Suicide Attempts in Major Depressed Patients with Personality Disorder

Suicide attempters who met criteria for borderline personality disorder (BPD) comorbid with major depressive disorder (MDD) were compared to both suicide attempters suffering from MDD alone and to attempters with comorbid MDD and other personality disorders (PD). Participants were 239 (158 patients with comorbid PD and 81 patients with MDD without comorbidity) inpatients consecutively admitted after a suicide attempt made in the last 24 hours. Suicide attempters with comorbid MDD and BPD had more frequent previous suicide attempts and were more likely to have a history of aggressive behaviors and alcohol and drug use disorders compared with patients suffering from MDD without Axis II comorbidity.     

Associations in the course of personality disorders and Axis I disorders over time

In this study, the authors examined time-varying associations between schizotypal (STPD), borderline (BPD), avoidant (AVPD), or obsessive-compulsive (OCPD) personality disorders and co-occurring Axis I disorders in 544 adult participants from the Collaborative Longitudinal Personality Disorders Study. The authors tested predictions of specific longitudinal associations derived from a model of crosscutting psychobiological dimensions (L. J. Siever & K. L. Davis, 1991) with participants with the relevant Axis I disorders. The authors assessed participants at baseline and at 6-, 12-, and 24-month follow-up evaluations. BPD showed significant longitudinal associations with major depressive disorder and posttraumatic stress disorder. AVPD was significantly associated with anxiety disorders (specifically social phobia and obsessive-compulsive disorder). Two of the four personality disorders under examination (STPD and OCPD) showed little or no association with Axis I disorders.     

Interpersonal precipitants and suicide attempts in borderline personality disorder

Borderline personality disorder (BPD) is often characterized by multiple low lethality suicide attempts triggered by seemingly minor incidents, and less commonly by high lethality attempts that are attributed to impulsiveness or comorbid major depression. The relationships among life events, impulsiveness, and type of suicidal behavior has hardly been studied in BPD and mood disorders. This study compared depressed attempters with and without BPD to identify specific suicide precipitants and risk factors in BPD and their relationship to severity of suicidal behavior. Attempters with comorbid BPD and major depressive disorder (MDD) had a higher number of lifetime suicide attempts; made their first attempt at a younger age; reported more interpersonal triggers; and had higher levels of lifetime aggression, hostility, and impulsivity, compared with attempters with major depression only. Environmental triggers of attempts in BPD are more likely to be interpersonal stressors. Lethality of attempts in BPD plus MDD is equal to that in MDD only, indicating that the seriousness of precipitants is unrelated to the lethality of the suicidal behavior. The differences between groups suggest that risk assessment and treatment should target both depression and personality disorder in those with combined illness.     

The predictive validity of cluster C personality disorders on the persistence of major depression in the national epidemiologic survey on alcohol and related conditions

The present study examined the predictive validity of Cluster C personality disorders (CCPDs) on major depressive disorder (MDD), using Waves 1 and 2 of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC, N = 34,653; time interval equals 3 years). Multiple logistic regression analyses were utilized to compare respondents with MDD and a concurrent CCPD to those with MDD only. Findings demonstrated that individuals with MDD and a comorbid CCPD were significantly more likely than those with MDD only to have MDD at Time 2. The presence of comorbid CCPD in individuals with MDD also predicts the subsequent occurrence of suicide attempts at Time 2 and the new onset of Axis I anxiety disorders. The chronic and enduring personality styles and interpersonal difficulties that characterize individuals with a CCPD likely lead to the exacerbation of MDD symptoms. Clinicians should be aware of the impact that CCPDs have on the outcome of MDD.     

The relationship of impairment to personality disorder severity among individuals with specific axis I disorders: results from the National Epidemiologic Survey on Alcohol and Related Conditions

The present study examined one dimensional approach to personality disorders (PDs) in a large (n = 43,093), nationally representative sample of the U.S. population. Respondents were classified in four personality severity categories (no PD, subthreshold PD, simple PD, complex PD). Linear regression analyses were conducted to examine mental disability by PD severity for major DSM-IV substance use, mood and anxiety disorders. Significant increases in disability were observed between no PD and simple PD and between simple PD and complex PD for each Axis I disorder except drug dependence, but few differences in disability were found between no PD and subthreshold PD. This study found support for the clinical utility of the dimensional classification of PD severity with regard to the distinction between simple and complex PD and for a combined no PD-subthreshold PD level of severity. Future planned analyses will address the clinical utility of the classification prospectively, with a full battery of all Axis II PDs.     

