Risk of Suicide in Teens with Borderline Personality Disorder

Treatment for Adolescent Borderline Personality Disorder Can Reduce Symptom Severity

Borderline personality disorder (BPD) is one of the most challenging and disruptive mental health disorders humans experience. This is true for the people who develop BPD as well as their friends, families, loved ones, and the mental health professionals who treat them. For decades, members of the psychiatric community thought BPD was undiagnosable in the children and adolescents. This led to misdiagnoses, unsuccessful attempts at treatment, and inappropriate treatment for many teens with BPD.

This, in turn, led to increased emotional and psychological distress for everyone involved – including family, friends, and treatment professionals.

However, the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) indicates that, when a full psychiatric assessment indicates an individual meets the criteria for clinical borderline personality disorder, a diagnosis of BPD during adolescence may be accurate and appropriate.

In addition, research over the past decade has changed attitudes toward BPD. Previously, professionals considered BPD close to untreatable, with some calling it “the disease that shall not be named.” That attitude, thankfully, is now where it belongs: in the past. New evidence shows there are effective treatments for BPD, and that people who receive treatment can and do learn to live with and manage the symptoms of BPD.

We’ll talk about treatment at the end of this article.

First, we’ll offer a definition of BPD, its primary symptoms, and the prevalence of BPD.

Next, we’ll address an aspect of BPD that’s distressing – and sometimes outright terrifying – for parents of teens with BPD: its association with self-harming behavior, known as non-suicidal self-injury (NSSI), suicidal ideation, and suicide attempts.

Let’s define BPD so we can be on the same page for the rest of this article.

What is BPD?

The National Institute of Mental Health (NIMH) defines BPD as:

“A mental illness marked by a pattern of varying moods, self-image, and behavior. These symptoms often result in impulsive actions and problems in relationships. People with BPD may experience intense episodes of anger, depression, and anxiety that can last from a few hours to days.”

In an adolescent, the presence of at least five of the following nine symptoms means an induvial may meet the clinical criteria for BDP diagnosis:

1. Extreme efforts to avoid or prevent abandonment
2. Unstable relationships with friends, family, and peers. Interactions may vacillate between positive/loving and negative/combative/angry.
3. Risky behavior, which may include alcohol/drug use, binge spending, reckless driving, gambling, disordered eating.
4. A distorted self-image that has a significant negative impact on mood, behavior, and relationships.
5. Suicidal behavior/NSSI, which include suicidal ideation, suicide attempts, and self-harming behavior such as cutting, branding, or burning.
6. Volatile mood swings that may persist for hours, and in some cases, for days
7. Recurring feelings of emptiness
8. Extreme anger that appears disproportionate to the external stimuli
9. Dissociation or dissociative experiences, which may include a sense of feeling cut off from their body, a sense of watching themselves from outside their body, and/or stress-induced psychotic episodes or paranoia

In the past, professionals hesitated to diagnose BPD in adolescents for two reasons. First, the changes that occur during adolescence are often rapid and appear illogical to an adult or outside observer. Therefore, BPD symptoms were often viewed as a “phase that will get better over time.” Next, the symptoms of BPD may overlap with symptoms of depression, anxiety, and bipolar disorder. This led to frequent misdiagnoses and treatment which, in some cases, exacerbated BPD symptoms, rather than relieved them.

Thanks to the work of clinicians and researchers, now we know that: 1. BPD in teens exists, and 2. specific treatment for BPD works. That’s important, because untreated or inappropriately treated BPD can lead to negative outcomes, whereas treatment can help improve symptoms and make life manageable for a person with BPD.

Prevalence of BPD: Facts and Figures

Evidence-based research estimates the prevalence of BPD as follows:

• Overall presence in general population: 1.6-5.9%
• Among people (adults and adolescents) in outpatient psychiatric care: 11%
• Among people (adults and adolescents) inpatient psychiatric care: 20%
• Adolescents: 3%
• Adolescents in outpatient psychiatric care: 11%
• Adolescent patients in inpatient psychiatric care: 50%
• Adolescent patients in psychiatric hospitalization for suicidality: 78%

We realize those percentages appear small. In a country with a population of over three hundred million, those small percentages are not small, at all. Five percent of the adult population – two hundred sixty million – is close to thirteen million people, while three percent of the adolescent population – about twenty-five million – is well over half a million people.

