Psychiatry Research 246 (2016) 261266

Contents lists available at ScienceDirect

Psychiatry Research
journal homepage: www.elsevier.com/locate/psychres

Clinical features and psychiatric comorbidities of borderline personality

disorder patients with versus without a history of suicide attempt

crossmark

Leo Shera,b, , Amanda M. Fishera, Caitlin H. Kellihera, Justin D. Pennera,b,d,

Marianne Goodmana,b,d, Harold W. Koenigsberga,b, Antonia S. Newa, Larry J. Sievera,b,d,
Erin A. Hazletta,c,d
a

Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, United States
Inpatient and Outpatient Psychiatry, James J. Peters VA Medical Center, Bronx, NY, United States
c
Department of Neuroscience, Icahn School of Medicine at Mount Sinai, New York, NY, United States
d
Mental Illness Research, Education, and Clinical Center (MIRECC; VISN 2 South), James J. Peters VA Medical Center, Bronx, NY, United States
b

A R T I C L E I N F O

A BS T RAC T

Keywords:
Suicide
Borderline personality disorder
Narcissistic personality disorder
Depression
Aective lability

Patients with borderline personality disorder (BPD) are at high risk for suicidal behavior. However, many BPD
patients do not engage in suicidal behavior. In this study, we compared clinical features of BPD patients with or
without a history of suicide attempts and healthy volunteers. Compared with healthy volunteers, both BPD
groups had higher Aective Lability Scale (ALS), ALS Depression-Anxiety Subscale, Barratt Impulsivity Scale
(BIS), and Lifetime History of Aggression (LHA) scores and were more likely to have a history of temper
tantrums. BPD suicide attempters had higher ALS, ALS Depression-Anxiety Subscale and LHA scores and
were more likely to have a history of non-suicidal self-injury or temper tantrums compared to BPD nonattempters. Also, BPD suicide attempters were more likely to have a history of comorbid major depressive
disorder and less likely to have comorbid narcissistic personality disorder (NPD) in comparison to BPD nonattempters. About 50% of study participants in each BPD group had a history of comorbid substance use
disorder (SUD). Our study indicates that BPD patients with a history of suicide attempt are more aggressive,
aectively dysregulated and less narcissistic than BPD suicide non-attempters.

1. Introduction
Suicide is a global medical and social issue (WHO, 2014). Every
year, approximately one million people around the world including
about 43,000 people in the United States commit suicide (CDC, 2015;
WHO, 2014). There are indications that for each person who died of
suicide there may have been more than 20 others attempting suicide
(WHO, 2014). Suicides and suicide attempts deeply aect family and
friends of suicidal individuals. More than 90% of suicides are associated with psychiatric illnesses, mostly with personality, mood,
psychotic and substance use disorders (SUD) (Barraclough et al.,
1974; Elman et al., 2013; Mann, 2002; Rihmer, 1996; Rihmer, 2007;
Sher et al., 2001; Sher, 2006). Major depressive disorder (MDD) is the
psychiatric disorder most frequently associated with suicide
(Barraclough et al., 1974; Henriksson et al., 1993; Rihmer, 1996;
Sher et al., 2001).
Patients with borderline personality disorder (BPD) are at high risk
for suicide attempts and completed suicide (Goodman et al., 2012;

Kolla et al., 2008). In DSM-5, BPD is the only personality disorder with
suicidal or self-injurious behavior explicitly included in the diagnostic
criteria (American Psychiatric Association, 2013). BPD has been
demonstrated to have higher associations with suicidal behaviors than
major depressive disorder, another disorder with a suicide-related
criterion (Yen et al., 2003). Apparently, maladaptive coping strategies
predispose individuals with BPD to suicidal behavior and this diagnosis
increases the risk for completed suicide (Kolla et al., 2008). About 8
10% of patients with BPD commit suicide which is many times greater
than the general population (American Psychiatric Assocaition, 2001).
Patients with BPD comprise 933% of all suicides (Kullgren et al.,
1986; Runeson and Beskow, 1991). The majority of suicidal patients
who had visited a psychiatric emergency department four or more
times in one year met criteria for BPD (Bongar et al., 1990). In crosssectional studies, suicide attempters with BPD had higher levels of
psychopathology, depression, hostility, impulsivity, increased number
of past attempts, and rst attempt at an early age as compared with
non-BPD attempters (Goodman et al., 2012).

