Evidence-Based Reviews

Beyond threats: Risk factors for suicide in borderline personality disorder

Current Psychiatry. 2009 May;8(5):33-41

References

1. American Psychiatric Association. Practice guideline for the treatment of patients with borderline personality disorder. Am J Psychiatry. 2001;158(suppl 10):1-52.

2. Zanarini MC, Frankenburg FR, Hennen J, et al. The McLean study of adult development: overview and implications of the first six years of prospective follow-up. J Personal Disord. 2005;19(5):505-523.

3. Paris J. Chronic suicidality among patients with borderline personality disorder. Psychiatr Serv. 2002;53(6):738-742.

4. Diagnostic and statistical manual of mental disorders, 4th ed, text rev. Washington DC: American Psychiatric Association; 2000.

5. O’Carroll PW, Berman AL, Maris RW, et al. Beyond the Tower of Babel: a nomenclature for suicidology. Suicide Life Threat Behav. 1996;26(3):237-252.

6. Miller AL, Rathus JH, Linehan MM. Dialectical behavior therapy with suicidal adolescents. New York, NY: Guilford; 2007.

7. Brown MZ, Comtois KA, Linehan MM. Reasons for suicide attempts and nonsuicidal self-injury in women with borderline personality disorder. J Abnorm Psychol. 2002;111(1):198-202.

8. Berk MS, Jeglic E, Brown GK, et al. Characteristics of recent suicide attempters with and without borderline personality disorder. Arch Suicide Res. 2007;11(1):91-104.

9. Soloff PH, Lynch KG, Kelly TM, et al. Characteristics of suicide attempts of patients with major depressive episode and borderline personality disorder: a comparative study. Am J Psychiatry. 2000;157(4):601-608.

10. Paris J, Nowlis D, Brown R. Predictors of suicide in borderline personality disorder. Can J Psychiatry. 1989;34(1):8-9.

11. Paris J. Completed suicide in borderline personality disorder. Psychiatr Ann. 1990;20:19-21.

12. Soloff PH, Fabio A. Prospective predictors of suicide attempts in borderline personality disorder at one, two, and two-to-five year follow-up. J Personal Disord. 2008;22(2):123-134.

13. Oldham JM. Borderline personality disorder and suicidality. Am J Psychiatry. 2006;163(1):20-26.

14. Black DW, Blum N, Pfohl B, et al. Suicidal behavior in borderline personality disorder: prevalence, risk factors, prediction, and prevention. J Personal Disord. 2004;18(3):226-239.

15. Kolla NJ, Eisenberg H, Links PS. Epidemiology, risk factors, and psychopharmacological management of suicidal behavior in borderline personality disorder. Arch Suicide Res. 2008;12(1):1-19.

16. McGirr A, Paris J, Lesage A. Risk factors for suicide completion in borderline personality disorder: a case control study of cluster B comorbidity and impulsive aggression. J Clin Psychiatry. 2007;68:721-729.

17. Mann JJ, Apter A, Bertolote J, et al. Suicide prevention strategies: a systematic review. JAMA. 2005;294(16):2064-2074.

18. Linehan MM. Cognitive-behavioral treatment of borderline personality disorder. New York, NY: Guilford Press; 1993.

19. Berk MS, Henriques GR, Warman DM, et al. Cognitive therapy for suicide attempters: overview of the treatment and case examples. Cogn Behav Pract. 2004;11:265-277.

20. Wenzel A, Brown GK, Beck AT. Cognitive therapy for suicidal patients: scientific and clinical applications. Washington, DC: APA Books; 2008.

21. Linehan MM, Armstrong HE, Suarez A, et al. Cognitive behavioral treatment of chronically parasuicidal borderline patients. Arch Gen Psychiatry. 1991;48(12):1060-1064.

22. Linehan MM, Comtois KA, Murray AM, et al. Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder. Arch Gen Psychiatry. 2006;63(7):757-766.

23. Beck AT, Steer RA, Brown GK. The Beck Depression Inventory, 2nd ed. San Antonio, TX: Psychological Corporation; 1996.

24. Paris J. Is hospitalization useful for suicidal patients with borderline personality disorder? J Personal Disord. 2004;18(3):240-247.

