Journal of Personality Disorders, 26(6), 927-938, 2012
© 2012 The Guilford Press
This article was accepted under the editorship of Paul S. Links.
From University of Houston (C. S., K. L.G., I. Y., A. V.); Harvard Medical School
(M. C. Z.); and Florida International University (J. P.)
Address correspondence to Carla Sharp, Department of Psychology, University of Houston, 126 Heyne
Building, Houston, TX 77024; E-mail: email@example.com
incremental validity of BPD
Sharp et al.
THE INCREMENTAL VALIDITY OF BORDERLINE
PERSONALITY DISORDER RELATIVE TO
MAjOR DEPRESSIVE DISORDER FOR
SUICIDAL IDEATION AND DELIBERATE
SELF-HARM IN ADOLESCENTS
Carla Sharp, PhD, Kelly L. Green, PhD, Ilya Yaroslavsky, PhD,
Amanda Venta, MA, Mary C. Zanarini, EdD, and Jeremy Pettit, PhD
Few studies have examined the relation between suicide-related behaviors
and Borderline Personality Disorder (BPD) in adolescent samples. The cur-
rent study investigated the incremental validity of BPD relative to Major
Depressive Disorder (MDD) for suicide-related behaviors in a psychiatric
sample of adolescents at the cross-sectional level of analysis. The sample
included N = 156 consecutive admissions (55.1% female; M age = 15.47;
SD = 1.41), to the adolescent treatment program of an inpatient treatment
facility. Of the sample 19.2% (n = 30) met criteria for BPD on the Child
Interview for DSM-IV Borderline Personality Disorder and 39.1% (n = 61)
met criteria for MDD on the Computerized Diagnostic Interview Schedule
for Children–IV. Results showed that BPD conferred additional risk for
suicidal ideation and deliberate self-harm. Our findings support the clinical
impression that BPD should be evaluated in inpatient samples of adoles-
cents either through intake interviews or more structured assessments.
Suicide and related behaviors are an important public health concern, partic-
ularly in the adolescent population, where these behaviors are highly preva-
lent. Most recent data indicate that suicide is the fifth leading cause of death
among individuals ages 5 to 14 and the third leading cause of death among
individuals ages 15 to 24 in the United States (Xu, Kochanek, Murphy, &
Tejada-Vera, 2010). Given the costs both in terms of lost productivity (Cor-
so, Mercy, Simon, Finkelstein, & Miller, 2007) and the emotional trauma
suffered by surviving family, friends, and communities (Crosby & Sacks,
2002), the identification of early markers of suicide-related behaviors to aid
in prevention and intervention efforts is important.
Psychiatric diagnostic status is one method of identifying adolescents
who may be at risk for suicide-related behaviors, considering that studies
928 INCREMENTAL VALIDITY OF BPD
have demonstrated that at least 90% of adolescents who die by suicide have
a preexisting psychiatric disorder (Brent, Baugher, Bridge, Chen, & Chiap-
petta, 1999; Shaffer, Gould, Fisher, & Trautman, 1996). Some have argued
for Major Depressive Disorder (MDD) as the most robust predictor (Chio-
queta & Stiles, 2003) and empirical studies have supported this link in adults
(Oquendo, Currier, & Mann, 2006; Mann et al., 2005). MDD in pre-adoles-
cent and adolescent youth has also been found to be associated with the risk
for later suicide in adulthood (Weissman et al., 1999).
Others have demonstrated predictive validity with Borderline Personal-
ity Disorder (BPD) for both suicidal behaviors and suicide attempts (Brod-
sky, Malone, Ellis, Dulit, & Mann, 1997; Yen et al., 2003). In the Collabora-
tive Longitudinal Personality Disorders Study, Yen et al. (2003) showed that
BPD washed out the effects of MDD for both suicidal behavior and suicide
attempts over a two-year follow-up period. Despite such promising find-
ings, few studies of suicide-related behaviors in adolescents have explicitly
examined or controlled for BPD (McGirr et al., 2008). This is curious since
BPD appears to be at least as lethal as many of the other major mental dis-
orders, with a suicide rate around 8–10% (e.g., Pompili, Girardi, Ruberto,
& Tatarelli, 2005).