Prospective predictors of suicide attempts in borderline personality disorder at one, two, and two-to-five year follow-up

Efforts to identify reliable predictors of suicidal behavior in Borderline Personality Disorder have been confounded by the marked dimensional heterogeneity of the disorder, frequent comorbidity with other high risk disorders, debilitating social and vocational consequences of BPD over time. Using survival analyses, we assessed the predictive association between risk factors in each of these symptom domains and suicide attempts in BPD subjects followed for 12 months, 18-24 months and 2-5 years. The suicide attempt rate was 19% in the first year, 24.8% through the second year. The risk of suicidal behavior among 137 BPD subjects completing the first 12 months was increased by comorbid MDD and poor social adjustment. Outpatient treatment decreased short-term risk. Among 133 subjects completing 18-24 months in the study, the relative risk of a suicide attempt was increased by hospitalization (prior to any attempt), and poor social adjustment. Among 122 subjects followed for 2-5 years, increased risk was associated with hospitalization and medication visits (prior to any attempt), an attempt in the first year, and a low GAS score at baseline. Long term risk was decreased by "any outpatient treatment." Predictors of suicidal behavior in BPD change over time. MDD has a short-term effect on suicide risk, while poor social adjustment may increase risk throughout each follow-up interval. Assessing and supporting family, work, and social relationships may decrease suicidal behavior in BPD, and should be a principal focus of long-term treatment.     

Childhood abuse in Chinese patients with borderline personality disorder

This study examined (1) the relative prevalence of childhood abuse and other pathological childhood experiences in China reported by outpatients with borderline personality disorder (BPD), with other personality disorders, and without personality disorders; and, (2) whether the primary predictors of BPD in North America are associated with the development of BPD in China. The childhood experiences of 203 outpatients with BPD, 109 outpatients with other personality disorders, and 70 outpatients without Axis II diagnoses were assessed with the Chinese version of the Childhood Experience of Care and Abuse Questionnaire (CECA.Q). Patients with BPD reported significantly more physical, emotional, and sexual abuse than either comparison group. Four types of childhood experiences were significant predictors of BPD: maternal neglect, paternal antipathy, sexual abuse, and maternal physical abuse. The findings suggest that maternal physical abuse is as strong a predictor of BPD in China as sexual abuse, a finding not replicated in North America.     

Borderline personality features predict alcohol use problems

This study assessed the relation between BPD features and problems associated with alcohol use 2 years later in young adults. Approximately 5,000 nonclinical young adults were screened for BPD features, and two cohorts of participants completed the laboratory phase of the study at Time 1 (total N = 421) and then again 2 years later at Time 2 (total N = 356). Measures included self-report and interview-based assessments of personality disorders, psychopathology in biological parents, Axis I psychopathology, and alcohol use problems. BPD features were found to significantly predict alcohol use problems 2 years later after controlling for parents' substance use disorders, Axis I psycho-pathology (including alcohol abuse/dependence), and non-BPD personality disorders. In addition, the BPD subscale that assesses impulsivity was found to be significantly associated with alcohol use problems once all predictors were entered into the model.     

Co-occurrence of personality disorders with mood, anxiety, and substance use disorders in a young adult population

The purpose of this study was to determine the co-occurrence of DSM- III-R personality disorders (PDs) with mood, anxiety, and substance use disorders in a young adult population. The members of the Northern Finland 1966 Birth Cohort Project, living in the city of Oulu with an age of 31 years (N = 1,609) were invited to participate in a two-phase field study. The SCID I and II were used as diagnostic instruments. One hundred and seventy-seven out of 321 interviewed subjects met the criteria for mood, anxiety, or substance use disorders. Altogether 72 (41%) of the subjects with an Axis I disorder met the criteria for at least one PD. The weighted co-occurrence rate of any PD varied from 28% for mood disorders to 47% for anxiety disorders. PDs, especially those in Cluster C, are highly associated with Axis I psychiatric disorders in population.     

The prevalence of personality disorders in a Kenyan inpatient sample

DSM-IV Axis I and II comorbidities and the pattern of Axis II diagnoses in patients admitted at Mathari (Psychiatric) Hospital, Nairobi, Kenya are unknown. To determine DSM-IV Axis I and II comorbidities and patterns of Axis II diagnoses in patients admitted at Mathari Hospital. Cross-sectional study on 148 randomly sampled patients. Twenty percent of the patients were confirmed for an Axis II diagnosis. Eighty-seven percent of the Axis II disorders were Cluster B Personality Disorders of various types. Using chi2 tests, significant associations were found between Axis I and II diagnoses and substance use/dependence (p < 0.001; 66.7%), mood disorder (p = 0.002; 46.7%) and schizophrenia (p < 0.001; 23.3%). The prevalence of personality disorders was lower than that reported in psychiatric patients in USA and Europe. The results are likely to be a true reflection of the actual epidemiological situation, but cannot be generalized to outpatient or general populations.     

