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          Original Investigation
          November?18, 2020

          Association of Borderline Personality Disorder Criteria With Suicide Attempts: Findings From the Collaborative Longitudinal Study of Personality Disorders Over 10 Years of Follow-up

          Author Affiliations
          • 1Beth Israel Deaconess Medical Center, Massachusetts Mental Health Center, Harvard Medical School, Boston, Massachusetts
          • 2Alpert Medical School, Brown University, Providence, Rhode Island
          • 3Yale Medical School, New Haven, Connecticut
          • 4Wesleyan University, Middletown, Connecticut
          • 5Providence Veterans Affairs Medical Center, Providence, Rhode Island
          • 6McLean Hospital, Harvard Medical School, Belmont, Massachusetts
          • 7Texas A&M University, Phoenix, Arizona
          • 8University of Arizona College of Medicine, Phoenix
          JAMA Psychiatry. Published online November 18, 2020. doi:10.1001/jamapsychiatry.2020.3598
          Key Points

          Question? Are borderline personality disorder (BPD) and its specific diagnostic criteria associated with who reports a suicide attempt(s) over 10 years of prospective follow-up?

          Findings? In this longitudinal study of adults with personality disorders, after controlling for significant demographic and other clinical risk factors, BPD and the specific criteria of identity disturbance, chronic feelings of emptiness, and frantic efforts to avoid abandonment emerged as significant factors associated with prospectively observed suicide attempt status.

          Meaning? Identity disturbance, chronic feelings of emptiness, and frantic efforts to avoid abandonment may be clinically overlooked features of BPD in context of suicide risk assessment.

          Abstract

          Importance? Borderline personality disorder (BPD) has been identified as a strong risk factor for suicidal behavior, including suicide attempts. Delineating specific features that increase risk could inform interventions.

          Objective? To examine factors associated with prospectively observed suicide attempts among participants in the Collaborative Longitudinal Study of Personality Disorders (CLPS), over 10 years of follow-up, with a focus on BPD and BPD criteria.

          Design, Setting, and Participants? The CLPS is a multisite, naturalistic, prospective study of adult participants with 4 personality disorders (PDs) and a comparison group of adults with major depressive disorder and minimal PD features. Participants were all treatment-seeking and recruited from inpatient, partial, and outpatient treatment settings across New York, New York, Boston, Massachusetts, New Haven, Connecticut, and Providence, Rhode Island. A total of 733 participants were recruited at baseline, with 701 completing at least 1 follow-up assessment. The cohorts were recruited from September 1996 through April 1998 and September 2001 through August 2002. Data for this study using this follow-up sample (N?=?701) were analyzed between March 2019 and August 2020.

          Main Outcomes and Measures? Participants were assessed annually using semistructured diagnostic interviews and a variety of self-report measures for up to 10 years. Multiple logistic regression analyses were used to examine baseline demographic and clinical risk factors, including BPD and individual BPD criteria, of suicide attempt assessed over 10 years of prospective follow-up.

          Results? Of the 701 participants, 447 (64%) identified as female, 488 (70%) as White, 527 (75%) as single, 433 (62%) were unemployed, and 512 (73%) reported at least some college education. Of all disorders, BPD emerged as the most robust factor associated with prospectively observed suicide attempt(s) (odds ratio [OR], 4.18; 95% CI, 2.68-6.52), even after controlling for significant demographic (sex, employment, and education) and clinical (childhood sexual abuse, alcohol use disorder, substance use disorder, and posttraumatic stress disorder) factors. Among BPD criteria, identity disturbance (OR, 2.21; 95% CI, 1.37-3.56), chronic feelings of emptiness (OR, 1.63; 95% CI, 1.03-2.57), and frantic efforts to avoid abandonment (OR, 1.93; 95% CI, 1.17-3.16) emerged as significant independent factors associated with suicide attempt(s) over follow-up, when covarying for other significant factors and BPD criteria.

          Conclusions and Relevance? In the multisite, longitudinal study of adults with personality disorders, identity disturbance, chronic feelings of emptiness, and frantic efforts to avoid abandonment were significantly associated with suicide attempts. Identity disturbance, chronic feelings of emptiness, and frantic efforts to avoid abandonment may be clinically overlooked features of BPD in context of suicide risk assessment. In light of the high rates of BPD diagnostic remission, our findings suggest that these criteria should be independently assessed and targeted for further study as suicide risk factors.

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