The lack of studies on BPD in adolescence is partly due to the fact that
the diagnosis of personality disorders in adolescents has been associated with
controversy until quite recently (Paris, 2003; Sharp & Bleiberg, 2007; Vito,
Ladame, & Orlandini, 1999). However, a substantial body of evidence now
indicates that BPD diagnostic criteria are no less reliable, valid or stable
prior to age 18 than they are in adulthood (Chanen, Jovev, & Jackson, 2007;
Cicchetti & Crick, 2009; Lenzenweger & Cicchetti, 2005; Westen, Shedler,
Durrett, Glass, & Martens, 2003). We now know that BPD affects up to
3% (Bernstein, Cohen, Velez, & Schwab-Stone, 1993) of community-dwell-
ing teens, with the cumulative prevalence for BPD at age 14 and age 16 re-
ported at 0.9% and 1.4%, respectively (Johnson, Cohen, Kasen, Skodol, &
Oldham, 2008). In clinical samples, the numbers are even higher with 11%
(Chanen et al., 2004) and 28.1% rates reported for adolescent outpatients
(Chanen et al., 2008), and up to 49% reported for adolescent inpatients
(Grilo et al., 1996).
The aim of the current study was to investigate the incremental validity
of BPD relative to MDD in predicting suicide-related behaviors in adoles-
cents. We use Silverman et al.’s (2007 a, b) nomenclature for the study of
suicidality, and therefore ascribe to their essential components of suicidal
behaviors: suicide-related ideations, suicidal plans, suicidal attempts, and
self-harm. Given the dearth of studies in adolescence, and to maximize the
incidence of suicide attempts in our sample, the current study focused on in-
patient adolescents. To avoid a potential confound between the independent
(BPD) and dependent variables (suicide-related behaviors), we excluded the
self-harm/suicide criterion of BPD in our analyses. Age was included as a co-
variate in all analyses as the incidence of suicide-related behaviors has been
shown to increase with age, with suicide attempt rates peaking at around ages
16 to 18, before declining gradually (Gould, Shaffer, & Greenberg, 2003).
Another covariate was sex, as studies in adolescence have demonstrated that
SHARP ET AL. 929
adolescent males die by suicide at a rate of roughly four to one relative to
females, while suicidal ideation and nonfatal attempts are more prevalent in
adolescent females relative to males (Gould et al., 1998; Gould et al., 2003;
Grunbaum et al., 2002; Heron, 2010; Lewinsohn, Rohde, & Seeley, 1996).
While it was not the aim of the current study to dispute the established
link between MDD and suicide-related behaviors, we wished to introduce
the possibility that BPD, which shows between 70.9% McGlashan et al.
(2000) to 90% (Zanarini et al., 1998) comorbidity with depression in adults,
is an important independent predictor of multiple forms of suicide-related
behaviors (ideation, attempts and self-harm). In fact, BPD diagnostic cri-
teria encompass many of the early markers of suicide attempts, and death
by suicide (e.g., impulsivity, affect dysregulation, relationship problems). It
is therefore reasonable to expect a main effect in the prediction of suicidal
behaviors independent of MDD, as has been demonstrated for other out-
come variables—see for instance Chanen et al. (2007) who demonstrated
the incremental validity of BPD over and above other Axis I disorders in
adolescent inpatients for outcomes of psychopathology, general functioning,
peer relationships, self-care, and family and relationship functioning. Evi-
dence in support of BPD’s predictive power at the cross-sectional level would
justify the assessment of BPD in service-use settings, especially following the
emergence of new assessment tools for borderline features in adolescents
and even children (Crick, Murray-Close, & Woods, 2005; Zanarini, 2003;
Sharp, Mosko, Chang, & Ha, 2011; Chang, Sharp, & Ha, 2011).
