Risk of Suicide in BPD Teens with Prior Suicide Attempts

What Increases Risk of Subsequent Suicide Attempts in Teens with BPD?

Over the past two years, we’ve published several articles on borderline personality disorder in teens. Our primary objective in all of these articles is to help parents of teens with BPD and teens with BPD learn as much as they can about the disorder. The goal of this knowledge is to support them as they navigate what we frequently call a challenging, frustrating, and difficult diagnosis. We get those words straight from mental health professionals, and we know from direct personal experience working with teens with BPD that they’re not exaggerating: BPD is all of those things.

It’s also scary.

It’s scary for parents, for the teens that have BPD, and for us, the mental health professionals who treat teens with BPD.

We know scary is not a clinical term, but nevertheless, it’s accurate. If you read our articles on BPD, such as Risk of Suicide in Teens with Borderline Personality Disorder, How Parents Can Help Their Teen Manage Borderline Personality Disorder, and review our Parent Guide on Borderline Personality Disorder in Teens, you’ll understand why. Those articles list the symptoms and characteristics of BPD, which include extreme mood swings, angry outbursts, rocky relationships with family and friends that may unpredictably vacillate between love and anger/hate/resentment, risky behavior that may include alcohol and drug use, reckless driving, disordered eating, sexual behavior, self-harm (NSSI), and suicidal ideation/suicide attempts.

The cumulative effect of all these symptoms makes BPD challenging, frustrating, difficult, and scary. But it’s that last symptom/characteristic that parents fear the most: the association of BPD with suicidal behavior, which includes suicidal ideation – i.e thinking or talking about suicide – and suicide attempts.

That’s what this article is about: risk of suicide in teens with BPD. Specifically, the risk of subsequent suicide attempts among teens with BPD who’ve attempted suicide before.

BPD and Suicide: What Parents Should Know

Here’s the first thing parents should know:

The presence of BPD in a teen increases the likelihood of a suicide attempt.

The data are clear on that. At the same time, it’s important to understand something else:

“Most patients with BPD, despite having suicidal thoughts for long periods of time and multiple suicide attempts, never kill themselves.”

That’s a tricky sentence to understand.

Suicidal thoughts and multiple suicide attempts over a long period of time is not a default situation anyone wants to live with. Not parents of teens with BPD and certainly not teens with BPD. Also, our hopeful nature guides us to focus on the positive aspect of that sentence: most don’t.

Unfortunately, the phrase most don’t means some do.

That’s why it’s absolutely critical for parents of teens diagnosed with BPD to understand their teen needs evidence-based treatment as soon as possible. They also need to understand that in the presence of additional risk factors, the likelihood of a suicide attempt by a teen with BPD increases. The most potent predictor of a suicide attempt in a teen with BPD is an initial suicide attempt. What that means is that if a teen with BPD attempts suicide once, they’re far more likely to attempt suicide (again) than a teen who has never attempted suicide.

We mention above that this article is about suicide attempts among teens with BPD who have a history of at least one suicide attempt. It’s about that, and more. It’s about identifying what factors accelerate risk of subsequent suicide attempts in that group of teens. To explore this topic, we’ll use information from a study published in 2020 called “Borderline Personality Disorder and Prior Suicide Attempts Define a Severity Gradient Among Hospitalized Adolescent Suicide Attempters.”

Factors that Increase Risk After an Initial Suicide Attempt in Teens with BPD

Before we dive into the data from that study, we’ll summarize the statistics on BPD and suicide we share in the BPD-specific articles we link to above. This will give you an idea of the big BPD/suicide picture without reading those articles. If you’re interested in more statistics on BPD, and a complete list of symptoms, we encourage you to read those articles. For the purpose of this article, however, what we’re about to share is sufficient for your understanding of the present subject.

First, the prevalence of BPD among teens.

Research indicates the following rates of BPD in the U.S.:

  • Among adolescents: 3% (about 500,00 teens nationwide)
  • Adolescents in outpatient psychiatric care: 11%
  • Adolescent patients in inpatient psychiatric care: 50%
  • Adolescent patients in psychiatric hospitalization for suicidality: 78%

Next, the basic statistics on suicidality among people with BPD.

