Understanding chronic suicidality in borderline personality disorder through comparison with depressive disorder: a systematic review

ABSTRACT

Objective

Chronic suicide risk identification in borderline personality disorder (BPD) is fundamental to risk tolerant intervention. To further the clinical understanding of chronic risk in BPD, this systematic review examined studies which compared factors associated with suicidality in BPD with those in any depressive disorder (DD).

Method

Databases PsycINFO, Medline Complete, EMBASE, and Proquest Dissertations and Theses Global were systematically searched using a set of relevant search terms. Studies written in English between 1996 and 9^th January 2023 meeting inclusion criteria (adult/adolescent participants; compared factors related to suicide attempts, ideation, intent, lethality or parasuicidal gestures in BPD and DD, or explored BPD traits within suicidality in DD; and used structured diagnostic assessments or expert interview based upon DSM) were reviewed and assessed for quality using Joanna Briggs Institute Checklists. Studies were grouped by how suicidality was operationalised, and organised by the constructs that were compared.

Results

Findings from 14 studies (5189 participants) indicated that interpersonal dysfunction, impulsivity, aggression, anger/hostility in adult samples, and early onset of depression and self-injury may discriminate suicidality in BPD from DD for recurrent suicide attempts only. Expressed suicidal intent is higher in BPD than DD, while lethality of attempts is the same.

Discussion

Comparison of suicidality in BPD and DD requires further investigation. Findings suggest associated factors that might support risk assessment in BPD.

KEY POINTS

What is already known about this topic:

1. Suicidal behaviour in borderline personality disorder (BPD) is recurrent or “chronic” in nature; on average an individual will attempt suicide 3.3 times in their lifetime.

2. Persons with BPD presenting with chronic suicidality can regress in their capacity to take responsibility for their own safety, when clinicians employ the protective or custodial interventions that are indicated for acute risk.

3. Clinical risk assessment and intervention in BPD can be complicated by the occurrence of comorbid depression, which may result in an acute episode of suicidality overlaying the individual’s chronic pattern of self-injury.

What this topic adds:

1. Suicidality in BPD may be differentiated from acute suicidality in depression by the presence of the BPD traits of interpersonal dysfunction, impulsivity, aggression, and anger/hostility (in adults), but only when suicide attempts are recurrent across the lifetime.

2. Early onset of psychopathology and a pattern of higher expressed suicidal intent despite lower lethality of attempts also appear to discriminate suicidality in BPD from that in depression.

3. Clinical risk formulation in BPD could be benefitted by further research into discriminating chronic suicidality; however, clinical assessment should focus on particular BPD traits, the developmental trajectory of psychopathology, and potential discrepancies between expressed intent and suicidal behaviour.

KEYWORDS:

• Borderline personality disorder
• suicide
• systematic review

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

The data that support the findings of this study are available from the corresponding author, KWM, upon reasonable request.