25. Clarkin JF, Levy KN, Lenzenweger MF, et al. Evaluating three treatments for borderline personality disorder: a multiwave study. Am J Psychiatry. 2007;164(6):1-7.

26. Bateman A, Fonagy P. Effectiveness of partial hospitalization in the treatment of borderline personality disorder: a randomized controlled trial. Am J Psychiatry. 1999;156(10):1563-1569.

27. Brown GK, Newman CF, Charlesworth SE, et al. An open clinical trial of cognitive therapy for borderline personality disorder. J Personal Disord. 2004;18(3):257-271.

28. Brown GK, Tenhave T, Henriques GR, et al. Cognitive therapy for the prevention of suicide attempts: a randomized controlled trial. JAMA. 2005;294(5):563-570.

29. Benedetti F, Sforzini L, Colombo C, et al. Low-dose clozapine in acute and continuation treatment of severe borderline personality disorder. J Clin Psychiatry. 1998;59(3):103-107.

30. Chengappa KN, Ebeling T, Kang JS, et al. Clozapine reduces severe self-mutilation and aggression in psychotic patients with borderline personality disorder. J Clin Psychiatry. 1999;60(7):477-484.

31. Schulz SC, Camlin KL, Berry SA, et al. Olanzapine safety and efficacy in patients with borderline personality disorder and comorbid dysthymia. Biol Psychiatry. 1999;15;46(10):1429-1435.

32. Rocca P, Marchiaro L, Cocuzza E, et al. Treatment of borderline personality disorder with risperidone. J Clin Psychiatry. 2002;63(3):241-244.

33. Nickel MK, Muehlbacher M, Nickel C, et al. Aripiprazole in the treatment of patients with borderline personality disorder: a double-blind, placebo-controlled study. Am J Psychiatry. 2006;163(5):833-838.

34. Nickel MK, Loew TH, Pedrosa Gil F. Aripiprazole in treatment of borderline patients, part II: an 18-month follow-up. Psychopharmacology (Berl). 2007;191(4):1023-1026.

35. Coccaro E, Kavoussi R. Fluoxetine and impulsive aggressive behavior in personality disordered subjects. Arch Gen Psychiatry. 1997;54:1081-1088.

36. Kallioniemi H, Syvalahti E. Citalopram, a specific inhibitor of serotonin reuptake, in treatment of psychotic and borderline patients. Nord J Psychiatry. 1993;47(suppl 28):79-84.

37. Kavoussi R, Liu J, Coccaro E. An open trial of sertraline in borderline personality disordered patients with impulsive aggression. J Clin Psychiatry. 1994;55:137-141.

38. FDA public health advisory: suicidality in children and adolescents being treated with antidepressant medications. Silver Spring, MD: U.S. Food and Drug Administration; October 15, 2004. Available at: http://www.fda.gov/cder/drug/antidepressants/SSRIPHA200410.htm. Accessed March 18, 2009.

39. Medication guide: about using antidepressants in children and teenagers. Silver Spring, MD: U.S. Food and Drug Administration; 2005. Available at: http://www.fda.gov/cder/drug/antidepressants/MG_template.pdf. Accessed March 18, 2009.

Box 2

‘Hope kit’ can help patients cope with suicidal crises

A ‘hope kit’ can be an extremely useful intervention with recent suicide attempters.^18,19 In a randomized, controlled trial, use of a hope kit as part of cognitive therapy for recent suicide attempters decreased suicide attempt rates by approximately 50%, compared with treatment as usual plus case management.²⁷

Instruct the patient to fill a box or container with tangible reminders of reasons to live (such as photos of loved ones) and cues to use coping skills (a relaxation tape, a comic book, music, positive written self-statements). Tell the patient to keep the hope kit easily accessible and use it to guide positive coping during a suicidal crisis.

Symptom-guided medication

Use pharmacotherapy to complement psychotherapy for BPD and to address comorbid Axis I conditions. The BPD symptom domains targeted by medications may be sorted into 3 categories: ( Table 4 ):¹

affective dysregulation
impulsive behavioral dyscontrol
cognitive and perceptual problems.

