Six-month trajectory of suicidal ideation in adolescents with borderline personality disorder

Suicidality and Personality Pathology in Adolescence: A Systematic Review

This work presents a review of research papers examining the role of emerging personality pathology in suicidal ideation and behaviours in adolescence. Initially, 226 studies were selected in line with PRISMA guidelines, and 33 articles were finally included in this review. The data show percentages of any personality disorder diagnosis ranging from 19.5 to 22.8% in suicide attempters, while in autopsy studies, the rate of personality disorder diagnosis varied between 29.6 and 42.1%. The overwhelming majority of the studies focus on the role of borderline personality disorder (BPD) in suicidal behaviours, also highlighting its predictive role at a longitudinal level. Furthermore, the literature review shows that personality traits supposed to underlie BPD, such as affective instability, impulsivity and identity diffusion, have specific predictive links with suicidal conduct. Other personality pathology dimensions, such as aggressiveness, sadism and perfectionism that are associated with other personality disorders, namely, antisocial and narcissistic personality disorders, have also shown a significant mediating role for suicidal risk. Overall, these results seem to parallel the role of personality pathology in predicting suicide in adulthood and point to the relevance of assessing the presence of emerging patterns of personality disorders for the clinical management of suicidal risk in adolescence.

Frequent follow-up of suicidal youth assessed in the emergency room: Long-term trajectory and predictors of suicidality

Suicide was the second‑leading cause of US deaths in 2018 among 15-24-year-olds. Suicide attempts, a risk factor for completions, and suicide ideation have doubled among pediatric emergency room (ER) patients during the past decade. Borderline Personality Disorder (BPD), a comorbid condition, has a 10% suicide rate. We examined the 4-year outcome of a cohort of suicidal adolescents, many also suffering from BPD and having undergone some form of treatment, to identify baseline factors which could inform intervention that would minimize suicidality 4 years post-discharge.

METHODS

We conducted a prospective longitudinal study of suicidality at twelve points (four assessment occasions) for 286 suicidal youth presenting to a pediatric ER, most suffering from BPD, with 36 suicide ratings from baseline to 2-, 6- and 48-month follow-up evaluations. We examined the trajectory and predictors of persisting suicidality.

RESULTS

Suicidality rapidly decreased within 2 months post-ER-discharge, subsequently remaining low throughout 48 months. Baseline functioning, female sex, stressful life events and BPD impulsiveness were most predictive of persisting suicidality at 48-month follow-up.

CONCLUSION

Most suicidal youth, many meeting BPD criteria, no longer feel suicidal 2 months after ER discharge. Management of participants' baseline poor functioning stressful life events and the impulsiveness component of BPD specifically in females could impact suicidality 4 years later, and guide treatment options. The absence of the BPD cognitive and affective subscales as predictors of suicidality at 4-year follow-up may reflect treatment received. Further investigation of treatment effects is warranted and under way.

The Relations Between Identity Disturbances, Borderline Features, Internalizing Disorders, and Suicidality in Inpatient Adolescents

Previous studies have demonstrated positive associations between identity disturbances and suicidality in adolescents; however, mechanisms underlying these relationships are not well understood. The authors propose that borderline features and various internalizing disorders may mediate these relations. The aim of this study was to test a multiple mediation model of the associations between these constructs using structural equation modeling. Ninety-six inpatient adolescents aged 12-17 years completed the Assessment of Identity Development in Adolescents, the Childhood Interview for DSM-IV Borderline Personality Disorder, the Youth Self-Report, and the Columbia-Suicide Severity Rating Scale. Findings partly confirmed the theoretical model. Borderline features mediated the positive effect of identity disturbances on suicidal ideation severity. Mediations of withdrawn/depression and anxiety/depression on the effect of identity disruption on suicidal ideation intensity were demonstrated. Identity disruptions and borderline and depressive symptoms could be possible targets for interventions for youth experiencing suicidal ideation.

Trajectories of change in depression symptoms and suicidal ideation over the course of evidence-based treatment for depression: Secondary analysis of a randomised controlled trial of cognitive behavioural therapy plus fluoxetine in young people

OBJECTIVES

Effective treatment of depression is a key target for suicide prevention strategies. However, only around one-third of young people with suicide risk respond to evidence-based treatments. Understanding the trajectory of suicidal ideation, as a marker of suicide risk, over the course of evidence-based treatment for depression might provide insight into more targeted and effective treatments.

