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Suicide in borderline personality disorder: A meta-analysis


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Suicide is the major cause of death among patients with borderline personality disorder; however, the literature on completed suicides in such disorder is inconclusive, as suicide rates vary greatly among cohorts of patients. We searched MedLine, Excerpta Medica and PsycLit from 1980 to 2005 to identify papers dealing with suicide in borderline personality disorder. We also searched the World Health Statistics Annual to ascertain the suicide rate in the age groups for specific years and country. We selected eight studies comprising 1179 patients with a diagnosis of borderline personality disorder. Of these patients, 94 committed suicide. Results obtained for each study were processed together to calculate the mean figure for each year of suicides for 100,000 individuals suffering from borderline personality disorder. Our meta-analysis shows that suicide among patients with borderline personality disorder is more frequent when compared with the general population. All study analyses reported that patients with borderline personality disorder committed suicide more often than their counterparts in the general population. Suicide seems more alarming in the first phases of follow-up than during chronic phases of illness.
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Suicide in borderline personality disorder:
A meta-analysis
Pompili M, Girardi P, Ruberto A, Tatarelli R. Suicide in borderline personality disorder: A
meta-analysis. Nord J Psychiatry 2005;59:319
/324. Oslo. ISSN 0803-9488.
Suicide is the major cause of death among patients with borderline personality disorder;
however, the literature on completed suicides in such disorder is inconclusive, as suicide rates
vary greatly among cohorts of patients. We searched MedLine, Excerpta Medica and PsycLit
from 1980 to 2005 to identify papers dealing with suicide in borderline personality disorder. We
also searched the World Health Statistics Annual to ascertain the suicide rate in the age groups
for specific years and country. We selected eight studies comprising 1179 patients with a
diagnosis of borderline personality disorder. Of these patients, 94 committed suicide. Results
obtained for each study were processed together to calculate the mean figure for each year of
suicides for 100,000 individuals suffering from borderline personality disorder. Our meta-
analysis shows that suicide among patients with borderline personality disorder is more frequent
when compared with the general population. All study analyses reported that patients with
borderline personality disorder committed suicide more often than their counterparts in the
general population. Suicide seems more alarming in the first phases of follow-up than during
chronic phases of illness.
Borderline, Meta-analysis, Suicide.
Maurizio Pompili, Department of Psychiatry, Sant’Andrea Hospital, Via di Grottarossa,
1035-1039, 00189 Roma, Italy, E-mail: or mpompili@mclean.; Accepted 25 May 2005.
he incidence of completed suicide in borderline
personality disorder (BPD) has been unknown
until recently. In two long-term follow-up studies of
borderline patients treated in residential settings,
McGlashan (1) and Stone et al. (2) found that 3%
and 9%, respectively, of borderline go on to complete
Patients with BPD represent 9
/33% of all suicides
(3, 4). Mehlum et al. (5) pointed out that a lack of
control of high intensity affects such as depression,
anxiety or anger may increase the tendency towards
suicidal behavior. Thus the notion of BPD as ‘‘the
suicidal personality disorder’’ may be justified. On the
other hand, the self-destructive tendency in subjects with
BPD may not primarily be due to the personality
disorder (PD) syndrome itself, but rather be caused by
some secondary or coexisting Axis I mental disorder,
such as a mood disorder, anxiety disorder or substance
abuse. Or it may be viewed as a result of a complex
interplay between state and trait dimension. Comorbid-
ity with major depression is highly prevalent in BPD (6);
however, the effect of this comorbidity on suicidal
behavior is unclear. Comorbidity with major depressive
episode has been associated with an increased mortality
rate in some (1, 7) but not all (8
/10) studies of suicidal
behavior in BPD. Comorbidity with major depressive
episode has also been associated with an increase in the
seriousness and frequency of suicide attempts among
inpatients with BPD (6). Other studies have found that
comorbidity with major depressive episode is not pre-
dictive of a history of suicide attempts with BPD (11)
and have found no relationship between comorbid
major episode and measures of suicidal intent, lethality
or risk (12). Peterson & Bongar (13) studied patients
with chronic suicidality that made four or more visits
in a year to a psychiatric emergency room; most
often, these patients met criteria for BPD. Paris et al.
(8) found that the strongest clinical predictor of com-
pleted suicide was previous attempts, although very
often these gestures are manipulative. These authors
also observed that higher education was strongly asso-
ciated with completed suicide, which was explained by
the crushed expectations of an educated person with
severe psychopathology.
