Predict Ores de Suicidabilidad en T. Borderline

7/31/2019 Predict Ores de Suicidabilidad en T. Borderline

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Article

484 ajp.psychiatryonline.org Am J Psychiatry 169:5, May 2012

consecutively studied borderline inpatients, with an aver-

age of three or more attempts at the time of initial assess-

ment (4). Comorbidity with borderline personality disor-

der increases the likelihood of suicidal behavior in other

high-risk disorders (5). Some population studies found a

comorbid diagnosis of borderline personality disorder in

one-quarter to one-third of completed suicides (6, 7), and

in half of parasuicidal patients admitted to hospital (8),

although prevalence varied greatly with sample character-

istics and study methods. With a suicide completion rateup to 10% and a community prevalence estimated at 2%

in the Epidemiologic Catchment Area Study (9), border-

line personality disorder is a high-risk, clinically relevant

model for the study of suicidal behavior.

A history of prior attempts is among the most power-

ful predictors of completed suicide. While only 10%15%

of suicide attempters become completers, 30%40% of

completers have a history of attempts (10). Previous at-

tempts increase the likelihood of subsequent attempts

(Am J Psychiatry 2012; 169:484490)

Pospctv Pdctos of Sucda Bhavo n Bodn

Psonaty ;sod at 6-Ya Foow-Up

Paul H. Soloff, M.D.

Laurel Chiappetta, M.S.

Objective: Recurrent suicidal behavior

isadeningcharacteristicof borderline

personality disorder. Althoughmostpa-

tients achieve remission of suicidal be-

haviorovertime,asmanyas10%dieby

suicide, raising thequestionofwhether

thereisahigh-risksuicidalsubtype.The

authorsconductedalongitudinalstudyof

suicidalbehaviorinborderlinepersonal-

itydisorderpatientsto identifyprospec-

tivepredictorsofsuicideattemptsandto

characterizethosepatientsathighestrisk

forsuicidecompletion.

Method: Demographic and diagnostic

characteristicsandclinicalandpsychoso-cialriskfactorsassessedatbaselinewere

examinedforpredictiveassociationwith

medicallysignicantsuicideattemptsus-

ingCoxproportionalhazardsmodels.The

authors dened prospective predictors

forparticipantswhocompleted6ormore

yearsinthestudyandcomparedthedata

tothoseofearlierintervals.

Results: Among 90 participants, 25

(27.8%) made at least one suicide at-

temptintheinterval,andmostattempts

occurredintherst2years.Theriskof

suicideattemptwasincreasedbylowso-

cioeconomic status, poor psychosocial

adjustment,familyhistoryofsuicide,pre-

viouspsychiatrichospitalization,andab-

senceofanyoutpatienttreatmentbefore

the attempt. Higher global functioning

scoresatbaselinedecreasedthisrisk.

Conclusions: Risk factors predictive of

suicide attemptchange over time.Acute

stressors such as major depressive dis-

order were predictive only in the shortterm(12months),whilepoorpsychosocial

functioninghadpersistentand long-term

effectson suicide risk.Halfof borderline

patientshavepoorpsychosocialoutcomes

despitesymptomaticimprovement.Aso-

cial and vocational rehabilitation model

oftreatmentisneededtodecreasesuicide

riskandoptimizelong-termoutcomes.

Suicide is a rare event, with an incidence of 12.0 deathsper 100,000 population (www.cdc.gov/nchs/fastats/sui-

cide.htm). The rarity of suicide makes it impossible to pre-

dict on the basis of known risk factors if or when a given

patient will die by suicide (1). While it is impossible to pre-

dict individual suicides, suicide rates in the general popu-

lation may be reduced by systematic physician education

on the identication and treatment of modiable risk fac-

tors (2). Identifying clinically relevant risk and protective

factors requires prospective studies of patients at highrisk for suicide that use multidimensional assessments

and systematic follow-up. The results of such studies are

immediately applicable to clinical assessments and treat-

ment interventions.