Corresponding author at: James J. Peters Veterans Administration Medical Center, 130 West Kingsbridge Road, New York, NY 10468, United States.
E-mail address: leo.sher@mssm.edu (L. Sher).

http://dx.doi.org/10.1016/j.psychres.2016.10.003
Received 14 April 2016; Received in revised form 31 July 2016; Accepted 2 October 2016
Available online 02 October 2016
0165-1781/ Published by Elsevier Ireland Ltd.

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L. Sher et al.

cluded: history of head trauma, neurological disease, organic mental

syndrome, mental retardation, current major depressive episode (in
past three months), SUD or acute medical illness. All participants
provided written informed consent approved by the Institutional
Review Board at the Icahn School of Medicine at Mount Sinai.

Aective lability can be dened as frequent and intense variations

in aect in response to both pleasant and unpleasant events (Aas et al.,
2015). Aective instability has assumed importance in contemporary
psychiatry as a criterion for BPD. Structural and functional neuroimaging work suggests that aective lability in BPD patients may be related
to reduced anterior and posterior cingulate cortex gray matter volume
(Hazlett et al., 2005; Tebartz van Elst et al., 2003), decreased
engagement of the dorsal anterior cingulate (Koenigsberg et al.,
2014) and exaggerated amygdala activation (Hazlett et al., 2012)
during habituation to repeated aversive stimuli.
Non-suicidal self-injury (NSSI) is frequently observed in individuals with BPD (Favazza, 2009; Klonsky et al., 2013; Sher and Stanley,
2009). NSSI refers to the intentional destruction of one's own body
tissue without suicidal intent and for purposes not socially sanctioned
(Favazza, 2009; Klonsky et al., 2013). Rates of NSSI are about 46% in
the adult general population and 20% in adult patient populations
(Briere and Gil, 1998; Klonsky, 2011). The interpersonal theory of
suicide (Klonsky et al., 2013; Van Orden et al., 2010) suggests that a
suicide attempt involves both the desire and capability for suicide.
NSSI indicates increased risk for suicidal desire through its association
with emotional and interpersonal distress (Klonsky and Muehlenkamp,
2007; Klonsky and Olino, 2008; Klonsky et al., 2003). NSSI increases
capability for suicide by allowing a person to habituate to self-inicted
pain and violence (Nock et al., 2006). NSSI prior to suicidal behavior
may serve as a gateway behavior for suicide (Whitlock et al., 2013).
BPD is frequently comorbid with other psychiatric disorders
including mood, personality and substance use disorders (Beatson
and Rao, 2013; Carpenter et al., in press; DellOsso et al., 2010; Sher
et al., 2015; Siever and Davis, 1991; Trull et al., 2000; Trull et al., 2004;
Zanarini et al., 1998). For example, lifetime prevalence of major
depression in the course of BPD was 83% in one large study, which
is consistent with other research and clinical observations (Beatson and
Rao, 2013; Zanarini et al., 1998). The co-occurrence of substance use
disorders and BPD is a frequently replicated nding in the Axis I/II
comorbidity literature (DellOsso et al., 2010; Siever and Davis, 1991).
Chronic suicidality describes the pattern of behavior exhibited by
many patients with BPD. However, many BPD patients do not engage
in suicidal behavior. In this study, we compared clinical features and
psychiatric comorbidities of BPD patients with a history of suicide
attempt(s) to those without, and healthy controls. We hypothesized
that BPD patients with a history of a suicide attempt are more severely
ill and impaired in comparison with BPD non-attempters.