# 2005 Taylor & Francis DOI: 10.1080/08039480500320025
Crumley (14) has shown a high incidence of BPD in
the adolescents and young adults aged 15 /24 years who
engage in suicidal behavior. Paris & Zweig-Frank
(15) indicated that this diagnosis significantly increases
the risk of eventual suicide. Those at higher risk
appeared to be young, ranging from adolescence into
the third decade (2, 16). The high rates of suicidal
behavior in patients with BPD are reflected by the
inclusion of recurrent suicidal behavior, gestures, threats
or self-mutilating behavior as diagnostic criteria in
the DSM IV. Also, among patients with BPD, im-
pulsivity, assessed as a diagnostic criterion, is associated
with the number of suicide attempts independent of
comorbid depression or substance use disorder. Soloff
et al. (17) observed that hopelessness predicted the
lifetime number of suicide attempts and the degree of
lethal intent. Hopelessness may contribute to the ser-
iousness of suicidal behavior in BPD, especially in
patients with comorbid depression, by increasing the
number of attempts, the level of subjective intent and
the degree of objective planning. A relation has
been found between increased suicidal behavior and
comorbidity of substance abuse disorder with BPD (3,
11, 18). Links et al. (18) examined the prognostic
significance of comorbid substance abuse in patients
with BPD. The patients were followed prospectively over
a 7-year period. These researchers found that patients
with comorbid substance abuse and BPD perceived
themselves to be at significantly more risk for suicide
than did the comparison groups of patients having
BPD without comorbidity, patients having substance
abuse without BPD and patients having borderline traits
Harris & Barraclough’s (19) comprehensive meta-
analysis on suicide as an outcome for mental disorders
included five studies dealing with suicide in personality
disorders. The five cohorts were mainly heterogeneous
spanning from the mid-1960s to the mid-1980s. These
authors combining the studies found a suicide risk seven
times the expected value.
Data concerning suicide among subjects with
BPD may be difficult to obtain because suicide statistics
are usually reported among many other variables.
Also, cohorts including only borderline patients and
followed up for a certain period of time are few;
this contrasts with the ever increasing availability of
data regarding suicidality among these patients. To our
knowledge, a meta-analytic investigation of suicide
among patients with a diagnosis of BPDs has still to
be performed in the international literature.
Materials and Methods
We conducted careful MedLine, Excerpta Medica
and PsycLit searches to identify papers in English
during the period 1980
/2005. The following search
terms were used: ‘‘suicid*’’ (which comprises suicide,
suicidal, suicidality and other suicide-related terms),
‘‘borderline’’ and ‘‘personality disorder’’. In addition,
each category was cross-referenced with the others
using the MeSH method (medical subject headings).
Study selection allowed the inclusion of only articles
published in peer-reviewed English-language journals.
Suicide of borderline patients is often reported among
cohorts of patients that received a diagnosis of person-
ality disorder. We avoided a systematic review of the
literature prior to 1980 because of diagnostic criteria
heterogeneity. Individuals analyzed in this study received
a diagnosis of BPD according to various diagnostic
criteria, mostly according to DSM-III or IV criteria
and were followed up or were studied retrospectively.
We excluded any study that reported suicide in border-
line patients as part of the analysis of suicidality
among individuals with personality disorders or with
any other psychiatric disorders. We also excluded
studies that mentioned data about suicide but were not
clear about follow-up times, method of statistical
analysis, diagnostic criteria and the number of patients
The World Health Organization publishes the World
Health Statistics Annual, a bulletin with the statistics of
all causes of death ismost countries worldwide. Each
cause of death is divided into age groups, providing for
each group rates and total number of male and female
deaths. Statistics in this bulletin are generally per
100,000 individuals.
For each study selected for our analysis, we searched
the Bulletin of the World Health Organization (WHO),
referring to the year of publication and the country
where the study was performed. We identified suicide
statistics for a specific year and country, and used only
those applicable to the age group indicated in the study.
A comparative analysis was performed in order to
ascertain whether suicide in BPD may be considered a
more frequent phenomenon in comparison to suicide
among the general population.
We selected eight studies comprising 1179 patients.
In this group of patients, 94 had committed suicide.
Follow-up observation ranged from 3 to 27 years. Table
1 provides information about the studies that we used
for our analysis (1, 2, 7, 10, 15, 19
/21). Each study has
been positioned in the table in chronological order.
Table 1 also illustrates the results of our compara-
tive analysis. Fig. 1 shows distribution of suicides
among patients with BPD compared with the general
population of the same age group in accordance with
the country and year of publication of a specific
Table 1. Results of the meta-analysis.
No. of
Author, year of publication and
diagnostic criteria (reference)
Size of
(years) Suicides
Expected suicides
in a year in 100,000
individuals if they
all suffered from
Expected suicide in a
year in a population
of 100,000
individuals (general
Expected suicide
in a year in a
population of
100,000 males
Expected suicide
in a year in a
population of
100,000 females
Age groups researched
in the WHO Bulletin
in accordance with the
mean age of the
1 Pope et al., 1983 (USA)
/ DSM-III (20) 33 3.5 2 1732 10.6 25.20 7.40 25/34
2 Akiskal et al., 1985 (USA) / DSM-III;
Gunderson-Singer (21)
100 3 4 1333 16.1
25.20 6.96 25/34
3 McGlashan, 1986 (USA)
Gunderson criteria (1)
81 15 2 165 16.0
25.41 6.61 25/34
4 Stone et al., 1987 (USA) / DSM-III;
Kernberg criteria (2)
251 16 19 473 11.2 20.50 4.40 15/24
5 Stone, 1989 (USA) / DSM-III;
Kernberg criteria (7)
299 16.5 27 547 12.0 21.30 4.30 15 /24
6 Modestin and Villinger, 1989
(Switzerland); DSM-III (22)
26 4.6 2 1672 25.2
36.60 13.70 35/44
7 Kjelsberg et al., 1991 (Norway),
Gunderson criteria (10)
289 20 21 363 24.9 29.80 11.30 25/34
8 Paris and Zweig-Frank, 2001
(Canada), Gunderson criteria (15)
100 27 17 630 14.1 27.30 7.00 35
Total 1179 105.6 94 6915 130.0
Not adjusted for gender.
