Hostname: page-component-78c5997874-lj6df Total loading time: 0 Render date: 2024-11-14T11:16:23.118Z Has data issue: false hasContentIssue false
  • English
  • Français

Predictors of suicide attempts in patients with borderline personality disorder over 16 years of prospective follow-up

Published online by Cambridge University Press:  22 March 2012

M. M. Wedig ,
M. H. Silverman ,
F. R. Frankenburg ,
D. Bradford Reich ,
G. Fitzmaurice  and
M. C. Zanarini
M. M. Wedig*
Affiliation:
Laboratory for the Study of Adult Development, McLean Hospital, Belmont, MA, USA Department of Psychiatry, Harvard Medical School, Boston, MA, USA
M. H. Silverman
Affiliation:
Laboratory for the Study of Adult Development, McLean Hospital, Belmont, MA, USA
F. R. Frankenburg
Affiliation:
Laboratory for the Study of Adult Development, McLean Hospital, Belmont, MA, USA Department of Psychiatry, Boston University School of Medicine, Boston, MA, USA
D. Bradford Reich
Affiliation:
Laboratory for the Study of Adult Development, McLean Hospital, Belmont, MA, USA Department of Psychiatry, Harvard Medical School, Boston, MA, USA
G. Fitzmaurice
Affiliation:
Laboratory for the Study of Adult Development, McLean Hospital, Belmont, MA, USA Department of Psychiatry, Harvard Medical School, Boston, MA, USA
M. C. Zanarini
Affiliation:
Laboratory for the Study of Adult Development, McLean Hospital, Belmont, MA, USA Department of Psychiatry, Harvard Medical School, Boston, MA, USA
*
*Address for correspondence: M. M. Wedig, Ph.D., Laboratory for the Study of Adult Development, McLean Hospital, 115 Mill St, Mail Stop 329, Belmont, MA 02478, USA. (Email: [email protected])
Get access Rights & Permissions [Opens in a new window]

Abstract

Background

It is clinically important to understand the factors that increase the likelihood of the frequent and recurrent suicide attempts seen in those with borderline personality disorder (BPD). Although several studies have examined this subject in a cross-sectional manner, the aim of this study was to determine the most clinically relevant baseline and time-varying predictors of suicide attempts over 16 years of prospective follow-up among patients with BPD.

Method

Two-hundred and ninety in-patients meeting Revised Diagnostic Interview for Borderlines (DIB-R) and DSM-III-R criteria for BPD were assessed during their index admission using a series of semistructured interviews and self-report measures. These subjects were then reassessed using the same instruments every 2 years. The generalized estimating equations (GEE) approach was used to model the odds of suicide attempts in longitudinal analyses, controlling for assessment period, yielding an odds ratio (OR) and 95% confidence interval (CI) for each predictor.

Results

Nineteen variables were found to be significant bivariate predictors of suicide attempts. Eight of these, seven of which were time-varying, remained significant in multivariate analyses: diagnosis of major depressive disorder (MDD), substance use disorder (SUD), post-traumatic stress disorder (PTSD), presence of self-harm, adult sexual assault, having a caretaker who has completed suicide, affective instability, and more severe dissociation.

Conclusions

The results of this study suggest that prediction of suicide attempts among borderline patients is complex, involving co-occurring disorders, co-occurring symptoms of BPD (self-harm, affective reactivity and dissociation), adult adversity, and a family history of completed suicide.

Keywords

Borderline personality disorderlongitudinal coursepredictorssuicide attempts
Type
Original Articles
Information
Psychological Medicine , Volume 42 , Issue 11 , November 2012 , pp. 2395 - 2404
Copyright
Copyright © Cambridge University Press 2012

