treatment-seeking patients with BPD who were followed for 10 years, the current study did not show significant associations with SAs for two other BPD criteria – identity disturbance and frantic attempts to avoid abandonment.

Grilo explained this might be because the earlier study included treatment-seeking patients instead of community cases, or because of differences in assessment interviews or other factors.

"Compelling Evidence"

"Our epidemiological sample has much broader generalizability and fewer potential confounds than the clinical treatment-seeking sample," said Grilo.

However, he noted that the two studies "converge strongly and provide compelling evidence that BPD is associated with substantially heightened risk for suicide attempts over the lifetime."

The two studies "also converge in finding that the presence of symptoms such as repeated self-harm and feelings of chronic emptiness are also associated with risk for suicide attempts."

The new findings highlight the need to ask potentially at-risk patients about feelings of emptiness as well as self-injurious behaviors. Clinicians could, for example, ask: "Have you often felt like your life had no purpose or meaning?" or "Have you often felt empty inside?"

Limitations of the study include reliance on retrospective self-reports and use of lay interviewers, although these interviewers were trained and had an average of 5 years of experience conducting health-related surveys.

Although the study included a representative sample of US adults, the sample did not include groups known to have high rates of suicide and self-harm behaviors, such as institutionalized, incarcerated, or homeless individuals.

In addition, the study did not evaluate severity and duration of BPD, although the authors noted they did adjust for age at BPD onset, this did not alter the findings.

Often Misdiagnosed

Commenting on the study, John M. Oldham, MD, distinguished emeritus professor, Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, and past-president, American Psychiatric Association, and an expert on BPD, had high praise for the research.

BPD is often misdiagnosed, Oldham told Medscape Medical News. Many patients seek help from primary care doctors who may label the symptoms as an anxiety disorder or a mood disorder, he said.

Although medications can help treat some BPD symptoms, "the primary, core evidence-based treatment for BPD is psychotherapy," said Oldham, who some years ago, helped develop evidence-based practice guidelines for BPD.

"It's a clear and very well-designed study, and I don't see any major limitations or problems with it," he said. "The authors kept their focus rigorously on their goals and they used really careful methodology."

He noted the "huge" numbers of patients included in the data and the relatively large percentage of men (43.7%).

"There's a general belief that it's mostly females who have BPD, but that's not true; it's females who come to treatment," said Oldham.

Requiring that all five criteria lead to seriously impaired functioning "is a much more rigorous diagnostic methodology" than requiring only one or two criteria to lead to such impairment, said Oldham. "This is really important" and makes it "a much stronger study."

The finding that self-harm behavior was linked to suicide attempts isn't that surprising as this association has been well documented, but the finding that chronic emptiness is also predictive of future suicide attempts "is news," said Oldham.

"We have not paid enough attention to this criterion in the clinical world or in the research world."

Oldham said one patient with BPD gave him an ideal metaphor for emptiness. "She said it's like there's just nobody home. Think of it as an empty house that may look fine on the outside but you go inside and nobody lives there; there's no furniture; no favorite things; no photos; no possessions."

The authors have "important messages we need to pay attention to, and the main one is to explore this sense of chronic 'nobody home' emptiness," said Oldham.

Grilo has reported receiving research grants from the National Institutes of Health; serving as a consultant for Sunovion and Weight Watchers; receiving honoraria for lectures, continuing medical education activities, and presentations at scientific conferences; and receiving royalties from Guilford Press and Taylor & Francis, all outside the submitted work.

JAMA Netw Open. 2021;4:e219389. Full text

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