Association of borderline personality disorder criteria with suicide attempts among US adults

Importance  Rates of suicide are increasing. Although borderline personality disorder (BPD) and other psychiatric disorders are associated with suicide, there is a dearth of epidemiological research on associations between BPD and suicide attempts (SAs). Delineating the SA risk associated with BPD and its specific criteria in a nationally representative sample of individuals could inform recognition and intervention efforts for SAs.

Objective  To examine the association of a BPD diagnosis and specific BPD criteria with SAs in US adults.

Design, Setting, and Participants  This cross-sectional study analyzed data from the National Epidemiological Survey on Alcohol and Related Conditions–III (NESARC-III), a psychiatric epidemiological survey of noninstitutionalized US adults aged 18 or older conducted from April 2012 to June 2013. Eligible adults were randomly selected from households within census-defined counties or groups of counties. Data were analyzed from December 2020 to January 2021.

Main Outcomes and Measures  Prevalence of Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) psychiatric and personality disorders, BPD and its specific criteria, SAs, and adverse childhood experiences (ACEs), as assessed by structured diagnostic or clinical interviews; prevalence is expressed as weighted means. Multivariable-adjusted logistic regression was used to compare the risk of lifetime and past-year SAs by BPD diagnosis and by each specific BPD criterion. Analyses were adjusted for demographic and clinical factors, including psychiatric comorbidity, age at BPD onset, and ACEs.

Results  Of 36 309 respondents, 20 442 (56.3%) were women and 52.9% were non-Hispanic White; the mean (SD) age was 45.6 (17.5) years. The prevalence (SE) of lifetime and past-year SAs among participants with a lifetime diagnosis of BPD based on original NESARC-III diagnostic codes was 22.7% (0.8%) (adjusted odds ratio [AOR], 8.40; 95% CI, 7.53-9.37) and 2.1% (0.2%) (AOR, 11.77; 95% CI, 7.86-17.62), respectively. With use of diagnostic codes requiring 5 BPD criteria to meet social-occupational dysfunction, prevalence (SE) of lifetime and past-year SAs was 30.4% (1.1%) (AOR, 9.15; 95% CI, 7.99-10.47) and 3.2% (0.4%) (AOR, 11.42; 95% CI, 7.71-16.91), respectively. After excluding the BPD criterion of self-injurious behavior (to eliminate criterion overlap), the prevalence (SE) of lifetime and past-year SAs was 28.1% (1.1%) (AOR, 7.61; 95% CI, 6.67-8.69) and 3.0% (0.4%) (AOR, 9.83; 95% CI, 6.63-14.55), respectively. In analyses adjusting for sociodemographic variables, psychiatric disorders, age at BPD onset, and ACEs, BPD diagnosis and specific BPD criteria of self-injurious behaviors and chronic feelings of emptiness were significantly associated with increased odds of lifetime SAs (BPD diagnosis: AOR, 2.10; 95% CI, 1.79-2.45; self-injurious behaviors: AOR, 24.28; 95 CI, 16.83-32.03; feelings of emptiness: AOR, 1.58; 95% CI, 1.16-2.14) and past-year SAs (BPD diagnosis: AOR, 11.42; 95% CI, 7.71-16.91; self-injurious behaviors: AOR, 19.32; 95% CI, 5.22-71.58; feelings of emptiness: AOR, 1.99; 95% CI, 1.08-3.66). In analysis with BPD criteria simultaneously entered (excluding self-injurious behavior), chronic feelings of emptiness were significantly associated with increased odds of lifetime SAs (AOR, 1.66; 95% CI, 1.23-2.24) and past-year SAs (AOR, 2.45; 95% CI, 1.18-5.08).

Conclusions and Relevance  In a national sample of adults, after adjusting for demographic and clinical variables, a BPD diagnosis and the specific BPD criteria of self-injurious behaviors and chronic emptiness were significantly associated with increased SA risk. Although BPD is a complex heterogeneous diagnosis, the results of this study suggest that the criteria of self-injurious behaviors and chronic feelings of emptiness should be routinely considered in suicide risk assessment.