2.2. Measures and procedures

Aective lability was assessed using Aective Lability Scale (ALS)
(Aas et al., 2015; Harvey et al., 1989). The ALS contains 54 items rated
on a 4-point scale: 1= very uncharacteristic of me, 2= somewhat
uncharacteristic of me, 3= somewhat characteristic of me, 4= very
characteristic of me. The responses are coded from 0 to 3. The total
score is the mean of all item responses divided by the number of
responses, thus ranging from 0 to 3, with a score closer to 3 indicating
greater aective lability. The ALS evaluates an individual's predisposition to rapid shifts between the dierent emotional states of anxiety,
depression, anger, and hypomania (Aas et al., 2015; Harvey et al.,
1989). This Scale measures primarily aective traits (i.e., general
emotional characteristics) not states (i.e., emotional characteristics
over a relatively short period of time). The Depression-Anxiety subscale
measures shifts between anxiety and depression (Aas et al., 2015;
Harvey et al., 1989).
Impulsivity was measured with the Barratt Impulsivity Scale (BIS)
(Barratt, 1965), a 34-item questionnaire that assesses motoric (acting
without thinking), cognitive (hasty decisions) and non-planning (failure to plan ahead) impulsiveness. Each item is rated on a 4-point scale
ranging from Rarely/Never to Almost always/Always (Patton et al.,
1995).
The lifetime history of aggressive behavior was examined using the
Lifetime History of Aggression (LHA) Questionnaire (Coccaro et al.,
1997). Any events that have occurred over the subjects lifetime
(including years as a teenager and young adult) are rated as follows:
0= no events; 1= one event; 2=a couple or a few (i.e., 23) events;
3=several or some (i.e., 49) events; 4=many or numerous (i.e.,
10+) events; 5=so many events that they cant be counted. The
lifetime history of temper tantrums which is an important clinical
manifestation of BPD was evaluated based on participants' responses to
the rst question of the LHA Questionnaire. Our group has achieved an
inter-rater reliability of kappa=0.800.81 for diagnosing BPD (e.g.,
Goodman et al., 2014). The inter-rater and test-retest reliability for
LHA is 0.95 and 0.9, respectively; the test-retest reliability for ALS and
BIS is 0.7 and 0.8, respectively (Coccaro et al., 1997; Harvey et al.,
1989; Patton et al., 1995).
Demographic and clinical features of healthy volunteers and BPD
patients were compared using the t-test and chi-square test. We used
the t-test and ANOVA to analyze continuous variables. The Least
Signicant Dierence (LSD) post-hoc test was used if a signicant
eect was found. The chi-square test was employed to test for
dierences in proportions between the groups. Psychiatric comorbidities were compared using the chi-square test. We used a general linear
model to control for gender in subjects with comorbid narcissistic
personality disorder (NPD) and BPD (please, see below). The SPSS 23
program was used to perform all statistical analysis.

2. Methods
2.1. Subjects
Our sample consisted of 435 participants: 146 healthy controls, 241
BPD patients without a history of suicide attempt, and 48 BPD patients
with a history of suicide attempt. Participants were recruited through
advertisements in local newspapers and internet postings, or via
referral from outpatient mental health clinics. For each subject,
diagnosis was established by a clinical psychologist with expertise in
evaluation of personality disorders using the Structured Clinical
Interview for DSM-IV Axis I disorders (SCID-1 (First et al., 2002))
and Structured Interview for DSM-IV Personality Disorders (SIDP-IV;
(Pfohl et al., 1997)). Healthy controls had no Axis I or personality
disorder. All BPD patients met DSM- IV criteria for BPD. BPD suicide
attempters had a mean lifetime history of 3.4 2.8 suicide attempts.
Ten BPD suicide attempters made at least one suicide attempt during
the year prior to the evaluation. Four of these 10 suicide attempters
made more than one suicide attempt during the year prior to the
evaluation.
Physicians screened participants for medical and neurological
illness via history, physical examination, and routine blood and urine
laboratory testing, just prior to participation. Exclusion criteria in-

3. Results
The demographic and clinical characteristics of the sample are
provided in Table 1. The groups did not dier in age or gender. Healthy
volunteers had more years of education compared to the each BPD
group. The percentage of subjects who were continuously working
during the 12 months prior to the evaluation was lower among BPD
suicide attempters in comparison to the other two groups. Healthy
volunteers had lower ALS, ALS Depression-Anxiety Subscale, BIS,
and LHA scores compared with any of the BPD groups (see Table 1).
BPD suicide attempters had higher ALS, ALS Depression-Anxiety
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L. Sher et al.