The number of suicides was calculated as suicides/100,000/number of patients in the study/follow up. Mean of suicides in a population suffering from BPD (projection of a population of 100,000
/898; standard deviation for a population suffering from BPD (projection of a population of 100,000 individuals)/660; mean of suicides expected in the general population (referring to
100,000 individuals)/16.6; standard deviation for the general population/6.
The results obtained for each study were processed
together to calculate the mean figure for each year of
suicides per 100,000 individuals suffering from BPD.
The mean of suicides expected in a population suffering
from BPD was calculated as follows: a[suicides (study
/suicides (study 2)/ ... suicides (study 8)]/8. A
comparison between mean figure of suicide in patients
with BPD and in the general population has statistical
relevance and allowed us to draw statistically significant
The standard deviation of a population suffering from
BPD has been calculated as follows:
Suicide among patients with BPD is a major issue
and in some studies, the number of suicides is dis-
turbingly high. This is not a new finding, because
BPD, by definition (DSM-IV), is characterized by
‘‘recurrent suicidal behavior, gestures or threats, or
self-mutilating behavior’’. Nevertheless, our meta-
analysis showed that suicide among patients with
BPD is a heterogeneous phenomenon when different
cohorts are compared. Suicide was more frequent in all
cohorts analyzed compared with the general population.
Even more striking is, however, the great difference
among cohorts. It is difficult to recognize background
elements that precipitated suicide in these cohorts in a
given length of time. One possible finding emerging
from our study is the identification that the number of
suicides would appear to be higher in short-term follow-
ups. If this assumption were true, suicide risk would be
higher during the first phases of the taking care rather
than during the chronic phases of the illness.
Comorbidity of psychiatric and personality disorders
is increasingly recognized as a major factor in suicide.
Comorbid disorders, especially those belonging to
DSM-IV Axis I, may play a central role in precipitating
suicide in BPD and should always be indicated in studies
of mortality of these patients.
Our study has a number of limitations. Firstly,
papers included in this meta-analysis may be only a
part of the literature; we only used cohorts available
from studies published in medical journals, which may
exclude data available in other reports. Secondly, the
studies analyzed used different diagnostic criteria; these,
although similar to each other, may represent a source
of bias. One of the main problems of this study is
the heterogeneity of cohorts included in the meta-
analysis, which might be to some degree incompatible
with one another. DSM IV diagnostic criteria for
personality disorders are usually the most common for
Number of study
Patients with BPD
General population
Tren d
Tren d
Number of suicides (in a year in a population of
100,000 individuals)
Fig. 1. Distribution of suicides among patients with BPD compared with the general population of the same age group in
accordance with the country and year of publication of a specific study. Dashed line, general population; straight line, patients
with BPD.
the assessment of patients. However, other diagnostic
criteria are sometimes preferred, as in the case of the
ICD classification or in the case of the Diagnostic
Interview for Borderlines (23). Also, other relevant
sources for diagnostic criteria are traceable in literature
(24, 25). The comorbidity with affective disorders
makes it difficult to ascertain whether suicidality is
caused by an Axis I or Axis II disorder, or both. Cohorts
analyzed generally had a variable ratio of male and
female as well as suicides in a given cohort presented
variable ratio of males and females. Also, some studies
do not provide clear data on the gender of patients
belonging to the cohort, which impairs a correct
comparison with the general population. We, therefore,
decided to compare the mean of the male and female
suicides in a given age group of the general population
for those studies with no clear indication on the gender
of suicide victims. This may reduce the role of gender in
the characterization of suicides, especially if cohorts
were made only or in a great proportion of males or
females. Also, follow-up time may play an important
role for reaching conclusions in the evaluation of
suicides in a cohort. In our meta-analysis of suicide in
BPD, we used studies with follow-up observation, which
varies greatly from one study to another. We compared
suicide of patients with BPD and those occurring in the
general population for the year of publication of each
study. In most cases, cohorts were analyzed years before
publication, making it difficult to ascertain when exactly
a suicide happened during the follow-up years. Meta-
analysis is a powerful tool that presents numerous
problems, some of them found in this investigation as
well (26).