The sample included 156 consecutive admissions (55.1% female) to the Ad-
olescent Treatment Program of a private tertiary care inpatient treatment
facility specializing in the evaluation and stabilization of adolescents who
failed to respond to previous interventions. Adolescents were between the
ages of 12 and 17 (M age = 15.47; SD = 1.41), and were predominantly
Caucasian (92%). All patients received a comprehensive psychiatric evalu-
ation at intake. Seventy point three percent of the sample was diagnosed
with a mood disorder (Dysthymia, MDD, Bipolar Disorder), 52.4% received
an anxiety disorder diagnosis (Post Traumatic Stress Disorder, Generalized
Anxiety Disorder, Social Phobia, other phobias, Obsessive Compulsive Dis-
order) and 20.5% were diagnosed with an externalizing disorder (Attention
Deficit Hyperactivity Disorder, conduct disorder, oppositional defiant disor-
der). The modal number of diagnoses was two and the average number of
diagnoses was between two and three.
Of the sample 19.2% (n = 30) met criteria for BPD on the Child Inter-
view for DSM-IV Borderline Personality Disorder (CI-BPD; Zanarini, 2003)
compared with 19.6% using clinician diagnosis (Kappa = .35; p < .001). In
contrast, 39.1% (n = 61) met criteria for MDD on the Computerized Diag-
nostic Interview Schedule for Children–IV (CDISC; Shaffer, Fisher Lucas,
930 INCREMENTAL VALIDITY OF BPD
Dulcan, & Schwab-Stone, 2000). While the unit was in principle open to
all mental disorders, the study adopted the following exclusion criteria: (a)
diagnosis of schizophrenia or any psychotic disorder, and/or (b) an IQ < 70.
Inclusion criteria were: (a) age between 12 and 17, and (b) sufficient fluency
in English to complete all assessments.
Borderline Personality Disorder. To determine a diagnosis of BPD in adoles-
cents, the CI-BPD (Zanarini, 2003) was used. The CI-BPD is a semi-struc-
tured interview that assesses DSM-IV BPD in children age six and older, as
well as adolescents. It was adapted for use in children and adolescents from
the Diagnostic Interview for DSM-IV Personality Disorders. After asking
a series of corresponding questions, the interviewer rates each DSM-based
criterion with a score of 0 (absent), 1 (probably present), or 2 (definitely
present). The patient meets criteria for BPD if five or more criteria are met
at the 2-level. The CI-BPD demonstrated adequate interrater reliability in
the original validation study (Zanarini, 2003). In the current sample, inter-
rater reliability was performed on 15% of the sample, with two independent
raters trained by the principal investigator of the study. The results of the
interrater analyses and the original diagnosis varied from Kappa = .78 (p
< .001) to Kappa = 1.00 (p < .001), with the average Kappa = .89. Internal
consistency was good with a Cronbach’s alpha of .83. To avoid a potential
confound between the independent (BPD) and dependent variables (suicide-
related behaviors), we excluded the self-harm/suicide item/criterion of the
CI-BPD in our analyses.
To assess borderline symptoms dimensionally, the Borderline Features
of the Personality Assessment Inventory for Adolescents (PAI; Morey, 2007)
was used. The PAI is a self-report measure of personality traits for use with
adolescents ages 12 to 18. It contains 264 items rated on a four-point scale
ranging from false to very true. The Borderline Features subscale produces
a standardized continuous measure of personality traits typically character-
izing BPD. Of importance to the current study is the fact that the subscale
does not contain any suicide-related items, thereby avoiding confounding the
independent (BPD) and dependent (suicide-related) variables in the current
Major Depressive Disorder. For a categorical diagnosis of MDD, the clini-
cian-administered computerized NIMH-Diagnostic Interview Schedule for
Children-IV (CDISC; Shaffer et al., 2000) was used. The CDISC is one of the
most widely used diagnostic instruments for children and adolescents. It cov-
ers DSM-IV, DSMIII-R, and lCD-10, for over 30 diagnoses. The interview
is organized into six diagnostic sections: anxiety disorders, mood disorders,
disruptive disorders, substance-use disorders, schizophrenia, and miscella-
neous disorders (eating, elimination, and so on). Within each section, each
disorder is assessed for presence within the past year and currently (last four
weeks). For the purposes of the current study, we used the current definition
SHARP ET AL. 931
Depressive symptoms were assessed continuously using the Youth Self
Report (Achenbach & Rescorla, 2001). The YSR is a self-report question-
naire for use with adolescents between the ages of 12 and 18. The mea-
sure contains 112 problem items, each scored on a three-point scale (0 =
not true, 1 = somewhat or sometimes true, or 2 = very or often true). The
measure yields a number of scales, some empirically derived (the Syndrome
Scales) and some theoretically based (the DSM-Oriented Scales). The DSM-
Oriented Affective Problems scale was used in this study as a continuous
measure of self-reported depressive symptoms. Van Lang, Ferdinand, Old-
ehinkel, Ormel, and Verhulst (2005) demonstrated a strong correlation with
the YSR Affective Problems scale and the MDD scale of the Revised Child
Anxiety and Depression Scale (Chorpita, Yim, Moffitt, Umemoto, & Fran-
cis, 2000). Similarly, Nakamura, Ebesutani, Bernstein, and Chorpita (2009)
found support for convergent validity with positive, significant correlations
of the Affective Problems subscale with several well-established dimensional
measures of youth depression.