Borderline personality disorder is the only DSM-IV di-

agnosis dened in part by recurrent suicidal and self-in-

jurious behaviors (called the behavioral specialty of the

borderline patient by Gunderson and Ridol [3]). In one

study, history of suicide attempt was noted in over 70% of

ThisarticleisfeaturedinthismonthsAJPAudo,isdiscussedinanedtoabyDr.Paris(p.445),isanarticlethat

providesCnca Gudanc(p.483),andisthesubjectofaCMecourse(p.547)

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Am J Psychiatry 169:5, May 2012 ajp.psychiatryonline.org 485

SOlOFF AN; CHiAPPeTTA

ment. Written informed consent was obtained after participants

were given a complete description of the study. Participantswere assessed in multiple sessions by experienced masters-levelclinical raters using semistructured interviews and standard-ized self-rated and interviewer-rated measures. Axis I diagnoses

were made using the Structured Clinical Interview for DSM-III-R(SCID; 14). DSM-IV criteria were used after that version was intro-duced. Axis II disorders were diagnosed using the International

Personality Disorders Examination, which has a lifetime timeframe (15), and borderline personality disorder was diagnosedusing the Diagnostic Interview for Borderline Patients (DIB; 16),

which has a 3-month to 2-year time frame for subsection scores.

The Diagnostic Interview for Borderline PatientsRevised (DIB-R)was added when that version became available (17), and it wasscored concurrently to preserve continuity with the longitudinalstudy. The DIB-R has a 2-year time frame. For inclusion in thestudy, participants met criteria for probable or denite bor-derline personality disorder on the International Personality Dis-orders Examination and denite on both versions of the DIB.Exclusion criteria included presence of schizophrenia, delusional(paranoid) disorder, schizoaffective disorder, any bipolar disor-der, psychotic depression, CNS pathology (e.g., organic mooddisorders and seizure disorder), drug or alcohol dependence,

physical disorders with known psychiatric consequences (e.g.,hypothyroidism), and borderline intellectual functioning (IQ


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Pre;iCTOrS OF SUiCi;Al BeHAViOr iN BOr;erliNe PerSONAliTY ;iSOr;er

In the 6-year interval, 25 participants (27.8%) reported

medically signicant suicide attempts. The survival curve

(Figure 1) illustrates the fact that most suicidal behavior

occurred in the rst 2 years (24.8% of 133 participants at

2 years) (13). Selected bivariate comparisons between

groups are presented in Table 1. (Bivariate comparisons for

all variables in the study are presented in Tables S1S6 in

the data supplement that accompanies the online editionof this article.) Attempters differed from nonattempters in

having signicantly lower socioeconomic status, less edu-

cation, and poorer social adjustment at baseline (p


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ing at year 6 was most signicant in the family, social, and

vocational subscales of the Social Adjustment Scale. Good

social support is a known protective factor against suicide,

buffering the adverse effects of negative life events, which

are prominent in the lives of patients with borderline per-

sonality disorder (31). Negative life events among patients

in the Collaborative Longitudinal Personality Disorders

Study predicted suicidal behavior in the month duringand preceding the adverse events (32). Poor GAF scores

at baseline and poor family relationships were signicant

predictors of poor psychosocial outcomes among border-

line patients at the 2-year follow-up (33). Functional im-

pairment in social relationships changed little despite im-

provement in diagnostic criteria (34). The McLean Study

of Adult Development found that half of the subjects with

borderline personality disorder failed to achieve social

and vocational recovery at the 10-year follow-up despite

symptomatic remission of diagnostic criteria in 93% (35).

Vocational failure contributed most to poor psychosocial

functioning. Suicidal and self-injurious behaviors remit-

ted early in the course of the McLean study (35); however,

symptomatic improvement did not prevent poor psycho-

social outcome in the long term. If the majority of border-

line patients can expect symptomatic remission in time,

who dies by suicide?

The attempters in our study are characterized by low

socioeconomic status, low educational achievement, and

poor psychosocial adjustment. Across many studies, poor

psychosocial functioning is a predictor of suicidal behav-

ior independent of diagnoses (5) and a predictor of high-

lethality attempts and suicide completion in some, but not

all, studies of borderline personality disorder (9) as well

attempts were predicted by major depressive disorder, an

acute stressor. Thereafter, no acute clinical stressors pre-

dicted attempts. Both of these results may be attributable

to illness severity and inpatient recruitment for nearly half

of this sample. The frequency of repeat suicide attempts

in the year after hospitalization for an index attempt has

been reported at 17%, independent of diagnosis (29). The

Collaborative Longitudinal Personality Disorders Study,a prospective study including borderline personality dis-

order, found that 20.5% of treatment-seeking borderline

patients attempted suicide during the rst 2 years of the

study (30). Worsening of major depressive disorder pre-

dicted suicide attempt in the following month in that

studys pooled personality disorders sample. Suicide at-

tempt after hospitalization (and predicted by major de-

pressive disorder) strongly suggests persisting depression.