Accurate diagnosis of personality disorders: Some critical factors

Issues pertaining to the accurate diagnosis of personality disorders are discussed from a scientist-practitioner perspective. An attempt is made to distinguish state (Axis I) from trait (Axis II) disorders, and personality (“normal”) from personality disorders (“abnormal”). The reliability and validity of personality disorder diagnoses are explored, and the four criteria for all personality disorder diagnoses are clarified: These criteria are: 1) presence of psychological symptomology, 2) stability over time, 3) consistency across situations, and 4) under-responsiveness to currently available treatments. Also, a distinction is made between categorical and dimensional diagnostic criteria, similar to the distinction between personality type and trait approaches. Recommendations are provided for improving the clinical and empirical work in this area, and implications for treatment are discussed.     

Heterogeneity of borderline personality disorder: do the number of criteria met make a difference?

Many studies have compared the demographic and clinical characteristics of patients with and without borderline personality disorder (BPD), but there is limited knowledge on differences within the population of borderline patients. One potential index of heterogeneity is disorder severity. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we examined whether the severity of borderline personality disorder, as measured by the number of criteria present, is associated with co-morbidity of Axis I and Axis II diagnoses, as well as demographic factors and psychosocial functioning. Two thousand three hundred psychiatric outpatients were interviewed with the Structured Interview for DSM-IV Personality (SIDP-IV). Approximately ten percent (n = 237) of the patients were diagnosed with BPD, and they were divided into four groups based on the number of DSM-IV criteria met, 5 (n = 89), 6 (n = 70), 7 (n = 46), and 8 or 9 (n = 32). There were greater rates of drug use disorders and comorbid Axis II disorders, as well as a greater number of suicidal gestures, in patients meeting seven or more BPD criteria. There were no significant differences between the groups in the number and specific rates of other co-morbid Axis I disorders, other measures of psychosocial functioning, or demographic correlates. Sub-typing of borderline patients by the number of criteria met provides a limited explanation for heterogeneity within BPD patients.     

Suicidal behavior in borderline personality disorder: prevalence, risk factors, prediction, and prevention

Suicidal behavior is frequent in patients with borderline personality disorder (BPD); at least three-quarters of these patients attempt suicide and approximately 10% eventually complete suicide. Borderline patients at greatest risk for suicidal behavior include those with prior attempts, comorbid major depressive disorder, or a substance use disorder. Comorbidity with major depression serves to increase both the number and seriousness of the suicide attempts. Hopelessness and impulsivity independently increase the risk of suicidal behavior, as does a turbulent early life and the presence of antisocial traits. In summary, because BPD is frequently complicated by suicidal behavior, clinicians must avoid the mistake of thinking that a pattern of repeated attempts indicates little desire to die. Clinicians have an important role in preventing suicide attempts and completed suicides by understanding the risk factors.     

Predicting recurrence of major depressive disorder in young adults: a prospective study.

Sixty-five young adults with remitted major depressive disorder (MDD) were followed for 18 months. Recurrence of MDD was reported by 41.5% of the initial sample and 49.1% of those who completed the study (n = 53). Survival analyses were used to identify predictors of recurrence so that individuals at greatest risk could be targeted for intervention. Potential predictors included measures of comorbid psychopathology (Axis II pathology, and current and lifetime nonmood Axis I diagnoses), depression-specific clinical features (number of episodes, past treatment, and suicidality), and self-reported cognitive and interpersonal constructs (hope, dysfunctional attitudes, and interpersonal problems). Only personality pathology (specifically, the total dimensional and Cluster B dimensional scores on the International Personality Disorder Examination) significantly predicted hazard of recurrence.     

Social phobia: Axis I and II correlates

The presence of Axis I and Axis II disorders in 71 social phobic patients was examined. Generalized anxiety disorder was the most common secondary Axis I disorder, followed by simple phobia. Avoidant personality disorder and obsessive-compulsive personality disorder were the most common Axis II diagnoses, and 88% of the sample exhibited features of these 2 personality styles. Subjects with additional Axis I diagnoses were more anxious and depressed than those with no additional Axis I disorder. Social phobics with additional Axis II disorders were more depressed but not more anxious than those with no Axis II diagnosis. Furthermore, those with an additional Axis I disorder had higher scores on measures of neuroticism, interpersonal sensitivity, and agoraphobia. The prevalence and impact of additional Axis I and II disorders on the etiology, maintenance, and treatment outcome for persons with social phobia are discussed.     