Suicide Ideation, Plans, and Attempts. The CDISC includes an assessment of
suicidal behaviors, used to form the following binary variables: (a) thoughts
of death or dying (without specific thoughts of suicide) during the past year,
(b) suicidal ideation during the past year, (c) suicidal ideation and a plan
(e.g., method, place, time) to commit suicide during the past year, (d) recent
suicide ideation in the past four weeks, (e) suicide attempt in the past year,
and (f) lifetime suicide attempt. Trained masters-level students administered
the CDISC to adolescents, since research has demonstrated stronger valid-
ity for adolescent report of suicidal behaviors compared with parent-report
(Prinstein, Nock, Spirito, & Grapentine, 2001).
Self-Harm Behavior. The Deliberate Self-harm Inventory (DSHI; Gratz,
2001) is a 17-item self-report measure that assesses the frequency, severity,
duration, and type of self-harm behavior. The DSHI has high internal con-
sistency (α = .82); adequate construct, convergent, and discriminate validity;
and adequate test-retest reliability over a 2–4 week period (Gratz, 2001).
Internal consistency in this sample was good with a Cronbach’s alpha of .76.
DATA ANALYTIC STRATEGY
Descriptive statistics and bivariate analyses were conducted to determine the
bivariate relations between independent (BPD and MDD) and dependent
(suicidal ideation, plans, and attempts, and self-harm behavior), and wheth-
er any covariates (sex and age) had to be added to multivariate analyses. To
examine the relationship between a diagnosis of BPD and suicidal behaviors
controlling for a diagnosis of MDD and covariates, a series of hierarchical
logistic regressions with covariates entered at Step 1, a diagnosis of MDD en-
tered at Step 2, and a diagnosis of BPD (without the self-harm item) entered
at Step 3 were carried out for the suicidal behavior outcome variables that
showed promise in the bivariate analyses. To examine the relationship be-
tween borderline symptoms and suicidal behaviors controlling for symptoms
932 INCREMENTAL VALIDITY OF BPD
of depression we used hierarchical linear regression with covariates entered
at Step 1, depressive symptoms at Step 2, and borderline symptoms at Step 3.
DESCRIPTIVE STATISTICS AND BIVARIATE ANALYSES
The only missing data in the dataset relate to the PAI Borderline Features
scale and the YSR Affective Problems scale. Missing data were excluded list-
wise from the correlational analyses (i.e., the only analyses that used these
variables) as the entire scales for these measures were missing, precluding the
use of data imputation methods.
Frequency analyses showed that 38% of the total sample reported
thoughts of dying, 41% reported suicidal ideation during the past year, 26%
reported having a suicide plan in place, 30% reported suicide ideation in the
last four weeks, 31% reported a lifetime suicide attempt, and 24% reported
a suicide attempt in the last year (see Table 1).
