Which BPD Criteria Are Associated With Suicidal Behavior?

Suicide risk is the most significant consideration in the treatment of psychiatric disorders. Suicidal behavior has significantly increased over the last decade, and preliminary studies suggest it has been increasing over this past year of pandemic. Many psychiatric illnesses are associated with an increased risk of suicide, however patients diagnosed with borderline personality disorder (BPD) frequently exhibit multiple attempts, and as many as 9-10% die by suicide.

Despite much research, therapists are still unable to accurately predict what clinical features may indicate a higher risk of self-injurious intent. Some previous studies have associated the extreme impulsivity and marked mood swings of BPD with self-destructive actions. However, these two features are shared with other psychiatric disorders and are not specific to BPD. Furthermore, impulsivity and affective instability are more prominent in younger BPD patients. Older adults with BPD more prominently reflect interpersonal and self-concept struggles.

A recent long-term study identifies criteria specific for BPD that are associated with suicidal activity. Unlike previous investigations that followed BPD patients no longer than two years, this research assessed patients over a period of ten years. Longer evaluation time may more accurately identify chronic determiners of harmful behavior more than the impulsive, acute manifestations of initial attempts in younger patients. In the first two years of the study, mood instability was the most significant risk factor, followed by impulsivity and identity disturbance. However, over ten years, the specific BPD criteria of identity disturbance, frantic efforts to avoid abandonment, and chronic feelings of emptiness were the most prominent independent features associated with self-destructive activity.

The study authors emphasize that risk factors of mood changes and impulsivity remain important considerations for clinicians assessing suicidal risk in BPD patients. These two features are more readily observable in patients. However, exploration of more subtle BPD features is also important for a full evaluation. Individuals who express identity, abandonment, and emptiness distress may also be at serious risk for self-destructive behavior.

Delineating specific symptoms associated with risk for self-harm may alert clinicians to increased urgency in treatment planning. Diagnostic evaluations must explore these internal and interpersonal attitudes more thoroughly. Adjustments in common therapeutic approaches, such as dialectical behavioral therapy, mentalization-based therapy, transference focused therapy, and others, may be indicated to focus more directly on areas in which identity disturbance, abandonment anxiety, and feelings of emptiness are expressed.

However, one must not conflate association with causation or prediction. The association of specific BPD characteristics with potential for self-harm are merely alerting, not predicting. Nevertheless, the more we understand what drives an individual with BPD to consider potentially fatal action, the more lives we can save. For most of these patients survival ultimately accompanies remission of the illness.

If you or someone you love is contemplating suicide, seek help immediately. For help 24/7 contact the National Suicide Prevention Lifeline, 1-800-273-TALK, or the Crisis Text Line by texting TALK to 741741. To find a therapist near you, see the Psychology Today Therapy Directory.