Suicide attempts occurred most frequently in the first two years of follow-up (e.g. 19% of 137 subjects in the first 12 months, 24.8% of 133 subjects by the second year). Thereafter, the number of new attempts decreased rapidly with time. Prospective predictors changed dramatically over time. In the shortest interval (12 months), attempts were predicted by MDD, an acute stressor. Thereafter, no acute clinical stressors predicted interval attempts. Both of these results may be attributable to illness severity and inpatient recruitment for nearly half of this sample. Frequency of repeat suicide attempts in the year following hospitalization for an index attempt has been reported at 17%, independent of diagnosis (29
). The Collaborative Longitudinal Personality Disorders Study (CLPS), a prospective study of 4 PDs, including BPD, found that 20.5% of treatment seeking BPD patients attempted suicide during the first 2 years of study (30
). Worsening of MDD predicted suicide attempts in the following month in their pooled PD sample. Suicide attempt following hospitalization, (and predicted by MDD), strongly suggests persisting depression. Similarly, illness severity, marked by psychiatric hospitalizations in the follow-up interval (but preceding any attempt), was predictive of subsequent attempt through the 4th
year of follow-up. It is noteworthy that any OPD treatment in the 12 month interval diminished the suicide risk, and suggests this is due to successful treatment of MDD or decreased illness severity. Importantly, absence of OPD treatment remained a predictor of suicide risk to the 6 year follow-up.
The most consistent predictors of suicide attempts across all time intervals were measures of psychosocial and global function. Poor psychosocial function (assessed by SAS-sr) predicted increased risk of suicidal behavior at 12 months, 2 years and 6 years, while high baseline GAS was protective at 4 and 6 year intervals. By year 6, low SES was also a predictor of high risk. Poor psychosocial function at year 6 was most significant in the family, social and vocational subscales of the SAS-sr. 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 BPD (31
). Negative life events among patients in the CLPS (especially in matters of love and marriage, or crime and legal events), predicted suicidal behavior in the month during and preceding the adverse events (32
). Poor baseline GAF scores and poor family relationships were among the significant predictors of poor psychosocial outcomes (low GAF scores) in BPD patients followed for 2 years in the CLPS study (33
). Functional impairment in social relationships changed little in BPD patients in this time frame despite improvement in diagnostic criteria (34
). The McLean Study of Adult Development found that half of BPD subjects failed to achieve social and vocational recovery at 10 year follow-up despite symptomatic remission of BPD diagnostic criteria in 93% (35
). Vocational failure contributed most to poor psychosocial functioning in this study. Suicidal and self-injurious behaviors remitted early in the course of the McLean study (35
); however, symptomatic improvement did not prevent poor psychosocial outcome in the long term. If the majority of BPD subjects can expect symptomatic remission in time, who dies by suicide?
Our interval attempters are characterized by low SES, low educational achievement and poor psychosocial adjustment. Across many studies, poor psychosocial function (defined by SES, social relationships, educational and vocational achievement) is a predictor of attempt behavior independent of diagnoses (5
), of high lethality attempts, and suicide completion in some, though not all, studies of BPD (9
), and in non-clinical populations. Community subjects with personality disorders (PD), including BPD, who complete suicide, have more problems with loss of relationships, jobs, unemployment and family compared to suicides with no PD. (9
). Community subjects with BPD have lower educational and vocational achievement than subjects with other PDs, and are more likely to be receiving disability payments compared to other Axis II patients (36
Recurrent suicidal behaviors early in the course of BPD are often characterized by impulsive, angry acts in response to acute stressors, such as perceived rejection. These are “communicative gestures,” i.e. impulsive behaviors with little lethal intent, objective planning or medical consequences. Impulsivity in BPD is significantly associated with number of suicide attempts but not degree of medical lethality (9
). The McLean Study found that “manipulative suicide efforts” diminished rapidly with time, from 56.4% of subjects at year 2 to 16.4% at 6 years of follow-up, and 4.2% by year 10 (37
). Completed suicide in BPD may occur after many years of illness, failed treatment, loss of supportive relationships, and social isolation. In their 27 year naturalistic follow-up study, Paris & Zweig-Frank (2001) (38
) found that BPD 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 poor prognosis, high lethality subgroup of BPD patients who are at greater risk over time.
To identify subjects who had increasing degrees of medical lethality with recurrent attempts, we recently reported a trajectory analysis of Lethality Rating Scale scores in BPD subjects who had 3 or more suicide attempts. Two distinct patterns were identified: a low lethality group of subjects with recurrent but minimally lethal behaviors, and a high lethality group with increasing medical lethality scores with recurrent attempts (39
). Subjects with the high lethality trajectory were characterized by inpatient recruitment (a severity marker), and poor psychosocial function, while the low lethality group had more negativism, substance use disorders, histrionic and/or narcissistic co-morbidity.
Our sample is still young (mean age 29 years) and early in the suicidal process. However, after 6 years of follow-up, low SES, poor psychosocial adjustment and absence of OPD treatment are predictors of suicidal behavior. We suggest that these are characteristics of a poor prognosis subtype. By 4 and 6 years of follow-up, a family history of suicide is a prominent risk variable. This risk factor includes heritable biological traits which increase the vulnerability to suicidal behavior. The poor prognosis subtype may include a biologic diathesis to suicidal behavior.
We did not find any predictive associations between risk factors such as impulsivity or aggression (BIS, LHA), co-morbidity with ASPD, histories of childhood maltreatment, and interval suicidal attempts, although each of these factors has been associated with suicidal behavior in BPD in cross-diagnostic studies (9
). Impulsivity is a diagnostic criterion for BPD, and is associated with number of suicide attempts, but not with medical lethality. Impulsive-aggression is an endophenotypic trait of temperament, mediated by diminished central serotonergic function, and associated with suicidal behavior in BPD and across diagnoses (12
). This heritable trait may be represented in our study by the family history of suicide.
Acute symptoms are unlikely to have predictive value for suicidal behavior in the long term course. The McLean study showed that acute symptoms remitted early in the course of BPD (i.e. remission rate exceeding 60% by 6 years) (37
). In the CLPS, suicide attempts were predicted by childhood sexual abuse (40
). Childhood sexual abuse is a known risk factor for suicidal behavior in BPD, and is associated with neurobiologic changes, including chronic dysregulation of the HPA, volume loss in areas of prefrontal cortex, hippocampus and amygdala, and diminished central serotonergic function (measured by the prolactin response to serotonergic pharmacologic challenge.) The increased frequency of suicidal behavior in sexually abused females with BPD, compared to non-abused BPD controls may be related to the effects of this altered neurobiology on behavior, including a diathesis to impulsivity, aggression, PTSD, and MDD.
Our mortality experience suggests that Substance Use Disorders (SUD), are a risk factor for premature death in subjects with BPD. Substance Use Disorders are ubiquitous in this sample (59.6%). Although the diagnosis does not distinguish interval attempters (64%) from non-attempters (57.8%), or prospectively predict suicide attempts, the mortality associated with SUD in our sample is a strong argument for early diagnosis and intervention for this co-morbid condition.
Finally, our data suggest that early OPD treatment directed at enhancing family, social and vocational functioning would decrease long term suicide risk in BPD. Current treatment modalities for BPD (e.g. DBT, pharmacotherapy) are focused on symptomatic relief. Efforts to increase overall psychosocial function may be more relevant to long term prognosis. A rehabilitation model of treatment (as in the treatment of schizophrenia) may be required to optimize outcome in BPD.