Before carrying out bivariate analyses, we removed item 7 from the CI-
BPD which relates to the DSM-IV criterion of suicidal behaviors as part of
the BPD diagnosis. This was done so as not to confound our independent
and dependent variables. Chi-square analyses to explore the bivariate rela-
tions between BPD and the six suicidal behaviors measured by the CDISC
showed adolescents with a diagnosis of BPD were significantly more likely
to report thoughts of death or dying during the past year, χ² (1, N = 156) =
3.80, p = .05, and suicidal ideation during the past year, χ² (1, N = 156) =
5.53, p = .02, than psychiatric controls without a diagnosis of BPD. Group
differences were not observed for presence of suicidal ideation during the
TABLE 1. Descriptive Statistics for subjects with BPD, subjects without BPD, and Total Sample
BPD Non-BPDTotal Sample
(n = 30)(n = 126)(n = 156)
Age 15.54 (1.56)15.42 (1.41)15.47 (1.41)
Sex73% female51% female55% female
(n = 22)(n = 64)(n = 86)
% MDD53 (n = 16)36 (n = 45)39 (n = 61)
% thoughts of death/dying53 (n = 16) 34 (n = 43)38 (n = 59)
% suicidal ideation, past year60 (n = 18)37 (n = 46)41 (n = 64)
% suicidal ideation, past 4 weeks40 (n = 12)28 (n = 35)30 (n = 47)
% suicide plan 30 (n = 9)25 (n = 31)26 (n = 40)
% lifetime suicide attempt 37 (n = 11)30 (n = 38)31 (n = 49)
% suicide attempt, past year27 (n = 8)23 (n = 29)24 (n = 37)
DSHI5.97 (3.22)2.82 (3.37)3.42 (3.56)
YSR Affective Problemsa
74.80 (10.19) 66.30 (12.44)67.95 (12.47)
PAI Borderline Featuresb
73.92 (12.06)57.69 (11.42) 60.65 (13.10)
Note. % MDD = percent meeting criteria for MDD; DSHI = Deliberate Self-Harm Inventory; YSR = Youth Self-Re-
port; PAI = Personality Assessment Inventory for Adolescents a 7 subjects in the total sample, 2 subjects in the Non-
BPD, and 5 subjects in the BPD groups missing data on YSR Affective Problems; b19 subjects in the total sample, 14
subjects in the Non-BPD, and 5 subjects in the BPD groups missing data on PAI-A.
SHARP ET AL. 933
prior four weeks, χ² (1, N = 156) = 1.72, p = .19, past year suicidal plans, χ²
(1, N = 156) = .37, p = .54, past year suicide attempts, χ² (1, N = 156) = .18,
p = .67, or lifetime suicide attempts, χ²1, N = 156) = .48, p = .49.
Chi-square analyses to explore the bivariate relations between MDD
and suicidal behaviors showed significance for all suicidal outcomes. Ado-
lescents with a diagnosis of MDD were significantly more likely to report
thoughts of death or dying during the past year, χ² (1, N = 156) = 7.20, p <
.01, suicidal ideation during the past year, χ² (1, N = 156) = 15.95, p < .001,
and in the past four weeks, χ² (1, N = 156) = 17.27, p < .001, suicidal plans
during the past year, χ² (1) = 12.37, p < .001, as well as past year suicide
attempts, χ² (1, N = 156)= 8.44, p < .01, and lifetime suicidal attempts, χ²
(1, N = 156) = 4.26, p = .04, compared with psychiatric controls without a
diagnosis of MDD.
Pearson correlations to explore the bivariate relations between the con-
tinuous variables of borderline symptoms, depressive symptoms, self-harm
and demographic variables, demonstrated significant correlations for self-
harm and borderline symptoms (r = .53; p < .001) and depressive symptoms
(r = .53; p < .001), but no relation with age (r = -.03; p = .75; see Table 2).
Borderline and depressive symptoms were highly correlated (r = .65; p <
.001). An independent sample t-test to examine the bivariate relation be-
tween self-harm and sex (a potential confound in the relation between BPD
and self-harm behavior) demonstrated a trend for females (M = 3.90; SD =
3.54) to engage in more frequent self-harm behavior than males (M = 2.84;
SD = 3.52; t = 1.85; df = 125; p = .07).