BPD Patients and Suicide

  • 75% of patients in a study of 394 adolescents and adults with BPD in an inpatient treatment setting attempted suicide
  • In a 27-year study of adults with BPD, 10% died by suicide
  • BPD patients have a mean of three lifetime suicide attempts
  • Drug overdose is the most common means of suicide attempt for people with BPD
  • Autopsy data from individuals who died by suicide show the presence of personality disorders (PD) in about half of suicides in people under age 35.
    • Among those, BPD is the most common category of PD.

That’s the big picture. BPD is a more common diagnosis than many people think, and suicidality is a feature that both adults and teens diagnosed with BPD experience.

Now let’s discuss the results of that study. Here’s the research objective, in the words of the study authors:

“The present study aimed to describe adolescent suicide attempters and identify at-risk groups while considering BPD diagnosis and history of SAs.”

To achieve this goal, researchers divide the adolescents in the study into three groups:

  • Teens without BPD with a history of one suicide attempt
    • This group included 80 teens, making up 26.5% of the group
  • Teens with BPD with a history of one suicide attempt
    • This group included 127 teens, making up 42% of the group
  • Teens with BPD and a history of multiple suicide attempts with BPD
    • This group include 95 teens, making up 31.5% of the study group

During the course of the study, the research team observed significant differences in the clinical profiles of each of these groups of teens. First, they identified what they label a severity gradient among the three groups. The presence of BPD and number of previous suicide attempts predicted where they located each teen on the severity gradient:

Lowest on the Severity Gradient (lower risk of subsequent suicide attempt):

  • Teens with no BPD and one previous suicide attempt
  • These teens showed the lowest frequency of subsequent suicide attempts

Middle of the Severity Gradient (moderate risk of subsequent suicide attempt):

  • Teens with BPD and one previous suicide attempt
  • These teens showed the next highest frequency of subsequent suicide attempts

Top of the Severity Gradient (highest risk of subsequent suicide attempt):

  • Teens with BPD and a history of multiple suicide attempts
  • These teens showed the highest frequency of subsequent attempts

We’ll stop here for a moment to interpret that data before we include the role of other factors in predicting suicide risk. Parents of teens with BPD should understand this breakdown: teens with the highest risk of subsequent suicide were teens with BPD and multiple suicide attempts, teens with moderate risk of subsequent suicide were teens with BPD and one previous suicide attempt, and teens with lower risk of subsequent suicide were those with no BPD and one previous suicide attempt.

We also need to contextualize this data.

All of these teens are at higher risk of suicide than teens with no history of suicide and no diagnosis of BPD. That’s important. These are gradations of risk that are, by default, higher than we see in the typical population, and also higher than we see in teens with mental health disorders that are not borderline personality disorder.

Again, we need to remind parents that in the big picture, teens with BPD are at increased risk of suicide and need evidence-based treatment sooner than later.

With that said, we’ll now look at the additional factors that may contribute to or mitigate risk of subsequent suicide for teens with BPD and one previous suicide attempt.

Teens With BPD: Additional Factors That Increase Suicide Risk

Once they established the severity gradient we show above, advanced statistical analyses allowed the research team to identify additional variables that may or may not have affected position on the severity gradient. Here are those variables, their effect on each teen’s position on the severity gradient, and how they’re associated with suicide attempts:

  • Highest severity, highest risk of multiple subsequent attempts:
    • Young age at first attempt
    • History of self-harming behavior (non-suicidal self-injury, a.k.a. NSSI)
    • Presence of anxiety disorder
  • Among teens with multiple subsequent suicide attempts:
    • 5% had BPD
    • 7% had major depressive disorder (MDD)
  • Among teens with a history of one suicide attempt:
    • Those with a diagnosis of oppositional defiant disorder (ODD) or conduct disorder (CD) were five times as likely to have BPD
  • Among teens at all levels of severity:
    • Attention-deficit hyperactivity disorder (ADHD) diagnosis had no effect on subsequent suicide attempts
    • MDD diagnosis had no effect on subsequent suicide attempts
  • However, among teens in the study (all of whom had at least one suicide attempt):
    • Most had an internalizing disorder, such as major depressive disorder (MDD)
    • Most also had an externalizing disorder, such as oppositional defiant disorder (ODD) or conduct disorder (CD
  • Teens in both BPD groups – BPD with one suicide attempt and BPD with multiple attempts – had an increased likelihood of diagnosis of alcohol or substance use disorder (AUD/SUD)

That information might not be easy to interpret, so we’ll clarify these bullet points in following section. Please note that these relationships are complex, and the language the researchers use – as well as the language we use above – reflects that complexity. This reiterates the general truth that BPD is a challenging disorder to manage, and therefore, teens with BPD need evidence-based treatment sooner rather than later.

