This paper reviews recent advances in our understanding of suicidality in borderline personality disorder (BPD), with a focus on suicide risk assessment, guidelines for treatment, and medicolegal concerns. Relevant material on distinctions between suicide completers and suicide attempters, contributions of published American Psychiatric Association Guidelines, the controversial role of hospitalization, and management strategies regarding litigation is addressed. Despite accumulating data on suicidality in BPD, the current state of knowledge offers only partial clues to help identify the BPD patients most at risk of death by suicide, and offers a limited armamentarium of treatment targeted to suicide prevention, creating discomfort in clinicians and fears regarding litigation in the event of a successful suicide. Promising new interventions include less resource-intensive psychotherapies as well as brief crisis intervention.
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Dr. Goodman has received grant support the US Department of Defense and Veterans Administration and received honoraria from the Northern California Psychiatric Association.
Dr. Paris has received royalties from Guilford Press.
Ms. Roiff and Ms. Oakes reported no potential conflicts of interest relevant to this article.
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
American Psychiatric Association: Practice Guideline for the Treatment of Patients with Borderline Personality Disorder. Am J Psychiatry, 2001. 158(Oct suppl).Google Scholar
Paris J. Chronic suicidality among patients with borderline personality disorder. Psychiatr Serv. 2002;53:738–42.PubMedCrossRefGoogle Scholar
Gunderson JG, Ridolfi ME. Borderline personality disorder. Suicidality and self-mutilation. Ann N Y Acad Sci. 2001;932:61–73.PubMedCrossRefGoogle Scholar
Soloff PH, Fabio A, Kelly TM, et al. High-lethality status in patients with borderline personality disorder. J Pers Disord. 2005;19:386–99.PubMedCrossRefGoogle Scholar
American Psychiatric Association: Practice Guideline for the Assessment and Treatment of Patients with Suicidal Behaviors. Am J Psychiatry 2003, 160(Nov suppl. The complete guideline, including Parts A and B, was published in May 2004 as a compendium and is available at: http://www.psych.org/psych_pract/treatg/pg/pg_suicidalbehaviors).
••McGirr A, Paris J, Lesage A, et al.: An examination of DSM-IV borderline personality disorder symptoms and risk for death by suicide: a psychological autopsy study. Can J Psychiatry 2009, 54:87–92. This important paper examines the role of BPD criteria in suicide completion using psychological autopsy.PubMedGoogle Scholar
McGirr A, Paris J, Lesage A, et al. Risk factors for suicide completion in borderline personality disorder: a case-control study of cluster B comorbidity and impulsive aggression. J Clin Psychiatry. 2007;68:721–9.PubMedCrossRefGoogle Scholar
Korzekwa MI, Dell PF, Links PS, et al. Estimating the prevalence of borderline personality disorder in psychiatric outpatients using a two-phase procedure. Compr Psychiatry. 2008;49:380–6.PubMedCrossRefGoogle Scholar
Stone M. Fate of borderline personality disorder patients. New York: Guilford; 1990.Google Scholar
Paris J. Half in love with easeful death: the meaning of chronic suicidality in borderline personality disorder. Harv Rev Psychiatry. 2004;12:42–8.PubMedGoogle Scholar
Pompili M, Girardi P, Ruberto A, Tatarelli R. Suicide in borderline personality disorder: a meta-analysis. Nord J Psychiatry. 2005;59:319–24.PubMedCrossRefGoogle Scholar
Lesage AD, Boyer R, Grunberg F, et al. Suicide and mental disorders: a case-control study of young men. Am J Psychiatry. 1994;151:1063–8.PubMedGoogle Scholar
Berk MS, Jeglic E, Brown GK, et al. Characteristics of recent suicide attempters with and without Borderline Personality Disorder. Arch Suicide Res. 2007;11:91–104.PubMedCrossRefGoogle Scholar
Brodsky BS, Groves SA, Oquendo MA, et al. Interpersonal precipitants and suicide attempts in borderline personality disorder. Suicide Life Threat Behav. 2006;36:313–22.PubMedCrossRefGoogle Scholar
Horesh N, Sever J, Apter A. A comparison of life events between suicidal adolescents with major depression and borderline personality disorder. Compr Psychiatry. 2003;44:277–83.PubMedCrossRefGoogle Scholar
Soloff PH, Lynch KG, Kelly TM. Childhood abuse as a risk factor for suicidal behavior in borderline personality disorder. J Pers Disord. 2002;16:201–14.PubMedCrossRefGoogle Scholar
•Chesin MS, Jeglic EL, Stanley B: Pathways to high-lethality suicide attempts in individuals with borderline personality disorder. Arch Suicide Res 2010, 14:342–62. This rigorous paper examines path analysis to high-lethality suicide in BPD.PubMedCrossRefGoogle Scholar