METHODS

This is a secondary analysis of data from the multicentre Youth Depression Alleviation-Combined Treatment trial. A total of 153 young people aged 15-25 years diagnosed with major depressive disorder were randomly assigned in this double-blind, placebo-controlled trial to either cognitive behavioural therapy plus fluoxetine or cognitive behavioural therapy plus placebo. Participants were assessed for depression and suicidal ideation at baseline and at weeks 4, 8 and 12.

RESULTS

Using group-based trajectory modelling, we identified two distinct depression trajectories. The first (Improving; 54.9%; n = 83) comprised those who experienced a consistent decline in depression symptoms. The second (Persisting; 45.1%; n = 70) comprised those who, despite treatment, still had clinically significant levels of depression by the end of treatment. For suicidal ideation, we identified four distinct trajectories: Non-clinical (15.5%; n = 20), Low Improving (47.1%; n = 75), High Improving (24.8%; n = 38) and High Persisting (12.7%; n = 20). Treatment allocation was not significantly associated with trajectory membership for either depression or suicidal ideation.

CONCLUSION

Understanding the course of depression and suicidal ideation during treatment has important implications for managing suicide risk. The findings suggest that there is an identifiable group of young people for whom enhanced psychological and/or pharmacological intervention might be required to ensure a better treatment response. Specific interventions for those with suicidal ideation may also be prudent from the outset.

CLINICAL TRIAL REGISTRATION

The Youth Depression Alleviation-Combined Treatment trial was prospectively registered with the Australian and New Zealand Clinical Trials Registry (ACTRN12612001281886).

Suicide risk around the world: a meta-analysis of longitudinal studies

PURPOSE

Suicidal thoughts and behaviors (STBs) have been a persistent problem worldwide. Identifying risk factors for STBs across distinct areas of the world may help predict who or where requires the greatest attention. However, risk factors for STBs are infrequently explored cross-nationally. The present study examined whether psychopathology prospectively predicts STBs across different areas of the world, and whether certain country-level factors moderate the degree of risk conferred.

METHODS

We conducted a meta-analysis of 71 longitudinal studies from 30 different countries that featured psychopathology-related variables predicting STB outcomes. Meta-regression was used to evaluate whether the following country-level factors modified risk: geographic region, income level, and degree of mental health structural stigma.

RESULTS

Over 90% of studies had been conducted in North America and Europe. When assessed by country income level, it was found that only one longitudinal study on psychopathology and STB was conducted outside of a high-income country. Moreover, less than 10% of studies were conducted in high structural stigma contexts. Meta-regression findings revealed that the variation in risk effect sizes across studies was not explained by models including country-level factors.

CONCLUSIONS

Our findings show critical underrepresentation of low- and middle-income countries, which account for a large proportion of global suicide deaths. This reveals a need to broaden the scope of longitudinal research on STB risk, such that countries across more regions, income levels, and degrees of structural stigma are fully accounted for. Such lines of research will improve generalizability of findings, and more precisely inform prevention efforts worldwide.

Suicide Ideation in Adolescents Following Inpatient Hospitalization: Examination of Intensity and Lability Over 6 Months

Understanding suicide ideation (SI) in adolescents, especially during the high-risk time following hospitalization for a suicidal event, is a crucial component of improving risk assessment. Most studies rely on single assessments of SI, despite the potential for SI to vary considerably over time. This study examined how indices of SI intensity (mean values) and lability (mean squared successive difference values) over a 6-month period predict suicide attempts (SAs) and self-harm, as well as how they relate to psychosocial risk factors and affective functioning, in a sample of 103 adolescents hospitalized for a SA or significant SI. Across the sample, SI intensity, but not lability, was associated with SAs and nonsuicidal self-injury at 6-month follow-up. SI intensity performed similarly to single time point SI assessments, and its relations were not moderated by SI lability. SI intensity was also associated with borderline personality disorder criteria and a history of sexual abuse. In contrast, SI lability was associated with greater negative affect intensity and lability. These findings suggest that intensity of SI may confer more risk posthospitalization, and provide support for using these statistical methods to capture two distinct parameters of SI.