4. Discussion

Subscale and LHA scores compared to BPD non-attempters (Table 1).

The BPD suicide attempters also were more likely to have a history of
non-suicidal self-injury (NSSI) and temper tantrums compared to nonattempters (Table 1).
BPD suicide attempters were more likely to have a history of
comorbid major depression or major depression with melancholia
compared to BPD non-attempters (see Table 2). The BPD groups did
not dier in terms of history of SUD. About 50% of the patients in each
group had a history of SUD (Table 2).
BPD suicide attempters were less likely to have comorbid narcissistic personality disorder (NPD) compared to BPD non-attempters
(Table 2). In our BPD sample, subjects with comorbid NPD were less
likely to have a history of NSSI (2 =6.8; df=1; p=0.009). Among the
patients with NPD in our sample, the percentage of men was higher
than the percentage of women (34.1% vs. 17.5%, (2 =10.6; df=1;
p=0.001). However, our results hold even if we control for gender:
attempters were less likely to have comorbid NPD compared with nonattempters (F=4.1; df=1286; p=0.04) and participants with NPD were
less likely to have a history of NSSI (F=5.4; df=1282; p=0.02).

Compared with healthy volunteers, subjects in both BPD groups are

more impulsive, aggressive, aectively dysregulated and more likely to
have a history of temper tantrums. BPD patients with a history of
suicide attempt are more aggressive, aectively dysregulated and less
narcissistic than BPD suicide non-attempters.

4.1. Clinical features

Our observations that the ALS and ALS Depression-Anxiety
Subscale scores are higher in suicide attempters and attempters are
more likely to have a history of temper tantrums compared to nonattempters are in agreement with observations that aective instability
is strongly related to suicide attempts in individuals with BPD (Links
et al., 2008; Yen et al., 2004). For example, the Collaborative
Longitudinal Personality Disorders Study research group found that
aective instability was the BPD criterion most strongly associated with
suicidal behavior (Koenigsberg et al., 2001; Yen et al., 2004).

Table 1
Demographic and clinical characteristics of healthy controls and patients with borderline personality disorder with or without a history of suicide attempt.

Age
Gender (% females)
Years of education
Subjects continuously employed
over the past 12 months
Aective Liability Scale (ALS)
Aective Liability Scale (ALS)
Depression-Anxiety
subdimension
Barratt Impulsivity Scale
Lifetime History of Aggression
Lifetime History of Temper
Tantrum
History of non-suicidal self-injury
a
b
c

Healthy controls
(n=146)

BPD patients without a history of

suicide attempt (s) (n=241)

BPD patients with a history of

suicide attempt (s) (n=48)

Statistical Analysis

Mean or
N

SD or %

Mean or N

SD or %

Mean or N

SD or %

df

Statistic F/2

p value

31.3
79
16.25
96

10.0
54.1%
2.99
65.8%

33.3
136
14.44
152

10.1
56.4%
2.65
63.1%

30.7
30
14.14
10

7.9
62.5%
2.69
40%

2434
2
2381
2

2.7
1.0
19.29
6.1

0.071
0.596
< 0.001
0.047

0.09a,b
0.12b,c

0.44
0.29

0.39
0.40

1.53
1.64

0.57
0.73

1.62
1.95

0.40
0.61

2352
2355

175.5
185.3

< 0.001
< 0.001

0.50a,b,c
0.51a,b,c

54.4
4.8
1.1

9.5
2.8
1.4

74.2
22.5
3.6

11.7
9.4
1.6

74.5
28.4
4.4

8.1
11.8
1.3

2316
2290
2292

112.8
118.3
70.2

< 0.001
< 0.001
< 0.001

0.42a,b
0.45a,b,c
0.33a,b,c

N/A

N/A

22

9.3%

27

56.3%

61.8

< 0.001

0.47a,b,c

Post-hoc and
effect size

healthy controls are dierent from BPD patients without a history of suicide attempt(s) at p < 0.05.
healthy controls are dierent from BPD patients with a history of suicide attempt(s) at p < 0.05.
BPD patients without a history of suicide attempt(s) are dierent from BPD patients with a history of suicide attempt(s) at p < 0.05.