The purpose of this study was to broaden the
knowledge of the magnitude of completed suicide in
BPD. Paris (27) pointed out that chronic suicidality is a
central feature of BPD; but whereas suicidal thoughts
and attempts are highly prevalent among these patients,
completion is relatively unpredictable. This is the first
meta-analysis of suicide in patients suffering from
BPD. Contrary to the expectation, in our meta-analysis,
suicide rates among patients with BPD are tremendously
heterogeneous. This might be related to various
reasons such as being inpatients or outpatients, comor-
bidity with affective disorders and substance abuse
disorder. Pompili et al. (28) reviewed papers dealing
with suicidality in patients with personality disorders.
These authors found that suicide is extremely repre-
sented among DSM IV cluster B personality disorders,
borderline being the most common disorder related to
suicide, affective disorders and substance abuse. Clearly
more knowledge about the prediction and prevention
of suicide in BPD is needed. In particular, future studies
are needed to clarify further the role of various factors
in mediating suicide risk. In fact, despite intensive
efforts, effective prediction and prevention strategies
have remained elusive, suggesting that our understand-
ing of the interplay of factors that eventuate in suicide in
BPD remains incomplete.
Acknowledgements */The authors thank Ing. Dr Stefano Zorzi for
statistical help and suggestions during the preparation of the
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Maurizio Pompili, M.D., Department of Psychiatry, Sant’ Andrea
Hospital, University of Rome ‘‘La Sapienza’’, Italy and McLean
Hospital, Harvard Medical School, Belmont, Massachusetts, USA.
Paolo Girardi, M.D., Department of Psychiatry, Sant’ Andrea
Hospital, University of Rome ‘‘La Sapienza’’, Italy.
Amedeo Ruberto, M.D., Department of Psychiatry, Sant’ Andrea
Hospital, University of Rome ‘‘La Sapienza’’, Italy.
Roberto Tatarelli, M.D., Department of Psychiatry, Sant’ Andrea
Hospital, University of Rome ‘‘La Sapienza’’, Italy.
... Borderline personality disorder (BPD) is a serious mental disorder with characteristic patterns of instability of affect regulation, behavioural control, interpersonal relationships and self-image (Gunderson et al., 2018). BPD is also burdened by a high suicide rate (Pompili et al., 2005) and severe psychosocial impairment (Gunderson et al., 2011;Mosiolek et al., 2018;Zanarini et al., 2010). Neurocognitive deficits among patients with BPD are receiving growing attention as their role in the pathogenesis of the disorder (Judd, 2005;Minzenberg et al., 2008;Mosiolek et al., 2018;Poletti, 2011) symptoms and psychosocial functioning (McClure et al., 2016) is becoming evident. ...
... Second, convergent validity was evaluated with a twostep approach (Gunderson et al., 2018): We computed correlations between each SCIP subtest and the corresponding domains of the neuropsychological battery (Pompili et al., 2005); we performed a t-test to compare the SCIP scores between subjects with or without cognitive deficits for each validated instrument (one SD below the HC mean). Each domain of the SCIP was validated against one domain from the neuropsychological battery: the VLT-I with the RBANS Immediate Memory Third, receiver operating characteristic (ROC) curve analyses were computed for each SCIP domain to assess the capacity to discriminate between cognitively impaired and non-impaired individuals. ...
Cognitive deficits are common in borderline personality disorder (BPD) and appear to be associated with psychopathology, functioning and outcome. The availability of a cognitive screening instrument could be of use in clinical settings in order to assess neurocognition in BPD patients. The Screen for Cognitive Impairment for Psychiatry (SCIP) proved to be reliable in different psychiatric populations, but it has not yet been validated in personality disorders. The purpose of this study is therefore to evaluate its psychometric properties in a sample of 58 BPD patients. The SCIP was validated against the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) and the Trail Making Test A and B (TMT A and B). The receiver operator curve analysis displayed an acceptable convergent validity (total score AUC: 0.78, 95% CI: 0.70–0.86; Se: 75%, Sp: 72%). A cut-off total score of 80 identified 81% of patients as cognitively impaired. The exploratory factor analysis displayed a one-factor solution explaining 55.8% of the total variance. The SCIP displayed adequate psychometric properties in BPD and could be integrated in the routine clinical assessment to provide a preliminary evaluation of cognitive features for BPD.
... To ensure that any significant findings could not be explained by other variables theoretically associated with the dependent variables (Tabachnick & Fidell, 2007), analyses were conducted with relevant demographic (age, racial/ethnic background, sex assigned at birth) and clinical (depression symptom severity, BPD) characteristics included as covariates in the models. Covariates were chosen based on their established associations with suicidal ideation, suicide attempts, and ITS variables Isometsä, 2014;Pompili et al., 2005;Silva et al., 2015). ...