THE RELATIONSHIP BETWEEN A DIAGNOSIS OF BPD AND SUICIDAL
BEHAVIORS CONTROLLING FOR A DIAGNOSIS OF MDD AND SEX
To test for unique relations between BPD and suicidal behaviors, a series of
hierarchical logistic regressions with age and sex entered at Step 1, a diag-
nosis of MDD entered at Step 2, and a diagnosis of BPD (without the self-
harm item) entered at Step 3 were carried out for the two suicidal behavior
outcome variables that showed promise in the bivariate analyses (past year
thoughts of death and past year suicidal ideation; see Table 3 for odds ra-
tios and confidence intervals obtained from Step 3 in the regression). For
thoughts of death, each diagnostic variable incrementally improved model
fit through likelihood ratio tests, Δ-2LL (1) = 15.96, p < .001; Δ-2LL (1) =
8.12, p < .01, and demonstrated good classification of those thinking and
TABLE 2. Summary of Intercorrelations for Age, DSHI, PAI Borderline Features, and YSR Affective Problems
2. DSHI -.03—
3. PAI Borderline Features .00.53*—
4. YSR Affective Problems .11.53*.65*—
Note. N = 136–156. DSHI = Deliberate Self-Harm Inventory; PAI = Personality Assessment Inventory for Adolescents;
YSR = Youth Self-Report * p < .01
934 INCREMENTAL VALIDITY OF BPD
not thinking about death (68%, Nagelkerke R2 = .13). A diagnosis of MDD
or BPD independently increased the odds for thinking about death by nearly
2.5 times, MDD, B = -.91; SE = .36; Wald statistic (1) = 6.56; p = .01, OR
=2.48; BPD, B = -.88; SE = .44; Wald statistic (1) = 4.02; df = 1, p < .05, OR
=2.42, with addition of BPD to the model robustly improving correct clas-
sification of those wishing to die from 29% to 41%. Being female similarly
increased risk for thinking about death, B = -.86; SE = .36; Wald statistic (1)
= 5.64; df = 1, p = .02, OR = 2.36.
A similar pattern emerged for past year suicidal ideation. Adding MDD
and BPD to the model led to incremental improvements in fit, Δ-2LL (1) =
32.84, p < .001; Δ 2LL (1) = 7.9, p < .01, and to good classification of adoles-
cents with and without suicidal ideation (65%, Nagelkerke R2 = .17). Diag-
noses of MDD and BPD independently increased odds for experiencing sui-
cidal ideations by 3.79 and 2.42 times, respectively (MDD, B = -1.33; SE =
.36; Wald statistic (1) = 13.98; p < .001, OR =3.79; BPD, B = -.89; SE = .45;
Wald statistic (1) = 3.89; p = .05, OR = 2.42). Together, these findings sup-
port the independent role of BPD in morbid thinking and suicidal ideation.
Next, to determine the uniqueness of the relation between borderline
symptoms and self-harm behavior after controlling for depressive symptoms,
we carried out a hierarchical linear regression with sex and age entered at
Step 1, depressive symptoms at Step 2, and borderline symptoms at Step 3.
Results showed that both depressive symptoms (B = 1.91; SE = .54; β = .26;
t = 3.57, p < .001) and borderline symptoms (B = 2.72; SE = .67; β = .30; t =
4.05, p = .03) retained significance. When the borderline symptom variable
was added to the model R² increased from 11% to 20%.
In summary, the current study provides support for the notion that BPD
provides incremental validity relative to MDD for suicidal ideation and de-
liberate self-harm in adolescents at the cross-sectional level. These findings
are noteworthy, especially given the fact that the suicide-related item for
BPD diagnosis was removed prior to data analyses. Despite these positive
findings, the lack of support in the current study for the incremental valid-
TABLE 3. Odds Ratios and Confidence Intervals for Logistic Regressions of MDD and BPD Predicting Suicidal Ide-
ation, a Suicidal Plan, and Lifetime Suicidal Attempts
Odds Ratio95% Confidence Interval
Thoughts about Death
Sex 2.36 .35–1.87
Note. MDD = Major Depressive Disorder; BPD = Borderline Personality Disorder.