Analyzing the Data: What Predicts Suicide Risk?

We’ll start with the two pieces of that data that are surprising and unexpected.

First, the fact that a previous ADHD diagnosis had no impact on subsequent suicide attempts. The researchers were confounded by this result. While impulsivity typically predicts higher levels of suicidality among teens with ADHD and BPD, this did not appear in the statistical analysis of these teens. We don’t have an explanation either: we’ll file this under things that make us want to research the relationship of ADHD, BPD, and suicide risk further.

Second, the fact that a previous MDD diagnosis had no impact on subsequent suicide attempts. The researchers do have a logical explanation for this observation. They theorize that among teens with BPD, severity of depressive symptoms predicts suicidality, rather than a diagnosis of MDD. To meet clinical criteria for MDD, specific symptoms must be present every day for two weeks or more. It’s entirely plausible that a teen with BPD might have intense, severe depressive symptoms, but not every day for two weeks or more. Therefore, severe depressive symptoms may predict suicide independently of an MDD diagnosis.

Now we’ll move on to our critical takeaway from this data. The most important thing for parents to learn from this research is the observation that a combination of three factors leads to the highest risk of subsequent suicide attempts after at least one suicide attempt among teens with BPD:

  1. Diagnosis of childhood anxiety
  2. Previous self-harming behavior (NSSI) such as cutting, burning, and branding
  3. Early age at first suicide attempt

It’s also important to realize that early NSSI and anxiety are predictors of later BPD diagnosis. Therefore, in the words of the study authors:

“Adolescents with early onset of suicidal behaviors, anxiety disorder and NSSI would benefit the most from intensive interventions.”

Evidence-Based Treatment for BPD

When they say interventions what they mean is evidence-based mental health treatment. And when they say intensive what they mean is treatment beyond biweekly office visits with a counselor or a psychologist.

The most effective treatment for teen BPD follows the integrated, comprehensive treatment model. This means that a teen with BPD needs a full psychiatric evaluation to receive and accurate diagnosis, followed by a treatment plan that includes a combination of psychotherapy, family participation in treatment, community support, and, if recommended by a licensed and qualified mental health professional, psychiatric medication.

Effective therapies include:

  • Dialectical behavior therapy (DBT)
  • Cognitive behavioral therapy (CBT)
  • Mentalization-based therapy (MBT)

Effective medications, if recommended by a qualified professional:

  • Antidepressants
  • Mood stabilizers
  • Anxiolytics (anti-anxiety medication)

Family participation in treatment includes:

  • Parents and/or siblings and caregivers attending group family therapy sessions
  • Parents and/or siblings and caregivers attending educational workshops on BPD
  • Friends, parents, siblings, and caregivers working with therapist to learn the best ways to support the individual with BPD with compassion and understanding, and without accidentally enabling counter-productive behavior

That last bullet point is much easier said than done, but it’s essential. As we mention at the outset, BPD can be a complicated and scary diagnosis. Family members who learn as much as they can about BPD are in a much better position to support their loved one with BPD than those who don’t take the time to understand the intricacies of the disorder.

When everyone is on the same page, including siblings, parents, caregivers, and the teen with BPD, then the chances of treatment success increase dramatically. It takes work, it takes time, and it takes effort, but treatment for teens with BPD can be effective. In the case of teens with BPD with a prior suicide attempt, effective treatment can be lifesaving.

Finding Help: Resources

If you’re seeking treatment for your teen, please navigate to our page How to Find the Best Treatment Programs for Teens and download our helpful handbook, A Parent’s Guide to Mental Health Treatment for Teens.

In addition, the American Academy of Child and Adolescent Psychiatry (AACAP) is an excellent resource for locating licensed and qualified psychiatrists, therapists, and counselors in your area. Both the National Institute of Mental Health (NIMH) and the National Alliance on Mental Illness also provide and high-quality online resources, ready and waiting for you right now