Background Despite research and theory linking emotion regulation (ER) difficulties to suicidal thoughts and behaviors, limited research has examined the relations of specific ER strategies to suicide risk outcomes, and almost no research has examined interpersonal ER strategies in particular. Thus, this study sought to examine associations of specific interpersonal (venting, reassurance-seeking) and intrapersonal (avoidance, acceptance) ER strategies to suicide ideation and attempt history. Methods A community sample of adults (N = 363) completed an online study, including measures of perceived burdensomeness, thwarted belongingness, past 3-month suicidal ideation, lifetime suicide attempts, and a scenario-based measure assessing the use of both interpersonal (venting, reassurance-seeking) and intrapersonal (avoidance, acceptance) ER strategies. Results When controlling for theoretically-relevant clinical and demographic covariates (and all other ER strategies), greater venting was uniquely associated with greater perceived burdensomeness. Greater avoidance was uniquely associated with greater thwarted belongingness, greater perceived burdensomeness, and a lifetime history of suicide attempts. Conclusion Results highlight the relevance of two specific ER strategies (venting and avoidance) that warrant further examination as potential treatment targets aimed at mitigating suicide risk. Limitations include examining only a subset of potential interpersonal and intrapersonal ER strategies, as well as the sole use of self-report measures.
... Although the specific mechanisms are not yet known, the origin of suicidal behavior occurs through the interaction of several factors, as biological, psychological, social, and environmental (O'Connor & Kirtley, 2018). Among the psychological factors related to suicidal behavior, studies have highlighted the pathological personality traits (Brezo et al., 2008;Jaksic et al., 2017;Perepjolkina et al., 2019;Pompili et al., 2005;Raczek et al., 1989). Evidence indicates an increased risk of suicide in people with personality disorders (pd) and an in people with high scores on pathological traits (Arsenault-Lapierre et al., 2004;Björkenstam et al., 2016), especially for borderline pd (Paris, 2002;Winsper et al., 2016). ...
Full-text available
This study aimed to investigate the discriminative capacity of iDCp-2 factors to identify people with suicide risk. Moreover, we are providing a suicide indicator for iDCp-2. Participated 346 people aged between 18 and 72 years who responded to aSiq , iDCp-2, and piD-5. We divided participants into three groups: low-risk group, moderate-risk, and high-risk group. We conducted mean comparisons, linear regression analysis, and ROC curve verification. The iDCp-2 factors were able to discriminate between the groups, with the high-risk presenting the highest means. The regression indicated Self-devaluation and Hopelessness as variables with a significant single contribution in explaining suicidal behavior. Suicide risk indicators demonstrated adequate performance in identifying people according to the risk group. Our findings indicate that the iDCp-2 factors can discriminate groups of people according to suicidal behavior. Besides, the suicide indicator developed showed sensitivity in the identification of people who reported attempted suicide.
... With the constant change in the instability of relationships, the creation and regulation of impulses and the sense of life were determined (3). BPD is a severe disorder that accounts for 20 to 40% of psychiatric admissions, and it is estimated that 84% of patients show suicidal behaviors, and 8% of them die due to suicide (4,5). BPD causes many problems for the patient and the community. ...
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Background Borderline personality disorder is a major mental illness characterized by a sustained relationship instability, impulsive behavior and intense affects. Adherence is a complex behavior, from minor refusals of treatment to inappropriate use of health services or even abandonment of treatment, which can be affected by various factors. Therefore, the present study aimed to investigate the factors affecting pharmacological and non-pharmacological adherence in patients with borderline personality disorder referred to an outpatient referral clinic in Tehran, Iran. Methods The study was a retrospective cohort. The files of patients with borderline personality disorder referred to the outpatient clinic of the Tehran Psychiatric Institute were reviewed as the first step. In the next step, we contacted the patients and asked them to fill out the questionnaires. Data were collected using the Drug Attitude Inventory (DAI) questionnaire and a researcher made questionnaire to determine the attitude of patients toward pharmacological and non-pharmacological treatment and therapeutic adherence. After collecting data, patients’ therapeutic acceptance was divided into three groups: poor, partial, good compliance. The data were analyzed by SPSS software version-22. Results Ninety-four patients were involved in the study and fifty four of them were women. In terms of psychotherapy adherence, patients with higher education and hospital admission history have better compliance. Medication attitudes were negative in 54 patients (57.4%), while 40.4% of them stated that psychotherapy or counselling did not help their condition and showed a negative attitude toward non-pharmacological treatment. Additionally, psychotherapy good adherence of the patients (44.7%) was higher than medication good adherence (31.9%). The most common reasons for discontinuation of treatment were medication side effects (53.1%), dissatisfaction with the therapist (40.3%) and then fear of medication dependence (40%). The results showed no relationship between other demographic factors and treatment adherence. Conclusions Results of the current study show that attitude toward psychotherapy is more positive than pharmacotherapy. In addition, according to the results, working on changeable factors such as patients’ fear of dependence to medication, dissatisfaction with the therapist, and medication side effects may improve patients' treatment adherence.
... BPD is characterized by pervasive instability in the domains of affect regulation, attachment, behavior, and self-image (Lieb, Zanarini, Schmahl, Linehand, & Bohus, 2004). Patients with BPD have highly compromised psychosocial functioning (Gunderson et al., 2011;Mosiolek, Gierus, Koweszko, & Szule, 2018;Zanarini, Frankenburg, Reich, Fitzmaurice, 2010) and frequently manifest suicidal behaviors (Pompili, Girardi, Ruberto, & Tatarelli, 2005). BPD is often associated with early traumatic experiences, which are thought to play an important role in its genesis (Zanarini, 2000). ...