Table 2
Psychiatric comorbidities of borderline personality disorder patients with or without a history of suicide attempt.

Cluster B personality disorders

Histrionic personality disorder
Narcissistic personality disorder
Antisocial personality disorder
Major depression
Major depressive disorder
Major depressive disorder with melancholic
features
Substance use disorder
Alcohol use disorder
Any substance use disorder

BPD patients without a history of suicide

attempt

BPD patients with a history of suicide attempt

(s)

Statistical Analysis

df

13
65
50

5.4
27
20.7

2
6
8

4.2
12.5
17.0

1
1
1

0.12
4.52
0.34

0.72
0.03
0.56

99
48

41.3
20

40
17

85.1
37.8

1
1

30.27
6.8

< 0.001
0.009

109
126

45.2
52.3

20
24

41.7
50.0

1
1

0.21
0.84

0.65
0.77

263

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L. Sher et al.

Our nding that BPD suicide attempters have higher lifetime

history of aggression scores compared to BPD non-attempters is
consistent with reports linking aggression and suicidality (Mann
et al., 1999; Oquendo et al., 2004; Placidi et al., 2001; Sher et al.,
2005; van Heeringen, 2003). Considerable evidence suggests that
suicide attempters are more aggressive than non-attempters (Mann
et al., 1999; Oquendo et al., 2004; Placidi et al., 2001; Sher et al., 2005;
van Heeringen, 2003). Given the evidence linking low serotonergic
activity independently to suicidal behavior, aggression, and BPD
(Linnoila et al., 1983; Mann et al., 1999; Placidi et al., 2001; Solo
et al., 2014; van Heeringen, 2003), low serotonergic activity may
underlie all three conditions. Low serotonergic activity may mediate
genetic and developmental eects on suicide, aggression, and BPD.
Our ndings indicate that BPD suicide attempters are more likely to
have a history of NSSI compared with BPD non-attempters. It has been
observed that individuals reporting self-injurious behavior without the
intent to die are more likely to have a history of previous suicide
attempts compared to individuals who do not self-harm (Whitlock
et al., 2006). A study of college students demonstrated that a history of
NSSI signicantly predicts concurrent or later suicidal thoughts or
behavior (Whitlock et al., 2013).
Our ndings indicate that both BPD groups have much higher ALS,
ALS Depression-Anxiety Subscale, BIS and LHA rating scale scores
compared with healthy controls. This underscores the fact that BPD
patients are very psychiatrically ill and function at a signicantly lower
level than healthy people (IsHak et al., 2013; Koenigsberg et al., 2009;
Skodol et al., 2002; Skodol et al., 2005; Zanarini et al., 2010). Studies
of clinical populations have shown that people with BPD experience
substantial impairment in their work, social relationships and leisure
(Skodol et al., 2002; Skodol et al., 2005; Zanarini et al., 2010). A
prospective study showed that patients with BPD showed no or little
improvement in their functioning over a 2-year period which indicates
that BPD patients are chronically impaired (Skodol et al., 2005).

2007; Grunebaum et al., 2004). It has been shown that suicide

attempters with MDD with melancholic features had a history of more
serious past suicide attempts and elevated probability of suicide
attempts during follow-up compared to suicide attempters with MDD
without melancholic features (Grunebaum et al., 2004).
In our sample, approximately 50% of the patients in both BPD
groups had a history of SUD. Many of them had a history of alcohol use
disorder. Our observations are consistent with multiple reports suggesting that BPD is frequently comorbid with alcohol and drug abuse
(Carpenter et al., In press; Trull et al., 2000; Trull et al., 2004). A
systematic review found that about 50% of BPD patients meet criteria
for alcohol use disorder which is in unison with our nding (Trull et al.,
2000). Evidence suggests that BPD is comorbid with SUD not only
cross-sectionally, but also over time (Walter et al., 2009; Zanarini et al.,
2011). BPD might inuence the development of SUD: BPD patients
might turn to psychoactive substances in order to self-medicate
aective disturbance or to cope with feelings of emptiness or abandonment (Dulit et al., 1990). Substance use can contribute to problems of
aective instability and aggressive behavior in patients with BPD (Trull
et al., 2000). Possibly, persons with a neurobiological susceptibility to
BPD might be particularly vulnerable to the neuropharmacological
sequelae of substance use.
A strength of this research is our large sample size of 435
participants, including 289 patients with BPD. Also, a comparison of
BPD attempters and BPD non-attempters is an extremely important
feature of our work because it allows us to better understand what
makes BPD patients suicidal. A weakness of this study is the use of selfreport scales. However, it is unlikely that the reported between-group
dierences in our BPD samples (BPD attempters vs. BPD nonattempters) would be a result of some type of bias in responding to
the questionnaires. Also, the study subjects were recruited in an urban
area and this may limit the generalizability of the results to the general
population.