Similarly, illness severity, marked by psychiatric hospi-

talizations in the follow-up interval (but preceding any

attempt), was predictive of subsequent attempt through

the fourth year of follow-up. Notably, any outpatient treat-

ment in the 12-month interval was associated with lower

suicide risk, suggesting the successful treatment of ma-

jor depressive disorder or decreased illness severity. The

absence of outpatient treatment remained a predictor of

suicide risk in the 6-year follow-up. The most consistent

predictors of suicide attempt across all intervals were

measures of psychosocial and global functioning. Poor

psychosocial functioning predicted increased risk of sui-

cidal behavior at 12 months, 2 years, and 6 years, while a

high GAS score at baseline was protective at 4- and 6-year

intervals. By the sixth year, low socioeconomic status was

also a predictor of high risk. Poor psychosocial function-

TABle 1. Chaactstcs of Sucd Attmpts and Nonattmpts n a Study of Pdctos of Sucda Bhavo n PatntsWth Bodn Psonaty ;sod

RiskFactor Attempters(N=25) Nonattempters(N=65) Analysis

N % N % c2 p

Female 19 76.0 48 73.8 0.06

Caucasian 18 72.0 54 83.0 1.30

Lowsocioeconomicstatus 13 52.0 18 27.7 4.51 0.03

Highschooldiploma 13 52.0 18 27.7 4.51 0.03

Majordepressivedisorder 11 44.0 37 56.9 1.08

Substanceabuse 16 64.0 38 58.5 0.29

Antisocialpersonalitydisorder 5 20.0 13 20.0 0.00

Familyhistoryosuicidea 2 8.0 0 0.0

Treatmentpriortoattemptb

Hospitalization 12 48.0 19 29.2 2.82 0.09

Outpatienttreatment 15 60.0 49 75.4 2.08

Psychiatricdrugs 12 48.0 19 29.2 2.82 0.09

Anytreatment 18 72.0 50 76.9 0.24

Mean SD Mean SD t

Age(years) 29.04 8.55 29.02 8.10 0.12

GlobalAssessmentScalescore 44.92 9.98 54.38 12.92 3.29 0.09

SocialAdjustmentScaleSel-

Reporttotalscore 2.78 0.61 2.40 0.64 2.37 0.02aFishersexacttest,p=0.08.bPriortoattemptindicatestreatmentthatoccurredintheintervalbetweenbaselineand6yearsbutbeorethefrstattemptintheinterval.



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To identify subjects who had increasing degrees of med-

ical lethality with recurrent attempts, we recently reported

a trajectory analysis of Lethality Rating Scale scores in bor-

derline patients who had three or more suicide attempts

(38). Two distinct patterns were identied: a low-lethality

group of subjects who had recurrent but minimally lethal

behaviors, and a high-lethality group who had increasingmedical lethality scores with recurrent attempts. Those

with the high-lethality trajectory were characterized by

inpatient recruitment (a severity marker) and poor psy-

chosocial functioning, while the low-lethality group had

more negativism, substance use disorders, and histrionic

or narcissistic comorbidity.

Our sample is still young (mean age=29 years) and early

in the trajectory of their suicidal behaviors. However, after

6 years of follow-up, we have observed that low socioeco-

nomic status, poor psychosocial adjustment, and absence

of outpatient treatment are predictors of suicidal behavior.

We suggest that these are characteristics of a poor progno-sis subtype. By follow-up at 4 and 6 years, a family history

of suicide is a prominent risk variable. This risk factor in-

cludes heritable biological traits that increase vulnerabil-

ity to suicidal behavior. The poor prognosis subtype may

include a biological diathesis to suicidal behavior.