Variability in Suicidal Ideation is Associated with Affective Instability in Suicide Attempters with Borderline Personality Disorder

Objective: Suicidal ideation (SI) is heterogeneous with different patterns and risk factors. SI can be persistent with stable severity, but may also fluctuate rapidly over a short period of time. The latter pattern is likely associated with affective instability and may consist of activation of SI at times of stress, that then subside. Although affective instability is a hallmark of borderline personality disorder (BPD), little is known about SI variability in BPD. We hypothesized that SI variability would be associated with affective instability in BPD suicide attempters. Method: Sample included 38 females with BPD and history of suicidal behavior. SI was assessed over 1 week using ecological momentary assessment (EMA) at six epochs daily. The relationship between SI variability (i.e., change of SI from one epoch to another) and SI severity (i.e., average scores across epochs), and affective instability, assessed using the Affective Lability Scale (ALS), were examined. Possible confounding effects of depression severity and impulsiveness were tested. Results: Participants demonstrated high ALS scores and wide range of SI variability. ALS scores predicted SI variability, even after controlling for depression severity. Although ALS also predicted SI severity, this association was driven by depression severity. ALS did not correlate with impulsiveness score. Conclusions: Affective instability may predict SI variability in BPD suicide attempters independent of depression severity. This supports our model of suicidal subgroups with different constellations of clinical aspects and risk factors. Future studies could examine these associations in larger samples and different populations to determine implications for suicide prevention.

Trajectories of Suicidal Ideation in People Seeking Web-Based Help for Suicidality: Secondary Analysis of a Dutch Randomized Controlled Trial

BACKGROUND

Suicidal ideation (SI) is a common mental health problem. Variability in intensity of SI over time has been linked to suicidal behavior, yet little is known about the temporal course of SI.

OBJECTIVE

The primary aim was to identify prototypical trajectories of SI in the general population and, secondarily, to examine whether receiving Web-based self-help for SI, psychiatric symptoms, or sociodemographics predicted membership in the identified SI trajectories.

METHODS

We enrolled 236 people, from the general Dutch population seeking Web-based help for SI, in a randomized controlled trial comparing a Web-based self-help for SI group with a control group. We assessed participants at inclusion and at 2, 4, and 6 weeks. The Beck Scale for Suicide Ideation was applied at all assessments and was included in latent growth mixture modeling analysis to empirically identify trajectories.

RESULTS

We identified 4 SI trajectories. The high stable trajectory represented 51.7% (122/236) of participants and was characterized by constant high level of SI. The high decreasing trajectory (50/236, 21.2%) consisted of people with a high baseline SI score followed by a gradual decrease to a very low score. The third trajectory, high increasing (12/236, 5.1%), also had high initial SI score, followed by an increase to the highest level of SI at 6 weeks. The fourth trajectory, low stable (52/236, 22.0%) had a constant low level of SI. Previous attempted suicide and having received Web-based self-help for SI predicted membership in the high decreasing trajectory.

CONCLUSIONS

Many adults experience high persisting levels of SI, though results encouragingly indicate that receiving Web-based self-help for SI increased membership in a decreasing trajectory of SI.

Developmental Trajectories of Suicidal Thoughts and Behaviors From Adolescence Through Adulthood

OBJECTIVE

Little is known about the patterns among individuals in the long-term course of suicidal thoughts and behaviors (STBs). The objective of this study was to identify developmental trajectories of STBs from adolescence through young adulthood, as well as risk and protective covariates, and nonsuicidal outcomes associated with these trajectories.

METHOD

A total of 180 adolescents (ages 12-18 years at recruitment) were repeatedly assessed over an average of 13.6 years (2,273 assessments) since their psychiatric hospitalization. Trajectories were based on ratings of STBs at each assessment. Covariates included psychiatric risk factors (proportion of time in episodes of psychiatric disorders, hopelessness, trait anxiety, impulsivity, and aggression in adulthood, sexual and physical abuse, parental history of suicidal behavior), protective factors (survival and coping beliefs, social support in adulthood, parenthood), and nonsuicidal outcomes (social adjustment and functional impairment in adulthood, school drop-out, incarcerations).

RESULTS

Using a Bayesian group-based trajectory model, 4 trajectories of STBs were identified: an increasing risk class (11%); a highest overall risk class (12%); a decreasing risk class (33%); and a low risk class (44%). The 4 classes were associated with distinct patterns of correlates in risk and protective factors and nonsuicidal outcomes.

CONCLUSION

Adolescents and young adults have heterogeneous developmental trajectories of STBs. These trajectories and their covariates may inform strategies for predicting STBs and targeting interventions for individuals at risk for suicidal behavior.

Predicting Persistence of Nonsuicidal Self-Injury in Suicidal Adolescents

Prospective predictors of persistent nonsuicidal self-injury (NSSI) were examined in adolescents admitted to an inpatient psychiatric unit for suicidal behaviors and followed naturalistically for 6 months. Seventy-one (77%) participants reported NSSI at baseline, and 40 (56%) persisted at the 6 month follow-up. Those who endorsed automatic positive reinforcement (APR) as the predominant reason for NSSI were more likely to persist in NSSI. Depression over follow-up, but not at baseline, also predicted persistence. These results suggest that helping high-risk adolescents to identify alternative ways of generating emotion(s) to counter the effects of APR that may accompany NSSI should be a high priority treatment target.