Clinical Point

Whenever suicidality or self-injury has occurred, make this the priority of the therapy session, before any other topics are discussed

Because impulsivity, comorbid major depression, and affective instability are risk factors for suicidal behavior in BPD patients, adjunctive pharmacology is critical in managing the safety of these patients.

Recommendations for pharmacologic management in BPD are based on a relatively small number of studies. Medication can decrease symptoms and increase the patient’s ability and willingness to engage in therapy. However, no drug has been proven effective or received FDA approval to treat BPD. Thus, our prescribing recommendations—though based on available evidence—are off-label uses.

In our experience, BPD patients often are prescribed multiple medications, probably because no single medication targets all symptoms of the disorder. To avoid the accumulation of medications that have lost or have not demonstrated therapeutic effect, we recommend caution when addressing BPD pathology with polypharmacy.

Table 4

Symptom-guided approach to medication for BPD patients

Symptom domain	Medication(s)
Affective dysregulation	SSRI (first-line) or mood stabilizer (second-line)
Impulsive behavioral dyscontrol	SSRI and/or low-dose atypical antipsychotic
Cognitive and perceptual problems, acute dissociation/psychotic symptoms	Low-dose atypical antipsychotic
Acute anxiety (severe)	Low-dose atypical antipsychotic
Chronic anxiety	SSRI
BPD: borderline personality disorder; SSRI: selective serotonin reuptake inhibitor
Source: Reference 1

Medication classes used for treating BPD symptoms are described below. Because of BPD symptom heterogeneity (in quality and quantity), we cannot recommend specific dosages. In general, we suggest starting with the lowest dosage recommended for a particular symptom and increasing slowly if needed.^1,29-34

Antidepressants. APA guidelines suggest a selective serotonin reuptake inhibitor (SSRI) as the first-line initial treatment for affective dysregulation and impulsive behavioral dyscontrol.^1,35-37 Because reports have shown increased risk of suicidal thoughts and behaviors with SSRI use in children, adolescents, and young adults,³⁸ follow FDA guidelines for monitoring these populations during the first 12 weeks of therapy.³⁹

Clinical Point

APA guidelines consider SSRIs first-line treatment for affective dysregulation and impulsive behavior in patients with BPD

Antipsychotics. Over the long term, low-dose atypical antipsychotics are the treatment of choice for cognitive and perceptual problems in BPD. Clozapine, olanzapine, risperidone, and aripiprazole also have been reported as useful in reducing impulse behaviors and ameliorating severe NSIB.^29-34

Dosages typically are lower than those used to treat Axis I psychotic disorders. Because of clozapine’s complex maintenance and potential for side effects, consider using it only after trials of other antipsychotics have failed. Also consider short-term antipsychotic use to manage acute symptoms such as dissociation, intense paranoia, hostility, or severe anxiety.

Agents to consider with caution. Because of the potential for abuse, tolerance, overdose, and behavioral disinhibition, be very cautious when using benzodiazepines to treat chronic and acute anxiety in BPD patients.¹

Clinical Point

Over the long term, low-dose atypical antipsychotics are the treatment of choice for cognitive and perceptual problems in BPD

Mood stabilizers may be effective for mood symptoms and to decrease the severity of impulsive aggression. You might use them as a second choice after failed attempts with SSRIs and/or antipsychotics, while very carefully considering the likelihood of overdose.¹

Tricyclic antidepressants and monoamine oxidase inhibitors are at times recommended for medication-resistant patients. Avoid these drugs in highly suicidal BPD patients because of the potential for lethal overdose.

Related resources

Linehan MM. Cognitive-behavioral treatment of borderline personality disorder. New York, NY: Guilford Press; 1993.
Berk MS, Henriques GR, Warman DM, et al. Cognitive therapy for suicide attempters: overview of the treatment and case examples. Cognit Behav Pract. 2004;11:265-277.
Behavioral Tech, LLC. Training courses in dialectical behavior therapy. www.behavioraltech.org.

Drug brand names

Aripiprazole • Abilify
Clozapine • Clozaril
Olanzapine • Zyprexa
Risperidone • Risperdal