Borderline Personality Disorder,  Suicide,  Treatment

Managing Suicidality in Patients With Borderline Personality Disorder

In BPD, the most typical suicidal behavior is an overdose of pills, occurring in an interpersonal context. These overdoses usually carry a message—sometimes for a lover and sometimes for a therapist. Patients with BPD also tend to cut their wrists repetitively, and/or carry out other actions to hurt themselves.

Managing Suicidality in Patients With Borderline Personality Disorder

July 01, 2006

By Joel Paris, MD

Suicidality is a defining feature of borderline personality disorder (BPD). It is also the feature that creates the most anxiety among those who treat patients with this disorder. It is rare to find patients with BPD who have never shown any suicidal behavior. As described in criterion 5 in DSM-IV-TR,1 these patients are characterized by “recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.” Suicidal ideas and threats are ubiquitous, and most patients make multiple suicide attempts.2 Suicidality in patients with BPD is chronic and can continue for extended periods (months to years).3,4 This feature helps distinguish patients with BPD from those with classic mood disorders, who are suicidal only when acutely depressed. While BPD often begins with repetitive suicide attempts starting in adolescence and continuing into young adulthood, these behaviors tend to remit over time.5,6 Suicidal thoughts vary in intensity over time, waxing when life is stressful and waning when it is not.7

Suicidality in patients with BPD is associated with traits of affective instability. 8-10 Instead of continuous depression or mania, lasting for weeks to months, the rapid mood swings of BPD occur in response to life events.11 The unique quality of these symptoms is shown by the failure of mood in BPD to respond consistently to antidepressants.12-14 Suicidal actions are also associated with impulsive personality traits.3 Soloff and associates2 reported a mean of 3 lifetime attempts in patients with BPD, and the frequency of attempts was related to levels of impulsivity.2,15

Suicide completion in BPD

Long-term naturalistic follow-up studies, with one exception,16 have shown that about 10% of patients with BPD eventually commit suicide and that about 90% do not.17-20 Although 2 recent prospective studies report suicide rates closer to 4%,21,22 these results may be limited to cohorts that were consistently compliant with treatment.

One of the most interesting findings that has emerged from long-term follow-up research in BPD is the age at which suicide completions occur. Threats and attempts peak early in the course of BPD, when patients are in their 20s, yet completion occurs much later. Thus, patients with BPD do not usually kill themselves at the time when they most alarm therapists, but later in development, usually if they fail to recover. In one follow-up study,17 the mean age of patients who completed suicide was 30, while in another,19 it was 37 (SD, ± 10). Clinicians should also keep in mind that since completions are rare relative to attempts, it is almost impossible to predict suicide in individual cases.23,24

The meaning of suicidality in BPD

In BPD, the most typical suicidal behavior is an overdose of pills, occurring in an interpersonal context.25 These overdoses usually carry a message—sometimes for a lover and sometimes for a therapist. Patients with BPD also tend to cut their wrists repetitively, and/or carry out other actions to hurt themselves. 26 However, self-mutilation is not truly suicidal behavior. It typically consists of superficial cuts on the wrists and arms, and patients report that it functions to provide short-term regulation of intense dysphoric affects.9,27 Self-mutilation can come to resemble addictive behavior.

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One Comment

  • findingtori

    Now that I’ve accepted the diagnosis and I’m learning all about it, everything is adding up (even this simple fact). I wish I’d accepted it and gotten specific help earlier but I’m doing what I can for it now.

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