We did not nd any predictive associations between

risk factors such as impulsivity or aggression, comorbidity

with antisocial personality disorder, history of childhood

maltreatment, and suicide attempts during the study in-

terval, although each of these factors has been associated

with suicidal behavior in borderline personality disorder

in cross-diagnostic studies, psychological autopsy studies,

as in nonclinical populations. Community members with

personality disorders who complete suicide have more

problems with relationships, jobs, unemployment, and

family compared with community members with no per-

sonality disorders who complete suicide (9). Community

subjects with borderline personality disorder have lower

educational and vocational achievement than subjectswith other personality disorders, and they are more likely

than other axis II patients to be receiving disability pay-

ments (36).

Recurrent suicidal behavior early in the course of bor-

derline personality disorder is often characterized by im-

pulsive, angry acts in response to acute stressors, such as

perceived rejection. These are communicative gestures

(i.e., impulsive behaviors with little lethal intent, objec-

tive planning, or medical consequences). Impulsivity in

borderline personality disorder is signicantly associated

with number of suicide attempts but not degree of medical

lethality (9). The McLean study found that manipulativesuicide efforts diminished with time, from 56.4% of sub-

jects at year 2 to 4.2% by year 10 (35). Completed suicide in

borderline personality disorder tends to occur after many

years of illness, failure to benet from treatment, loss of

supportive relationships, and social isolation. In their 27-

year naturalistic follow-up study, Paris and Zweig-Frank

(37) observed that borderline patients who completed

suicide had burned out their social supports and were

no longer involved in active treatment. The average age

at death was 37 years. This suggests that there may be a

high-lethality subgroup of borderline patients with poor

prognosis who are at greater risk over time.

TABle 2. Pospctv Pdctos n a Study of Sucda Bhavo n Patnts Wth Bodn Psonaty ;sod

Variable RelativeRisk 95%CI p

12months:increasedrisk

Baselinemajordepressiondisorder 13.23 3.3851.73


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The authors report no fnancial relationships with commercial in-

terests.

Supported by NIMH grant RO1 MH 048463 (Dr. Solo).

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or retrospective chart reviews of suicides (9). Impulsivity

is a diagnostic criterion for borderline personality disor-

der and is associated with number of suicide attempts but

not with medical lethality. The McLean study showed that

core symptoms of borderline personality disorder, includ-

ing impulsivity, diminish over a 10-year period (35). We

observed that such borderline symptoms had no predic-

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that substance use disorders are a risk factor for prema-

ture death in patients with borderline personality disor-

der. Substance use disorders are common in this sample

(59.6%). Although the diagnosis does not distinguish at-

tempters (64%) from nonattempters (57.8%) or prospec-

tively predict suicide attempts, the mortality associated

with substance use disorders in our sample is a strong

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ality Disorders Study at 7 years (39) to 4.1% in the McLean

study at 10 years (35). Recruitment source, which is related

to illness severity, and prospective study designs may in-

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operative participants who comply with repeated follow-

up interviews over many years. This design is required to

assess the predictive power of predened suicide risk fac-

tors; however, the resulting sample may exclude unstable

patients who are more likely to drop out of treatment and

complete suicide. With a mean age of 29 years, our sample

is still not in the age range of highest risk for suicide andmay experience further mortality in the years to come.

Our data suggest that outpatient treatment directed at

enhancing family, social, and vocational functioning de-

creases the likelihood of suicidal behavior in borderline

patients. However, our design does not permit inferences

on treatment effectiveness, which would require random

assignment to systematic treatments and comparison

with control conditions. In a naturalistic design, it is likely

that higher-functioning patients will choose to participate

in treatment (and get the most out of it), while lower-func-

tioning patients may not. This limits the interpretation of

treatment participation in our data. Current treatment

modalities for borderline personality disorder (e.g., dia-

lectical behavior therapy and pharmacotherapy) are fo-

cused on symptomatic relief. A psychiatric rehabilitation

model for borderline patients, emphasizing skills training

and family involvement, may be required to improve long-

term outcomes (40).

Presented at the 165th annual meeting o the American Psychiatric

Association, Honolulu, May 1418, 2011. Received Sept. 13, 2011; re-

vision received Dec. 13, 2011; accepted Dec. 23, 2011 (doi: 10.1176/

appi.ajp.2011.11091378). From the Department o Psychiatry, School

o Medicine, and the Department o Statistics at the University o Pitts-

burgh. Address correspondence to Dr. Solo ([email protected]).



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