Very few studies have focused on the relationship between cognitive functions and clinical features in borderline personality disorder (BPD). Subjects with BPD and healthy controls were administered the Repeatable Battery for the Assessment of Neuropsychological Status, Trail Making Test A and B, and the Wisconsin Card Sorting Test. The Brief Symptom Inventory (BSI-53) was used to assess the severity of current symptoms. Attachment style was assessed with the Experiences in Close Relationship Questionnaire, identity integration with the Personality Structure Questionnaire, and other domains of personality dysfunction with the RUDE Scale for Personality Dysfunction. Patients with BPD performed significantly worse than healthy controls in all cognitive domains. Cognitive functions, particularly delayed memory and visuospatial abilities, displayed meaningful associations with trait-like clinical features, above the effect of global cognition and state psychopathology. These findings highlight the need to evaluate effects of cognitive rehabilitation on trait features among individuals with BPD.
Posttraumatic stress disorder (PTSD) is a commonly co-occurring mental health diagnosis among individuals who have borderline personality disorder (BPD), with comorbidity rates up to 75%. Research has suggested that these co-occurring disorders can interact in ways that maintain each other and interfere with response to treatments for PTSD and BPD separately. Therefore, treatment that aims to address both disorders is likely needed to achieve optimal outcomes. Four general approaches to treating PTSD have been evaluated among individuals with BPD, including: (1) single-diagnosis treatments, (2) parallel treatments, (3) phase-based treatments, and (4) integrated treatments. This chapter reviews the results of randomized controlled trials that have examined these treatment approaches among individuals with BPD with varying levels of disorder. Additionally, common challenges that arise when conducting trauma-focused treatment with this clinical population are discussed, including suicidal and self-injurious behaviors, emotion dysregulation, and dissociation. The chapter concludes with a case vignette that illustrates an integrated treatment that combines Dialectical Behavior Therapy (DBT) for BPD with the DBT Prolonged Exposure (DBT PE) protocol for PTSD.
Several studies report that borderline personality disorder (BPD) is a risk factor for suicidality in adults. However, this issue requires further research in adolescents, as it is not clear which individual BPD symptoms are significant correlates of suicidality in this age group. The main aim of the current study was to test which symptoms of BPD are associated with suicidality in adolescent inpatients, even when controlling for age, gender, and depressive symptoms. Inpatient adolescents (N = 339) aged 12-17 years completed the Childhood Interview for DSM-IV Borderline Personality Disorder, the Beck Depression Inventory-II, the Modified Scale for Suicidal Ideation, and reported their number of lifetime suicide attempts. Multivariable regression analyses showed that, after controlling for confounding variables, overall BPD symptom severity was positively related to suicidal ideation and suicide attempts. Of the individual BPD symptoms, identity disturbance, chronic emptiness, avoid abandonment, and transient paranoia were the most robust correlates of suicidal ideation intensity, and only identity disturbance was associated with the number of lifetime suicide attempts. To assess the risk of suicidality in youth, it is essential to assess for BPD symptoms; it is important to focus on adolescents’ subjective feelings to assess the severity of identity disturbance and chronic emptiness.
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Background Specialized evidence-based treatments have been developed and evaluated for borderline personality disorder (BPD), including Dialectical Behavior Therapy (DBT) and Schema Therapy (ST). Individual differences in treatment response to both ST and DBT have been observed across studies, but the factors driving these differences are largely unknown. Understanding which treatment works best for whom and why remain central issues in psychotherapy research. The aim of the present study is to improve treatment response of DBT and ST for BPD patients by a) identifying patient characteristics that predict (differential) treatment response (i.e., treatment selection) and b) understanding how both treatments lead to change (i.e., mechanisms of change). Moreover, the clinical effectiveness and cost-effectiveness of DBT and ST will be evaluated. Methods The BOOTS trial is a multicenter randomized clinical trial conducted in a routine clinical setting in several outpatient clinics in the Netherlands. We aim to recruit 200 participants, to be randomized to DBT or ST. Patients receive a combined program of individual and group sessions for a maximum duration of 25 months. Data are collected at baseline until three-year follow-up. Candidate predictors of (differential) treatment response have been selected based on the literature, a patient representative of the Borderline Foundation of the Netherlands, and semi-structured interviews among 18 expert clinicians. In addition, BPD-treatment-specific (ST: beliefs and schema modes; DBT: emotion regulation and skills use), BPD-treatment-generic (therapeutic environment characterized by genuineness, safety, and equality), and non-specific (attachment and therapeutic alliance) mechanisms of change are assessed. The primary outcome measure is change in BPD manifestations. Secondary outcome measures include functioning, additional self-reported symptoms, and well-being. Discussion The current study contributes to the optimization of treatments for BPD patients by extending our knowledge on “Which treatment – DBT or ST – works the best for which BPD patient, and why?”, which is likely to yield important benefits for both BPD patients (e.g., prevention of overtreatment and potential harm of treatments) and society (e.g., increased economic productivity of patients and efficient use of treatments). Trial registration Netherlands Trial Register, NL7699 , registered 25/04/2019 - retrospectively registered.