Now it’s time to talk about the aspect of BPD that frightens parents the most: its association with NSSI and suicidal behavior.

Have a look at these statistics:

BPD Patients, Suicide, and Self-Harming Behaviors (NSSI)

• A study of 104 adolescents and 290 adults with BPD in an inpatient treatment setting showed:
  • 75% attempted suicide
  • 90% engaged in NSSI
• A 27-year study of 64 adults with BPD showed 10% died by suicide
• BPD patients have a mean of three lifetime suicide attempts
  • Overdose is the most common means of suicide attempt
• Self-harm behaviors, a.k.a. non-suicidal self-injury (NSSI), are common in people with BPD.
  • NSSI usually presents as superficial cuts to the wrists and arms
• As with NSSI in the non-BPD population, NSSI among people with BPD is not done with suicidal intent:
  • In most cases, NSSI occurs in people with BPD due to emotional regulation problems
  • People with BPD may cut themselves habitually to relieve painful emotional symptoms
  • Cutting offers temporary symptom relief, but, again, as with NSSI in the non-BPD population, NSSI among people with BPD does not necessarily mean they want to die
• Autopsies on suicides indicate the presence of personality disorders (PD) in about half of suicides in people under age 35, with BPD being the most common category of PD.

With all of that in mind, it’s important to understand something we haven’t mentioned before. In most cases, people BPD report improvement over time, with significant symptom reduction and improved life function observed in adulthood. In the words of Dr. Joel Paris, author of the study Suicidality in Borderline Personality Disorder:

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

Clearly, BPD is not an easy mental health disorder to live with. Suicidal thoughts and suicide attempts reveal deep emotional pain. However, people with BPD and families of adolescents with BPD should know that, despite the volatility and extreme nature of the symptoms and behavior – including repeated claims they plan to kill themselves – most patients with BPD do not die by suicide.

Unfortunately, some people with BPD – including adolescents – do die by suicide. We’ll now discuss some of the factors associated with escalation from BPD symptoms to suicidal behavior.

BPD and Suicide: What Causes Teens to Escalate to Suicidal Behavior

Researchers have not identified one specific thing that causes an individual with BPD to attempt suicide. However, there are several characteristics of BPD that increase risk of suicide:

• The duration of the disorder: suicide is more common the longer a person shows significant BPD symptoms.
• The presence of other mental health disorders, including anxiety and depression
• Alcohol and drug use
• Emotional dysregulation
• Unstable mood
• Impulsive behaviors
• Unstable interpersonal relationships

All of the above increase risk of NSSI and suicidal behavior among teens with BPD. Recent research says that one characteristic, above all others, contributes the most to increased suicide risk: emotion dysregulation.

The Role of Emotion Dysregulation in BPD

Emotional dysregulation is a common feature of mental health disorders in teens, and a risk factor for the development of mental health disorders in people of any age. It’s one of the things that causes discomfort: emotions are powerful, and people who lack the coping skills to manage strong emotions in a healthy and productive way often experience significant pain and distress. Their symptoms – the emotions – can lead to impulsivity, NSSI, suicidal ideation, and suicidal behavior in the absence of BPD, which means that in adolescents with BPD, the presence of emotional dysregulation amplifies overall suicide risk.

Here’s a clinical definition of emotion dysregulation, which begins with a definition of its opposite, emotion regulation:

“Emotional regulation can be described as how a person sustains, strengthens, or impedes their emotions according to their purposes or goals. Negative physiological emotions are counterbalanced by positive ones. However, this delicate and refined mechanism may sometimes become dysfunctional when negative emotions are not correctly counterbalanced. This imbalance may cause maladaptive behaviors, especially during adolescence, a period where emotional states should be finely regulated.”

In adolescents with BPD, researchers propose that emotional dysregulation plays a mediating role in suicide attempts: those with extreme emotional dysregulation are more likely than those with limited emotional dysregulation to commit suicide.

