Manipulative, “just threats,” or suicide gestures are terms you may have heard or used to label suicidal thoughts and behavior in individuals with borderline personality disorder (BPD). These terms imply that the risk of injury or death is low, but evidence shows that BPD patients are at high risk for completed suicide1-3 —and clinicians who use these labels may underestimate this risk and respond inadequately.
BPD is the only personality disorder to have suicidal or self-injurious behavior among its diagnostic criteria.2 A prospective study showed a 3.8% completed suicide rate in a sample of borderline patients at 6-year follow-up.2 Earlier studies reported rates from 8% to 10%—approximately 50 times greater than the general population.1
Recent suicide attempts by individuals with BPD have shown:
- the same degree of lethality and intent to die ( Box 1 )5-7 as recent suicide attempts by individuals without BPD8
- no differences in degree of intent to die compared with attempts by persons experiencing a major depressive episode or persons with both BPD and depression.9
Moreover, patients with BPD (including those with comorbid depression) have reported greater lethality for their most serious life-time suicide attempt than those with depression alone.9
Based on the literature and our clinical experience, this article offers recommendations for assessing and treating suicidal behavior in BPD patients. We review risk factors for suicide and suicide attempts and suggest strategies for safety management, psychotherapy, and pharmacotherapy. Because of the high-risk nature of this population, we recommend that all clinicians working with suicidal BPD patients obtain consultation and supervision as needed when using these strategies.
Self-injury: Address all potentially harmful behaviors
Self-injurious behavior in borderline personality disorder (BPD) patients can be divided into 2 categories: suicide attempts and nonsuicidal self-injury.
- Suicide attempts are performed with some evidence of intent to die.5
- Nonsuicidal self-injury behaviors (NSIB) are performed without intent to die.6
How can clinicians respond effectively when suicidal behaviors are repetitive and performed both with and without the intent to die? Although patients may perform NSIB for reasons other than intent to die (such as to express anger, punish oneself, or relieve distress),7 these behaviors require active intervention because of the possibility of serious injury (intentional or accidental). Also, the intent of a self-injurious behavior may change as the patient performs the behavior; what started as a nonsuicidal act may turn into a suicide attempt.6 Therefore, address all potentially harmful behaviors.
Risk factors for suicidal behavior
Several risk factors for suicide attempts and completed suicide among individuals diagnosed with BPD have been identified. Previous suicide attempts are one of the strongest predictors of completed suicide and suicide attempts in individuals with BPD.10-12 In general, clinicians cannot accurately predict which individuals will die by suicide.10,13 Suicide risk factors identified in BPD ( Table 1 )12-16 are similar to those in persons without the BPD diagnosis. In BPD patients, risk factors for attempted and completed suicide largely overlap.
Individuals with BPD may be distinguished by elevated risk factors for suicidal behavior as compared with suicide attempters without the BPD diagnosis. In a study comparing recent suicide attempters with and without BPD, those with BPD showed greater severity across a number of risk factors, including overall psychopathology, depression, hopelessness, suicide ideation, past suicide attempts, and social problem solving skills.8
Table 1
Common risk factors for suicidal behavior in BPD
| Behavioral factors Previous suicide attempts Impulsivity Aggression Poor social problem-solving skills Poor social adjustment |
| Cognitive/emotional factors Affective instability Hopelessness |
| Comorbid diagnoses Major depressive disorder Antisocial personality disorder Substance abuse disorders |
| Psychosocial/psychiatric history Childhood physical abuse Childhood sexual abuse Psychiatric hospitalizations |
| BPD: borderline personality disorder |
| Source: References 12-16 |
Remove lethal means
When working with patients with a history of suicidal behavior, it is critical to ensure the safety of the patient’s environment. Restricting access to lethal means has been shown to be an effective form of suicide prevention.17 Direct all patients with a history of recent suicidality or nonsuicidal self-injurious behavior (NSIB) to remove lethal means and means of self-harm from their homes and possession ( Table 2 ). Continue to monitor access to lethal means throughout treatment, as patients may acquire new means or reveal possession of items they had previously concealed.