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Motivation: This paper is an attempt to explain the psychiatric and psychological aspects of a clinical case of psychiatry, namely, a patient with borderline personality disorder with obvious paranoid traits (and elements of antisocial personality structure), followed in longitudinal evolution over several months. This case study aims to highlight how, in terms of borderline personality disorder, along with features of other disorders in cluster B-narcissistic, histrionic and antisocial-and cluster A-paranoid, the personality and behavior of the individual are so disorganized, especially in the case of relationships with others and their social integration, so that the individual fails to adapt to the requirements of the environment to which he belongs, having numerous conflicts with others and resorting to extreme attitudes for self-validation. Objectives: Highlighting the determining factors that led to the borderline personality disorder, having as reference point the paranoid core, as well as the interpretations that the patient makes in accordance with his life history. The construction of the stress-diathesis model is desired, related to the patient's life history, in which the early psychotraumas are identified, as well as the triggers of the episodes he had. Hypothesis: For the patient in question, the pathology manifested itself "in balance" between the psychiatric and neurological plane, this functioning in the first period of life in optimal parameters, followed by the pathology of personality disorder, having as predominant elements in the patient's life spasmodic episodes with the externalization of aggression and anger, caused mainly by the feeling of abandonment, isolation or misunderstanding in relationships with others. Methods: Neurological examination, psychiatric interview, psychodynamic interview, psychiatric and psychological monitoring of the daily evolution under treatment, psychological tests and their interpretations. Results: The diagnosis of borderline personality disorder is made explicit and supported in the psychiatric register, accompanied by features characteristic of paranoid (cluster A), histrionic and narcissistic personality that are included in cluster B. In the psychodynamic register, in terms of functioning the patient notices deep feelings of inner emptiness and fear of abandonment, which resides from attachment disorder, having as defense mechanisms a childish and expansive behavior (taking action), accompanied by an arrogant attitude and lack of affection in terms of expression (isolation), well outlined by feelings of superiority, while being superficial in relationships with others. The patient is meticulous, attentive to details in interpersonal relationships, and in terms of relating to life he works immaturely in a register "here and now", cancels the realities considered unjust and is also fascinated by fairness, equality, meaning and reason. Conclusions: The defense mechanisms aim at the systematic manipulation of others, highlighting the desire for power, assertion and the need for justice. The emphasis is on borderline personality disorder, which has as a reference point at the diagnostic level, the paranoid core intertwined with the narcissistic one. Due to the patient's emotional impoverishment in terms of pre-existing attachment disorder and deep feeling of inner emptiness that affects optimal functioning, psychiatric treatment with psychotherapy sessions is needed over the next few months to reduce the risk of depressive exacerbation.
Despite ample evidence for Dialectical Behavior Therapy (DBT) as an effective treatment for borderline personality disorder (BPD), close examination of the trajectory of change in BPD symptoms over the course of DBT is lacking. There also remain questions regarding the directionality of changes in different domains of BPD symptoms, such as improvements in dysfunctional behaviors and thoughts/feelings. In order to provide more fine-grained information about treatment process in DBT, the current study aimed to (1) examine the trajectories of change of BPD-associated negative thoughts/feelings and behaviors, and positive behaviors, and (2) test the temporal relationship between changes in negative behaviors and thoughts/feelings. The study involved 55 adult clients attending a six-month outpatient DBT program for BPD who completed assessments of BPD symptoms every four sessions. Growth curve models suggested that clients experienced a faster rate of decrease in negative behaviors during the initial phase of treatment, whereas steady rates of improvement were found for negative thoughts/feelings and positive behaviors, respectively, throughout treatment. Further, a random-intercept cross lagged panel model found that the within-person fluctuations in negative behaviors preceded the within-person changes in negative thoughts/feelings at a subsequent time point during the later phase of treatment, while within-person fluctuations in thoughts/feelings were followed by changes in negative behaviors at the beginning and end of the treatment. These results highlighted the complexity of patterns and processes of change in BPD symptomatology during the course of DBT.
• To test the validity of the DSM-III diagnosis of borderline personality disorder (BPD), we examined the phenomenology, family history, treatment response, and four-to-seven-year long-term outcome of a cohort of 33 patients meeting DSM-III criteria for BPD. We found that (1) BPD could be distinguished readily from DSM-III schizophrenia; (2) BPD did not appear to represent "borderline affective disorder," although many patients displayed BPD and major affective disorder concomitantly; and (3) BPD could not be distinguished on any of the Indices from histrionic and antisocial personality disorders.