The aetiological and psychopathological validity of borderline personality disorder in youth: A systematic review and meta-analysis

Controversy surrounds the diagnosis of Borderline Personality Disorder (BPD) in youth. This meta-analysis summarised evidence regarding the aetiological and psychopathological validity of youth BPD (the extent to which youth and adult BPD share common risk factors and psychopathology). We identified 61 studies satisfying predetermined inclusion criteria. Statistically significant pooled associations with youth (19 years of age and under) BPD were observed for sexual abuse (all youth: odds ratio=4.88; 95% confidence interval=3.30, 7.21; children: OR=3.97; 95% CI=1.51, 10.41; adolescents: OR=5.41; 95% CI=3.43, 8.53); physical abuse (all youth: 2.79 [2.03, 3.84]; children: 2.86 [1.98, 4.13]; adolescents: 2.60 [1.38, 4.90]); maternal hostility/verbal abuse (all youth: 3.28 [2.67, 4.03]; children: 3.15 [2.55, 3.88]; adolescents: 4.71 [1.77, 12.53]); and neglect (all youth: 3.40 [2.27, 5.11]; children: 2.87 [1.73, 4.73]; adolescents: 4.87 [2.24, 10.59]). Several psychopathological features were also associated with youth BPD, including comorbid mood (3.21 [2.13, 4.83]), anxiety (2.30 [1.44, 3.70]) and substance use (2.92 [1.60, 5.31]) disorders; self-harm (2.81 [1.61, 4.90]); suicide ideation (all youth: 2.02 [1.23, 3.32]; children: 6.00 [1.81, 19.84]; adolescents: 1.75 [1.20; 2.54]) and suicide attempt (2.10 [1.21, 3.66]). Results demonstrate that adult and youth BPD share common aetiological and psychopathological correlates. This offers some support for the diagnostic validity of youth BPD and indicates the need for clinical recognition in this age group.

Identifying risk of deliberate self-harm through longitudinal monitoring of psychological distress in an inpatient psychiatric population

BACKGROUND

While cross-sectional correlates of deliberate self-harm, such as psychological distress, have been identified; it is still difficult to predict which individuals experiencing distress will engage in deliberate self-harm, and when this may occur. Therefore, this study aimed to explore the ability of longitudinal measurements of psychological distress to predict deliberate self-harm in a psychiatric population.

METHOD

Participants (N = 933; age range 14-93 (M = 38.95, SD = 14.64; 70% female) were monitored daily in terms of suicidal ideation, depression, anxiety, worthlessness and perceptions of not coping. Latent Growth Curve Analysis was used to check if groups of inpatients reporting suicidal ideation, who shared early change in measures of psychological distress, existed. Logistic regression tested whether different groups were at higher (or lower) risks of deliberate self-harm.

RESULTS

Four groups were found. Of these, Non-Responders (high symptoms, remaining high) were more likely to engage in deliberate self-harm than patients with high, medium and low symptoms which improved over one week. Group membership was a greater predictor of deliberate self-harm than initial distress scores. Females and patients with personality disorders were significantly more likely to be Non-Responders.

CONCLUSIONS

Continuous monitoring and subsequent grouping of inpatients according to their early change in psychological distress provides a novel and practical approach to risk management. A lack of early improvement in psychological distress may indicate a higher risk of deliberate self-harm.

Adolescent inpatient girls׳ report of dependent life events predicts prospective suicide risk

Adolescents with a history of suicidal behavior are especially vulnerable for future suicide attempts, particularly following discharge from an inpatient psychiatric admission. This study is the first to test whether adolescents׳ tendency to generate stress, or report more dependent events to which they contributed, was predictive of prospective suicide events. Ninety adolescent psychiatric inpatients who were admitted for recent suicide risk, completed diagnostic interviews, assessments of history of suicidal behavior, and a self-report questionnaire of major life events at baseline. Participants were followed over the subsequent 6 months after discharge to assess stability vs. onset of suicide events. Cox proportional hazard regressions were used to predict adolescents׳ time to suicide events. Results supported hypothesis, such that only recent greater dependent events, not independent or overall events, predicted risk for prospective suicide events. This effect was specific to adolescent girls. Importantly, dependent events maintained statistical significance as a predictor of future suicide events after co-varying for the effects of several established risk factors and psychopathology. Results suggest that the tendency to generate dependent events may contribute unique additional prediction for adolescent girls׳ prospective suicide risk, and highlight the need for future work in this area.