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Bernstein, EM, Putnam, FW (1986). Development, reliability, and validity of a dissociation scale. Journal of Nervous and Mental Disease 174, 727–735.CrossRefGoogle ScholarPubMed
Black, DW, Blum, N, Pfohl, B, Hale, N (2004). Suicidal behavior in borderline personality disorder: prevalence, risk factors, prediction, and prevention. Journal of Personality Disorders 18, 226–239.Google Scholar
Borges, G, Angst, J, Nock, MK, Ruscio, AM, Kessler, RC (2008). Risk factors for the incidence and persistence of suicide-related outcomes: a 10-year follow-up study using the National Comorbidity Surveys. Journal of Affective Disorders 105, 25–33.CrossRefGoogle ScholarPubMed
Borges, G, Nock, MK, Haro Abad, JM, Hwang, I, Sampson, NA, Alonso, J, Andrade, LH, Angermeyer, MC, Beautrais, A, Bromet, E, Bruffaerts, R, de Girolamo, G, Florescu, S, Gureje, O, Hu, C, Karam, EG, Kovess-Masfety, V, Lee, S, Levinson, D, Medina-Mora, ME, Ormel, J, Posada-Villa, J, Sagar, R, Tomov, T, Uda, H, Williams, DR, Kessler, RC (2010). Twelve-month prevalence of and risk factors for suicide attempts in the World Health Organization World Mental Health Surveys. Journal of Clinical Psychiatry 71, 1617–1628.CrossRefGoogle ScholarPubMed
Brent, DA, Mann, JJ (2005). Family genetic studies, suicide, and suicidal behavior. American Journal of Medical Genetics. Part C 133C, 13–24.Google Scholar
Brent, DA, Melhem, N (2008). Familial transmission of suicidal behavior. Psychiatric Clinics of North America 31, 157–177.Google Scholar
Brodsky, BS, Groves, SA, Oquendo, MA, Mann, JJ, Stanley, B (2006). Interpersonal precipitants and suicide attempts in borderline personality disorder. Suicide and Life-Threatening Behavior 36, 313–322.Google Scholar
Brodsky, BS, Malone, KM, Ellis, SP, Dulit, RA, Mann, JJ (1997). Characteristics of borderline personality disorder associated with suicidal behavior. American Journal of Psychiatry 154, 1715–1719.CrossRefGoogle ScholarPubMed
Chesin, MS, Jeglic, EL, Stanley, B (2010). Pathways to high-lethality suicide attempts in individuals with borderline personality disorder. Archives of Suicide Research 14, 342–362.CrossRefGoogle ScholarPubMed
Costa, PT, McCrae, RR (1992). NEO PI-R: Professional Manual (Revised NEO Personality Inventory (NEO PI-R) and NEO Five-Factor Inventory (NEO-FFI). Psychological Assessment Resources, Inc.: Odessa, FL.Google Scholar
Fyer, MR, Frances, AJ, Sullivan, T, Hurt, SW, Clarkin, J (1988). Suicide attempts in patients with borderline personality disorder. American Journal of Psychiatry 145, 737–739.Google Scholar
Gunderson, JG (2001). Borderline Personality Disorder: A Clinical Guide. American Psychiatric Publishing: Washington, DC.Google Scholar
Hollingshead, AB (1957). Two factor index of social position (unpublished document). New Haven, CT.Google Scholar
Hor, K, Taylor, M (2010). Suicide and schizophrenia: a systematic review of rates and risk factors. Journal of Psychopharmacology 24, 81–90.CrossRefGoogle ScholarPubMed
Hörz, S, Zanarini, MC, Frankenburg, FR, Reich, DB, Fitzmaurice, G (2010). Ten-year use of mental health services by patients with borderline personality disorder and with other axis II disorders. Psychiatric Services 61, 612–616.CrossRefGoogle ScholarPubMed
Kraft, TL, Jobes, DA, Lineberry, TW, Conrad, A, Kung, S (2010). Brief report: why suicide? Perceptions of suicidal inpatients and reflections of clinical researchers. Archives of Suicide Research 14, 375–382.CrossRefGoogle ScholarPubMed
Lipschitz, DS, Kaplan, ML, Sorkenn, J, Chorney, P, Asnis, GM (1996). Childhood abuse, adult assault, and dissociation. Comprehensive Psychiatry 37, 261–266.Google Scholar
McGirr, A, Paris, J, Lesage, A, Renaud, J, Turecki, G (2007). Risk factors for suicide completion in borderline personality disorder: a case-control study of cluster B comorbidity and impulsive aggression. Journal of Clinical Psychiatry 68, 721–729.CrossRefGoogle ScholarPubMed
Nock, MK, Borges, G, Bromet, EJ, Alonso, J, Angermeyer, M, Beautrais, A, Bruffaerts, R, Chiu, WT, de Girolamo, G, Gluzman, S, de Graaf, R, Gureje, O, Haro, JM, Huang, Y, Karam, E, Kessler, RC, Lepine, JP, Levinson, D, Medina-Mora, ME, Ono, Y, Posada-Villa, J, Williams, D (2008). Cross-national prevalence and risk factors for suicidal ideation, plans and attempts. British Journal of Psychiatry 192, 98–105.CrossRefGoogle ScholarPubMed