• In a retrospective study of 180 inpatients with DSM-III borderline personality disorder (BPD), the degree and direction of psychiatric comorbidity were used to examine the extent to which BPD is a homogeneous entity with clearly defined boundaries. Ninety-one percent of patients with BPD had one additional diagnosis, and 42% had two or more additional diagnoses. Both patients with BPD and controls with other personality disorders had similar rates and directions of comorbidity. The two groups did not differ significantly in prevalence of affective disorder. The DSM-III BPD appears to constitute a very heterogeneous category with unclear boundaries, overlapping with many different disorders but without a specific association with any one Axis I disorder. Comorbidity in patients with BPD may reflect base rates of psychopathology rather than anything inherent to BPD. Future studies should control for comorbidity to ensure homogeneity of comparison groups.
The conditions of 40 adolescents in treatment following a suicide attempt were diagnosed according to the multiaxial classification of the American Psychiatric Association's proposed third edition of the diagnostic and statistical manual. All were psychiatrically ill before the suicide attempt. The most common diagnoses were those of depressive disorders and substance abuse disorders on the clinical psychiatric syndrome axis and borderline personality disorder on the personality and developmental disorder axis. The typical patient was a polydrug-abusing girl with a borderline personality disorder and a superimposed major depressive disorder. The most prominent personality characteristics associated with suicide attempts by these adolescents were a tendency to react severely to a loss, poorly controlled rage, and impulsivity. Suicide attempts by adolescents should be taken seriously by the physician and necessitate a thorough search for a possible underlying pathological condition. (JAMA 241:2404-2407, 1979)
This review of the descriptive literature on borderline patients indicates that accounts of such patients vary depending upon who is describing them, in what context, how the samples are selected, and what data are collected. The authors identify six features that provide a rational means for diagnosing borderline patients during an initial interview: the presence of intense affect, usually depressive or hostile; a history of impulsive behavior; a certain social adaptiveness; brief psychotic experiences; loose thinking in unstructured situations; and relationships that vacillate between transient superficiality and intense dependency. Reliable identification of these patients will permit better treatment planning and clinical research.
The authors describe the evaluation and follow-up of matched samples of borderline and schizophrenic patients to determine the ways that borderline disorders are similar to or different from schizophrenia. The borderline patients presented more confusing diagnostic pictures, but they could be differentiated from the schizophrenic patients by the absence of definite or prolonged psychotic episode, by the relative severity of their dissociative experiences, by more severe anger, and by less anxiety. Despite the discrepant symptom pictures of the two patient groups, a systematic review of prehospitalization functioning and two-year posthospitalization course did not reveal significant differences between them.
Twenty-one borderline patients (in accordance with Gunderson) who had committed suicide were compared with matched borderline patients who stayed alive. The suicide group had more frequent childhood loss, lack of treatment contact before hospitalization, longer hospitalization, and they were more frequently discharged for violating the treatment contract. These variables were combined into a predictive model for suicide in borderline patients.
Fifty-eight consecutive suicides committed between 1984 and 1987 by adolescents and young adults (ages 15 to 29 years) in an urban community were the subject of retrospective investigation through interviews with survivors and analyses of medical records. Classification in accordance with DSM-III-R showed a large proportion of axis II disorders. Borderline personality disorder (BPD) was found in 19 subjects (33%). When compared with subjects with other disorders, BPD subjects showed more antisocial traits and substance use disorders. Early parental absence, substance abuse in the homes, employment and financial problems, lack of a permanent residence, and sentence by court were also more frequent in BPD subjects.
The present study involves a retrospective chart review of all patients who visited the Emergency Mental Health Service during the period of July 1, 1985 to June, 30, 1986 (total visits = 2,772). It compares those 'suicidal' patients seen only once during the index year with those seen multiple times (comparison of first visit only for both 'one-timers' and 'repeaters'). The 'repeaters' were generally found to be older and were more likely to have a diagnosis of schizophrenia and personality disorder. Unlike previous studies, substance abuse and affective disorder did not significantly differentiate the two groups. The 'repeaters' were also more likely to be taking antipsychotic and antiparkinson medications, have histories of past psychiatric hospitalizations in the public sector, be living alone, and most importantly, to have made a previous suicide attempt.
Using a semi-structured interview, 18 DSM-III borderline personality disorder (BPD) patients and 17 other (nonborderline) personality disorder (OPD) patients were compared blind 4 1/2 years after their index discharge. Although significantly younger and mostly single, BPD patients did not differ from OPD patients in the degree of overall psychopathology or in the level of psychosocial functioning and adjustment. They do not seem to represent a particularly severe personality disorder group. Those characteristics differentiating BPD patients from affective disorders and schizophrenia may be nonspecific regarding other personality disorder types. As such, more attention should be paid to cases of OPD in the future.
In a long-term follow-up study of hospitalized border-line patients with narcissistic traits that either fell short of or fulfilled DSM criteria for narcissistic personality disorder (NPD), outcome was similar to outcome in the borderline group as a whole. An exception was encountered in the subgroup of narcissistic borderlines who also showed marked antisocial traits: poor outcome was the rule in this subgroup. In general, borderlines with NPD tended to be male and to be more at risk for suicide than non-NPD borderlines.