Heightened subjective experience of depression in borderline personality disorder

Despite the frequent comorbidity of major depression and borderline personality disorder (BPD), limited research has examined what effect this comorbidity has on the severity, course, and presentation of depression. The purpose of this study was to examine whether the severity of major depressive disorder (MDD) in the context of comorbid borderline personality disorder (BPD) differs from MDD when comorbid BPD is not present and to determine whether different measures of depression yield convergent findings. Sixty patients diagnosed with DSM-IV MDD participated in this study. Twenty-nine were diagnosed with DSM-IV BPD, while the remaining 31 had no Axis II diagnosis. Depression was evaluated with both clinician (Hamilton Rating Scale for Depression) and self-report (Beck Depression Inventory) ratings. While the two groups were rated as similarly depressed by clinicians on the overall rating and the factor scores, the MDD/BPD group reported more severe depressive symptoms on the self-report measure. This difference was significant even after controlling for clinician-rated severity. Gender interacted with diagnosis, males in the BPD group showed the largest discrepancies between clinician ratings and self-reports. Posthoc analyses of HDRS factors with the BDI showed that the clinicianrated cognitive disturbance and retardation factors were correlated with self-rated severity overall. Within subgroups, only the retardation factor was correlated with the BDI. Our results suggest that while depressed individuals with and without BPD may be rated as similarly depressed when assessed with objective rating methods, the subjective experience of the depression may be rated as more intense or severe by patients with comorbid BPD. The mechanism underlying this effect remains unknown, and requires further research.     

The children in the community study of developmental course of personality disorder

The Children in the Community (CIC) Study is an ongoing investigation of the course of psychiatric disorders including personality disorders (PDs) in an epidemiological sample of about 800 youths. In addition to tracking developmental trajectories over 20 years from adolescence into adulthood, the CIC Study has used prospective data to investigate early risks for Axis II disorders and symptoms (including both environmental factors and early characteristics), implications of comorbidity with Axis I disorders, and associated negative prognostic risk of adolescent PDs into adulthood. The substantial independent impact of PD on subsequent Axis I disorders, suicide attempts, violent and criminal behavior, interpersonal conflict, and other problematic adult outcomes confirms the importance of attention to these problems when they manifest in early adolescence. The implications of study findings for potential changes in the DSM are discussed.     

Distinguishing general and specific personality disorder features and implications for substance dependence comorbidity

Clinical and population-based samples show high comorbidity between Substance Use Disorders (SUDs) and Axis II Personality Disorders (PDs). However, Axis II disorders are frequently comorbid with each other, and existing research has generally failed to distinguish the extent to which SUD/PD comorbidity is general or specific with respect to both specific types of PDs and specific types of SUDs. We sought to determine whether ostensibly specific comorbid substance dependence-Axis II diagnoses (e.g., alcohol use dependence and borderline personality disorder) are reflective of more pervasive or general personality pathology or whether the comorbidity is specific to individual PDs. Face-to-face interview data from Wave 1 and Wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions were analyzed. Participants included 34,653 adults living in households in the United States. We used hierarchical factor models to statistically partition general and specific personality disorder dimensions while simultaneously testing for specific PD-substance dependence relations. Results indicated that substance dependence-Axis II comorbidity is characterized by general (pervasive) pathology and by Cluster B PD pathology over and above the relationship to the general PD factor. Further, these relations between PD factors and substance dependence diagnoses appeared to largely account for the comorbidity among substance dependence diagnoses in the younger but not older participants. Our findings suggest that a failure to consider the general PD factor, which we interpret as reflecting interpersonal dysfunction, can lead to potential mischaracterizations of the nature of certain PD and SUD comorbidities.     

An exploratory study of the relationship between diverse life events and specific personality disorders in a sample of suicide attempters

Personality disorder (PD) increases risk for suicidal behavior. Certain life events (LE) can precipitate suicidal behaviors in patients with PD. A fundamental question is whether specific combinations of LE and PD increase suicidal risk. Four hundred forty-six suicide attempters (SA) were recruited from emergency rooms. We used a healthy control group (n = 515) to identify the best cut-off point for the instrument used to diagnose PD. We used the DSM-IV version of the International Personality Disorder Questionnaire-Screening Questionnaire, the Mini International Neuropsychiatric Interview, and the Social Adjustment Scale to assess PD, Axis I disorders, and LE, respectively. After controlling for Axis I disorders, we found that "Death of spouse" preceded suicidal acts in those with antisocial PD (FET p = 0.024) and patients with narcissistic PD attempted suicide after being Fired at work (FET p = 0.002), among others. Our data suggest the presence of particular LE-PD associations in suicide attempters. Some LE-PD relationships appear independent of Axis I disorders in suicide attempters. This may offer a basis for specific targeted therapies or prevention programs aimed at decreasing suicidal risk.