Nock, MK, Favazza, AR (2009). Nonsuicidal self-injury: definition and classification. In Understanding Nonsuicidal Self-Injury (ed. Nock, M. K.), pp. 9–18. American Psychological Association: Washington, DC.Google Scholar
Nock, MK, Joiner, Jr. TE, Gordon, KH, Lloyd-Richardson, E, Prinstein, MJ (2006). Non-suicidal self-injury among adolescents: diagnostic correlates and relation to suicide attempts. Psychiatry Research 144, 65–72.CrossRefGoogle ScholarPubMed
Nojomi, M, Malakouti, SK, Bolhari, J, Poshtmashhadi, M (2007). A predictor model for suicide attempt: evidence from a population-based study. Archives of Iranian Medicine 10, 452–458.Google Scholar
Oquendo, MA, Currier, D, Mann, JJ (2006). Prospective studies of suicidal behavior in major depressive and bipolar disorders: what is the evidence for predictive risk factors? Acta Psychiatrica Scandinavica 114, 151–158.CrossRefGoogle ScholarPubMed
Pagura, J, Stein, MB, Bolton, JM, Cox, BJ, Grant, B, Sareen, J (2010). Comorbidity of borderline personality disorder and posttraumatic stress disorder in the U.S. population. Journal Psychiatric Research 44, 1190–1198.Google Scholar
Paris, J (2006). Predicting and preventing suicide: do we know enough to do either? Harvard Review of Psychiatry 14, 233–240.CrossRefGoogle Scholar
Perroud, N, Baud, P, Mouthon, D, Courtet, P, Malafosse, A (2011). Impulsivity, aggression and suicidal behavior in unipolar and bipolar disorders. Journal of Affective Disorders 134, 112–118.Google Scholar
Skodol, AE, Bender, DS, Pagano, ME, Shea, MT, Yen, S, Sanislow, CA, Grilo, CM, Daversa, MT, Stout, RL, Zanarini, MC, McGlashan, TH, Gunderson, JG (2007). Positive childhood experiences: resilience and recovery from personality disorder in early adulthood. Journal of Clinical Psychiatry 68, 1102–1108.Google Scholar
Soloff, PH, Fabio, A (2008). Prospective predictors of suicide attempts in borderline personality disorder at one, two, and two-to-five year follow-up. Journal of Personality Disorders 22, 123–134.Google Scholar
Soloff, PH, Lynch, KG, Kelly, TM, Malone, KM, Mann, JJ (2000). Characteristics of suicide attempts of patients with major depressive episode and borderline personality disorder: a comparative study. American Journal of Psychiatry 157, 601–608.CrossRefGoogle ScholarPubMed
Spitzer, RL, Williams, JB, Gibbon, M, First, MB (1992). The Structured Clinical Interview for DSM-III-R (SCID). I: History, rationale, and description. Archives of General Psychiatry 49, 624–629.CrossRefGoogle ScholarPubMed
StataCorp (2005). Stata Statistical Software: Release 9.2. StataCorp LP: College Station, TX.Google Scholar
StataCorp (2009). Stata Statistical Software: Release 11.2. StataCorp LP: College Station, TX.Google Scholar
Stepp, SD, Pilkonis, PA (2008). Age-related differences in individual DSM criteria for borderline personality disorder. Journal of Personality Disorders 22, 427–432.Google Scholar
Stiglmayr, CE, Ebner-Priemer, UW, Bretz, J, Behm, R, Mohse, M, Lammers, CH, Anghelescu, IG, Schmahl, C, Schlotz, W, Kleindienst, N, Bohus, M (2008). Dissociative symptoms are positively related to stress in borderline personality disorder. Acta Psychiatrica Scandinavica 117, 139–147.Google Scholar
van den Bosch, LM, Verheul, R, van den Brink, W (2001). Substance abuse in borderline personality disorder: clinical and etiological correlates. Journal of Personality Disorders 15, 416–424.Google Scholar
van Dijke, A, van der Hart, O, Ford, JD, van Son, M, van der Heijden, P, Bühring, M (2010). Affect dysregulation and dissociation in borderline personality disorder and somatoform disorder: differentiating inhibitory and excitatory experiencing states. Journal of Trauma and Dissociation 11, 424–443.Google Scholar
Weissman, MM, Bland, RC, Canino, GJ, Greenwald, S, Hwu, HG, Joyce, PR, Karam, EG, Lee, CK, Lellouch, J, Lepine, JP, Newman, SC, Rubio-Stipec, M, Wells, JE, Wickramaratne, PJ, Wittchen, HU, Yeh, EK (1999). Prevalence of suicide ideation and suicide attempts in nine countries. Psychological Medicine 29, 9–17.Google Scholar
Wilcox, HC, Arria, AM, Caldeira, KM, Vincent, KB, Pinchevsky, GM, O'Grady, KE (2010). Prevalence and predictors of persistent suicide ideation, plans, and attempts during college. Journal of Affective Disorders 127, 287–294.CrossRefGoogle ScholarPubMed