This evidence-based observation explains why two approaches to mental health treatment work can help teens: cognitive behavioral therapy (CBT) and dialectical behavior therapy (DBT). Of these two, DBT is the most effective, but we’ll discuss both in the following section.

Effective Treatments for Teen BPD

Since research pinpoints emotional dysregulation as a primary driver in NSSI and suicidality among teens with BPD, it’s logical that approaches to treatment that help teen manage difficult emotions also help teens manage BPD overall.

There are the two types of therapy known to be effective for BPD treatment in teens. Here’s the first:

Cognitive Behavioral Therapy (CBT)

• During CBT therapy, a CBT-trained therapist works with a teen to:
  • Identify disruptive or intrusive behaviors and symptoms
  • Identify the connection between thought and emotion
  • Explore the connection between emotion and behavior
  • Replace unwanted, intrusive thoughts and behaviors with productive, desirable thoughts and behaviors

There’s an element of CBT, however, that does not always serve teens with BPD: the focus on working through emotional issues with logic. Due to the nature of BPD – dissociation, distortions of reality, and the extremes of emotion – logical dialogue or discussion is not always effective. In many cases, it works. But in others, the thoughts, beliefs, and behaviors associated with BPD are driven by emotions that are so powerful, logic simply does not work.

That’s why another approach – one the teaches teens to experience and observe emotions without succumbing to them or judging them – can help teens with severe emotional dysregulation. We’ll talk about that approach now.

Dialectical Behavior Therapy (DBT)

• During DBT therapy, a DBT-trained therapist works with a teen to cultivate the four core DBT skills:
  • Mindfulness teaches teens to observe and experience the present moment without judgment
  • Emotion Regulation helps teens manage overwhelming feelings
  • Interpersonal Effectiveness helps teen enrich and improve relationships
  • Distress tolerance teaches teens manage overwhelming emotions without engaging in risky behavior
• The person who invented DBT, Dr. Marsha Linehan, develop a fifth DBT skill specifically for adolescents with severe emotion dysregulation. It’s called Walking the Middle Path. This core skill includes five critical sub-skills. These skills teach teens to:
  • Accept the world without the need to change it.
  • Understand every problem has more than one solution
  • Validate opposing viewpoints perceptions
  • Validate personal viewpoints
  • Believe change is possible through intentional action

Both CBT and DBT can help teens manage the symptoms of BPD and live a full and productive life. A study published in 2021 indicates that teens with severe BPD, after intensive inpatient treatment, showed the following:

• Significant reductions in emotion-related symptoms, i.e. anger, depression, or fear of abandonment
• Significant reductions in behavioral symptoms, i.e. non-suicidal self-injury, suicidal ideation, and suicidal behavior

This is important for families, teens, their families – and the therapists who treat teen with BPD. When reading about treatment for BPD, you come across an interesting phenomenon: for years, many therapists felt – and would say so among themselves – that BPD was difficult, if not impossible, to treat. We mention in the beginning of this article that BPD can be frustrating for therapist. The last article we cited, above, close with the line:

“Like adult BPD, adolescent BPD appears to be not as intractable and treatment resistant as previously thought, mitigating against therapeutic nihilism.”

Nihilism – or the belief that life is essentially meaningless – does not mix well with treatment for mental health disorders. In fact, what matters most in treatment is the opposite of nihilism: the belief that change is possible.

Treatment for BPD: The Role of Hope

Treatment relies on hope, and hope relies on belief in the potential for a positive, bright future. We espouse the idea that there’s hope for every teen, including teens with borderline personality disorder whose symptoms are extreme, disruptive, and difficult to manage. Those teens can learn to manage their symptoms effectively. They can reduce their risk of NSSI and suicidal behavior, and in turn reduce the likelihood of premature mortality.

It takes commitment, time, work, and belief in the process.

It takes hope.

The right treatment, at the right time – especially for a challenging disorder like BPD – can be both life changing and life-saving: we’ve seen it happen.

That’s how stay positive, and know that for every teen we meet, there’s hope, and real chance for treatment success.