4.2. Comorbidity with psychiatric disorders

5. Conclusion

Our observation that BPD patients with comorbid NPD are less
likely to have a history of suicide attempt or NSSI is in agreement with
a popular belief that Narcissists rarely commit suicide. When a
Narcissist threatens to do this, it's generally as a means of manipulation (Saeed, 2014). However, some studies suggest that NPD is
associated with suicidal behavior (Heisel et al., 2007; Links et al.,
2003; Stone, 1989). For example, a 15-year follow up study of patients
admitted to a psychiatric hospital in New York showed that patients
with NPD or narcissistic traits were signicantly more likely to die from
suicide compared to individuals without NPD or narcissistic traits
(Stone, 1989). Another study suggests that depressed older adults with
narcissistic personalities are at increased suicide risk (Heisel et al.,
2007). One possibility is that a NPD diagnosis reduces suicide risk
when it is comorbid with BPD but NPD increases suicide risk in
individuals without BPD. Additional work is needed to fully resolve this
issue.
Our observation that comorbidity of MDD and BPD is associated
with increased risk of suicide attempt is consistent with reports that
this comorbidity is related to elevated suicide risk (Brodsky et al., 2006;
Solo et al., 2000) For example, a study showed that attempters with
comorbid BPD and MDD had a higher number of lifetime suicide
attempts and made their rst attempt at a younger age compared to
subjects with BPD alone (Brodsky et al., 2006). It is of interest to note
that another study observed that patients with comorbid MDD and
BPD reported signicantly higher levels of objective planning for
suicide than patients with either disorder alone (Solo et al., 2000).
In our sample, BPD patients with a history of MDD with melancholic
features were more likely to have a history of suicide attempt compared
to BPD non-attempters. Some reports suggest that MDD with melancholic features is associated with high suicide risk (Agargun et al.,

Our study sample consisted of 435 participants including 289

patients with BPD. This is one of the largest BPD samples to date.
Our ndings indicate that BPD patients with a history of suicide
attempt(s) are more psychiatrically ill than BPD suicide non-attempters as indicated by higher levels of aective lability, aggression,
depression, anxiety, and NSSI. This indicates that BPD patients need
a very careful evaluation, including history of suicidal behavior, and
treatment. BPD patients with a history of NSSI, MDD, and/or
aggressive behavior should be regarded as individuals with high suicide
risk. Treatments focusing on enhancing perceived meaning in life and
building positive relationships with others may be particularly eective
in reducing suicide risk among BPD patients. Dialectical Behavior
Therapy, Mentalization-Based Treatment, and Transference-Focused
Psychotherapy may also help to prevent suicidal behavior in patients
with BPD.
We have also observed that the NPD diagnosis is associated with
decreased suicidal attempts and NSSI in BPD patients. This is a novel
nding that needs further study and replication.
The results of our study point to factors that may be predictive of
suicide attempts in BPD patients and highlights the value of distinguishing between BPD patients with and without histories of suicidal
and NSSI acting out.
Conict of interest
All authors declare that they have no conicts of interest.
Funding
This work was supported by a VA Merit award (I01CX000609) to
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EAH and the Mental Illness Research, Education, and Clinical Center
(MIRECC; VISN 2 South) at the James J. Peters VA Medical Center.
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