SHARP ET AL. 935
ity of BPD for suicide attempts stands in contrast to the adult literature that
demonstrate stronger predictive validity of BPD for suicide attempts. For in-
stance, Soloff, Liz, Kelly, and Cornelius (1994) reported that 55% of suicide
attempters have a diagnosis of BPD, with an average of three lifetime suicide
attempts. Links, Gould, and Ratnayake (2003) reported that patients with
BPD represent 9-33% of all suicides, while Bongar, Peterson, Golann, and
Hardiman (1990) showed that patients with chronic suicidal behaviors who
made four or more visits to a psychiatric emergency room per year often met
criteria for BPD. These patients accounted for 12% of all psychiatric emer-
gency room visits. In adults, evidence suggests that BPD is an independent
predictor of suicidal behaviors when considering the effects of depression
(Brodsky et al., 1997). Moreover, in one of few prospective studies that in-
vestigated the predictive utility of a BPD diagnosis alongside a diagnosis of
MDD and Substance Use Disorder, it was found that BPD was predictive of
suicide attempts while MDD was not (Yen et al., 2003). BPD is not only as-
sociated with a higher frequency of suicide attempts, but the risk for suicide
is around 10%, which is comparable to other clinical groups such as Schizo-
phrenia and mood disorders (Paris, 2002).
The overwhelming evidence for the link between BPD and suicide at-
tempts (as well as completed suicide) discussed above, combined with the
lack of evidence for this link in our study, may point to a developmental
argument. In line with Joiner’s (2005) theory of suicidal behaviors, adoles-
cents with BPD may start off with suicidal ideation and self-harm (as demon-
strated in this study), which, in time, may build momentum to solidify into
a clearer pattern of suicide attempts. Only follow-up studies can speak to
this possibility. Indeed, Greenfield et al. (2008), in one of the few prospective
studies of BPD and suicidal behaviors in adolescents, showed persistent sui-
cidal behavior assessed six months after intake to an emergency department
was best predicted by sex, BPD, previous suicide attempts, and drug use. In
this study, depression did not predict future suicidal behaviors. In addition,
it may be that the effect of BPD is more apparent in its role as a comorbid
disorder, moderator or mediator, than as an independent predictor. For in-
stance, in a sample of inpatient adolescents with comorbid MDD and BPD,
it was found that comorbid BPD and Cluster B symptoms were better pre-
dictors of past suicide attempts than depressive symptoms (Corbitt, Malone,
Haas, & Mann, 1996).
Taken together, our study supports the notion that BPD should be evalu-
ated in inpatient samples of adolescents either through intake interviews or
more structured assessments. With shorter, questionnaire-based screens now
developed for use in adults and adolescents (Chang et al., 2011; Crick et al.,
2005; Sharp et al., 2011; Zanarini, 2003), the assessment of BPD is feasible
in clinical settings.
Strengths of the current study include its use of an interview specifically
designed for child and adolescent samples, in contrast to most other studies
which have relied completely on self-report, thereby possibly resulting in
problems of shared method variance. Additionally, the current study pro-
vides preliminary support for the role of BPD not only in inpatient pediatric
samples, as previous studies have demonstrated, but specifically with inpa-
936 INCREMENTAL VALIDITY OF BPD
tient samples of treatment-refractory adolescents. However, several limita-
tions of the current study should also be noted. Our study is limited by its
cross-sectional nature and retrospective reports of suicide-related behaviors
(past year and past four weeks). While we acknowledge this as a limitation
that can only be addressed by longitudinal designs, we also acknowledge
the fact that the DSM-IV diagnosis made on the basis of interview-based
assessments in the current study (BPD and MDD) were also based on retro-
spective reports of symptoms over the past four weeks or past year, as are all
diagnoses in psychiatry. Nevertheless, conclusions cannot be drawn about
the causal role of either BPD or MDD for suicide-related behavior based on
the data reported in the current study. The dichotomous measurement of
suicide-related behaviors in the CDISC is a further limitation, as we were un-
able to compare more specific groups of suicidal individuals (e.g., single ver-
sus multiple attempters). Additionally, the data were limited by not including
other predictors of suicide-related behaviors such as hopelessness.
Notwithstanding these limitations, further research in this area is war-
ranted because suicides by young people with BPD may pose particular risk
for survivors given that 44% of attempts were witnessed compared with
17% of suicide attempts by patients with other diagnoses (Runeson, Beskow,
& Waern, 1996). In particular, longitudinal follow-up work establishing the
predictive risk status of BPD should be conducted in both outpatient and
inpatient samples of adolescents.
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