Wilson, ST, Fertuck, EA, Kwitel, A, Stanley, MC, Stanley, B (2006). Impulsivity, suicidality and alcohol use disorders in adolescents and young adults with borderline personality disorder. International Journal of Adolescent Medicine and Health 18, 189–196.Google Scholar
Yen, S, Shea, MT, Sanislow, CA, Grilo, CM, Skodol, AE, Gunderson, JG, McGlashan, TH, Zanarini, MC, Morey, LC (2004). Borderline personality disorder criteria associated with prospectively observed suicidal behavior. American Journal of Psychiatry 161, 1296–1298.Google Scholar
Yen, S, Shea, MT, Sanislow, CA, Skodol, AE, Grilo, CM, Edelen, MO, Stout, RL, Morey, LC, Zanarini, MC, Markowitz, JC, McGlashan, TH, Daversa, MT, Gunderson, JG (2009). Personality traits as prospective predictors of suicide attempts. Acta Psychiatrica Scandinavica 120, 222–229.Google Scholar
Yen, S, Shea, MT, Walsh, Z, Edelen, MO, Hopwood, CJ, Markowitz, JC, Ansell, EB, Morey, LC, Grilo, CM, Sanislow, CA, Skodol, AE, Gunderson, JG, Zanarini, MC, McGlashan, TH (2011). Self-harm subscale of the Schedule for Nonadaptive and Adaptive Personality (SNAP): predicting suicide attempts over 8 years of follow-up. Journal of Clinical Psychiatry 72, 1522–1528.Google Scholar
Zanarini, MC, Frankenburg, FR (2001). Attainment and maintenance of reliability of axis I and II disorders over the course of a longitudinal study. Comprehensive Psychiatry 42, 369–374.CrossRefGoogle ScholarPubMed
Zanarini, MC, Frankenburg, FR, Chauncey, DL, Gundersun, JG (1987). The diagnostic interview for personality disorders: inter-rater and test-retest reliability. Comprehensive Psychiatry 28, 467–480.Google Scholar
Zanarini, MC, Frankenburg, FR, DeLuca, CJ, Hennen, J, Khera, GS, Gunderson, JG (1998). The pain of being borderline: dysphoric states specific to borderline personality disorder. Harvard Review of Psychiatry 6, 201–207.Google Scholar
Zanarini, MC, Frankenburg, FR, Hennen, J, Reich, DB, Silk, KR (2005 a). The McLean Study of Adult Development (MSAD): overview and implications of the first six years of prospective follow-up. Journal of Personality Disorders 19, 505–523.Google Scholar
Zanarini, MC, Frankenburg, FR, Hennen, J, Silk, KR (2003). The longitudinal course of borderline psychopathology: 6-year prospective follow-up of the phenomenology of borderline personality disorder. American Journal of Psychiatry 160, 274–283.CrossRefGoogle ScholarPubMed
Zanarini, MC, Frankenburg, FR, Jager-Hyman, S, Reich, DB, Fitzmaurice, G (2008 a). The course of dissociation for patients with borderline personality disorder and axis II comparison subjects: a 10-year follow-up study. Acta Psychiatrica Scandinavica 118, 291–296.Google Scholar
Zanarini, MC, Frankenburg, FR, Reich, DB, Fitzmaurice, G, Weinberg, I, Gunderson, JG (2008 b). The 10-year course of physically self-destructive acts reported by borderline patients and axis II comparison subjects. Acta Psychiatrica Scandinavica 117, 177–184.Google Scholar
Zanarini, MC, Frankenburg, FR, Reich, DB, Hennen, J, Silk, KR (2005 b). Adult experiences of abuse reported by borderline patients and Axis II comparison subjects over six years of prospective follow-up. Journal of Nervous and Mental Disease 193, 412–416.Google Scholar
Zanarini, MC, Frankenburg, FR, Ridolfi, ME, Jager-Hyman, S, Hennen, J, Gunderson, JG (2006). Reported childhood onset of self-mutilation among borderline patients. Journal of Personality Disorders 20, 9–15.Google Scholar
Zanarini, MC, Frankenburg, FR, Vujanovic, AA (2002). Inter-rater and test-retest reliability of the Revised Diagnostic Interview for Borderlines. Journal of Personality Disorders 16, 270–276.Google Scholar
Zanarini, MC, Gunderson, JG, Frankenburg, FR, Chauncey, DL (1989). The revised diagnostic interview for borderlines: discriminating BPD from other axis II disorders. Journal of Personality Disorders 3, 10–18.CrossRefGoogle Scholar
Zanarini, MC, Williams, AA, Lewis, RE, Reich, RB, Vera, SC, Marino, MF, Levin, A, Yong, L, Frankenburg, FR (1997). Reported pathological childhood experiences associated with the development of borderline personality disorder. American Journal of Psychiatry 154, 1101–1106.Google ScholarPubMed