Clark DC, Gibbons RD, Fawcett J, Scheftner WA. What is the mechanism by which suicide attempts predispose to later suicide attempts? A mathematical model. J Abnorm Psychol. 1989;98:42–9.PubMedCrossRefGoogle Scholar
••Soloff PH, Fabio A: Prospective predictors of suicide attempts in borderline personality disorder at one, two, and two-to-five year follow-up. J Pers Disord 2008, 22:123–34. This was a prospective study examining suicide attempts in BPD.PubMedCrossRefGoogle Scholar
Garcia-Forero C, Gallardo-Pujol D, Maydeu-Olivares A, Andres Pueyo A. Disentangling impulsiveness, aggressiveness and impulsive aggression: an empirical approach using self-report measures. Psychiatry Res. 2009;168:40–9.PubMedCrossRefGoogle Scholar
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;63:757–66.PubMedCrossRefGoogle Scholar
Bateman A, Fonagy P. Effectiveness of partial hospitalization in the treatment of borderline personality disorder: a randomized controlled trial. Am J Psychiatry. 1999;156:1563–9.PubMedGoogle Scholar
Kernberg OF, Yeomans FE, Clarkin JF, Levy KN. Transference focused psychotherapy: overview and update. Int J Psychoanal. 2008;89:601–20.PubMedCrossRefGoogle Scholar
Mehlum L. Clinical challenges in the assessment and management of suicidal behaviour in patients with borderline personality disorder. Epidemiol Psichiatr Soc. 2009;18:184–90.PubMedGoogle Scholar
Blum N, St John D, Pfohl B, et al. Systems Training for Emotional Predictability and Problem Solving (STEPPS) for outpatients with borderline personality disorder: a randomized controlled trial and 1-year follow-up. Am J Psychiatry. 2008;165:468–78.PubMedCrossRefGoogle Scholar
Stanley B, Brodsky B, Nelson JD, Dulit R. Brief dialectical behavior therapy (DBT-B) for suicidal behavior and non-suicidal self injury. Arch Suicide Res. 2007;11:337–41.PubMedCrossRefGoogle Scholar
Zanarini MC, Frankenburg FR. A preliminary, randomized trial of psychoeducation for women with borderline personality disorder. J Pers Disord. 2008;22:284–90.PubMedCrossRefGoogle Scholar
Stanley B, Siever LJ. The interpersonal dimension of borderline personality disorder: toward a neuropeptide model. Am J Psychiatry. 2010;167:24–39.PubMedCrossRefGoogle Scholar
Hopko DR, Sanchez L, Hopko SD, et al. Behavioral activation and the prevention of suicidal behaviors in patients with borderline personality disorder. J Pers Disord. 2003;17:460–78.PubMedCrossRefGoogle Scholar
•Zaheer J, Links PS, Liu E: Assessment and emergency management of suicidality in personality disorders. Psychiatr Clin North Am 2008, 31:527–43, viii–ix. This paper reviews the epidemiology of suicide and BPD and provides an approach to the suicidal patient presenting in the emergency department.Google Scholar
Black DW, Blum N, Pfohl B, Hale N. Suicidal behavior in borderline personality disorder: prevalence, risk factors, prediction, and prevention. J Pers Disord. 2004;18:226–39.PubMedCrossRefGoogle Scholar
Vijay NR, Links PS. New frontiers in the role of hospitalization for patients with personality disorders. Curr Psychiatry Rep. 2007;9:63–7.PubMedCrossRefGoogle Scholar
Linehan MM. Cognitive behavioral therapy of borderline personality disorder. New York: Guilford; 1993.Google Scholar
Dawson D, MacMillan HL. Relationship management of the borderline patient: from understanding to treatment. New York: Brunner/Mazel; 1993.Google Scholar
Chiesa M, Fonagy P, Holmes J, Drahorad C. Residential versus community treatment of personality disorders: a comparative study of three treatment programs. Am J Psychiatry. 2004;161:1463–70.PubMedCrossRefGoogle Scholar
Berrino A, Ohlendorf P, Duriaux S, et al. Crisis intervention at the general hospital: an appropriate treatment choice for acutely suicidal borderline patients. Psychiatry Res. 2011;186:287–92.PubMedCrossRefGoogle Scholar
Chemtob CM, Hamada RS, Bauer G, et al. Patients’ suicides: frequency and impact on psychiatrists. Am J Psychiatry. 1988;145:224–8.PubMedGoogle Scholar
Hendin H, Haas AP, Maltsberger JT, et al. Factors contributing to therapists’ distress after the suicide of a patient. Am J Psychiatry. 2004;161:1442–6.PubMedCrossRefGoogle Scholar
Krawitz R, Batcheler M. Borderline personality disorder: a pilot survey about clinician views on defensive practice. Australas Psychiatry. 2006;14:320–2.PubMedGoogle Scholar
Blinder M. Suicide, psychiatric malpractice, and the bell curve. J Am Acad Psychiatry Law. 2004;32:319–23.PubMedGoogle Scholar
Krawitz R, Jackson W, Allen R, et al. Professionally indicated short-term risk-taking in the treatment of borderline personality disorder. Australas Psychiatry. 2004;12:11–7.PubMedCrossRefGoogle Scholar
Maltsberger JT. Calculated risk taking in the treatment of suicidal patients: ethical and legal concerns. Death Stud. 1994;18:439–52.PubMedCrossRefGoogle Scholar