The United States is in the midst of a suicide crisis. A report from the Centers for Disease Control and Prevention last year found that suicide rates have skyrocketed in the United States in recent years, becoming the nation’s 10th leading cause of death.
In 2016 alone, nearly 45,000 Americans died by suicide. In 2017, the most recent year for which data is available, the number rose to 47,173.
Get that number in your head. In a single year, more than 47,173 people committed suicide. By comparison, AIDS killed 50,628 Americans at the height of the epidemic in 1995. Meanwhile, it’s estimated that more than 42,000 women will die from breast cancer this year.
However, before you can take concrete steps to solve a problem, you have to understand it. Unfortunately, the reason for the rise in suicide rates is not entirely clear, nor is it likely to be due to a single factor or even a combination of related factors, although rates increased between 2008 and 2017 for both men and women and across all age groups.
For younger Americans, the rise in suicide rates could be due to social isolation, social media, and bullying. For middle-aged Americans, the rise could be related to economic insecurity, opioid addiction, or social exclusion. Other conditions are likely to affect older adults.
It would seem wrong to assume that there is a single silver bullet that can address all of these issues, as different groups of Americans face different social and environmental factors that can impact suicide rates.
However, one of the underlying issues that particularly affects Americans with mental illnesses may be the lack of adequate mental health services and resources, with data indicating a significant increase in suicides among patients after discharge from the hospital. In 2005, Chen and Nordentoft found that, compared to healthy controls, patients in the week following discharge from hospital had a significantly higher risk of suicide—102 times higher for men and 246 times higher for women.
While suicide can be linked to severe and persistent mental illnesses (SPMI) such as major depression, bipolar disorder, and schizophrenia, it is also associated with personality disorders. Although not traditionally thought of as an SPMI, borderline personality disorder can also be considered an SPMI because of its lifelong impact.
What is the difference between a mood disorder and a personality disorder?
When one thinks of mental illness, one often thinks of personality disorders. These mental illnesses arise from a combination of neurobiological, genetic, and psychosocial factors. Historically, there has been a distinction between personality disorders and personality disorders. While personality disorders are recognized as having a strong genetic or neurobiological component, personality disorders are thought to be primarily psychosocial. However, new data suggests that there may be a neurological component to these disorders, which will be explored below.
The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) defines personality disorders as “an enduring pattern of internal experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, begins in adolescence or early adulthood, stabilizes over time, and leads to distress or impairment.”
A personality disorder is not a mere quirk or eccentricity, nor is it a trait that comes and goes only in moments of extreme stress or duress. By their very nature, personality disorders are deeply ingrained behaviors that persist even when those behaviors could lead to potentially dangerous conditions.
The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) lists several personality disorders that fall into three basic groups, as well as a variety of other personality disorders that will be omitted here. The disorders that fall into the three groups are:
Cluster A
Paranoid Personality Disorder
Schizotypal Personality Disorder
Schizotypal Personality Disorder
Cluster B
Antisocial Personality Disorder
Borderline Personality Disorder
Histrionic Personality Disorder
Narcissistic Personality Disorder
Cluster C:
Avoidant Personality Disorder
Dependant Personality Disorder
Obsessive-Compulsive Personality Disorder
In many cases, a patient may have more than one personality disorder. In addition, some may also have a co-occurring mood disorder or substance abuse disorder. These comorbidities can put patients with personality disorders at greater risk for engaging in potentially dangerous behaviors.
Borderline Personality Disorder and Suicide
Of all the personality disorders listed above, data suggest that borderline personality disorder (BPD) has the strongest association with suicidal behavior. According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), BPD is characterized by “a pervasive pattern of instability in interpersonal relationships, self-image, emotions, and marked impulsivity that begins in early adulthood and is present in a variety of contexts.”
People with BPD experience intense distress when they feel they are being rejected or abandoned and often lash out at people for even minor perceived slights. They may also exhibit psychotic-like symptoms during times of extreme stress.
Another feature of BPD is a tendency toward self-harm. The DSM-5 notes that people with BPD exhibit “recurrent suicidal behavior, gestures, threats, or self-injurious behavior.” Meanwhile, Linehan and Hard have found that between 60% and 80% of people with borderline personality disorder engage in suicidal behavior, and Joel Paris recently confirmed the findings of a study he co-authored in 2001 with Haley Zweig-Frank, which found that completed suicide occurs in more than 10% of these individuals.
People with borderline personality disorder are at greater risk for suicide if they have comorbidities such as depression, substance abuse, or another personality disorder. Unfortunately, these comorbidities are very common.
About a quarter of people with borderline personality disorder meet the criteria for antisocial personality disorder, while alcohol use disorder and substance use disorder are much more common—affecting 50% and 40% of people with borderline personality disorder, respectively. Given that more than two-thirds of people who commit suicide have a diagnosable substance use disorder, this is a major concern.
When all these factors are taken into account, it reinforces the idea put forward by Apter et al., that two distinct motivations precede suicidal behavior. The first is associated with depression and a desire to die. The second, which seems more relevant among patients with borderline personality disorder, is associated with aggression and impulsivity. It is more akin to a desire to escape in the moment without fully considering the consequences of one’s actions.
Neuroscience and Borderline Personality Disorder
The neuroscience of personality disorders—and borderline personality disorder in particular—must be understood in the context of developmental and psychosocial factors. Personalities develop because of a convergence of factors, and emerging data suggest that there may be specific predispositions and neurochemical abnormalities that influence personality disorders more than previously thought.
For example, aggressive and impulsive behavior are part of the criteria for borderline personality disorder. While environmental and psychosocial components play a strong role in fostering these behaviors, evidence suggests that the serotonin and dopaminergic systems within the brains of patients with borderline personality disorder differ from healthy controls, making it harder for them to control impulses.
Researchers have found additional differences in the brains of individuals with borderline personality disorder when compared to healthy controls. Paul Solove of the University of Pittsburgh, in particular, has pioneered several studies that have examined how borderline personality disorder correlates with gray matter volumes in specific parts of the brain associated with impulsivity, aggression, emotional regulation, and episodic memory.
In 2012, he and his team wrote in the journal Psychiatric Research that “MRI studies in patients with borderline personality disorder compared with healthy controls indicate volume loss and reduced gray matter concentrations in frontal lobe regions, including the orbitofrontal cortex and anterior cingulate cortex, and in medial temporal lobe regions, including the hippocampus and amygdala.”
Even more interestingly, these findings did not just indicate differences in gray matter volume between patients with borderline personality disorder and healthy controls; They also found variations within the BPD group:
“We found significant differences in gray matter concentrations between BPD attempters and non-attempters, and between high- and low-risk suicide attempters, suggesting a potential role for specific neural circuits in suicidal behavior. The affected regions include the orbitofrontal, temporal, insular, and limbic structures, which are widely involved in emotion regulation, behavioral control, executive cognitive function, and adaptive response in social situations. This suggests structural differences not only between BPD patients and controls but also between BPD patients who attempt suicide and those who do not, as well as between high- and low-risk suicide attempters.”
These studies do not suggest that the behaviors of patients with BPD are solely the result of a brain disorder or disease. Rather, they suggest that there may be a neurological basis beyond the psychological and social factors that make individuals more susceptible to developing certain personality disorders such as BPD. Furthermore, these studies suggest that comprehensive treatment of personality disorders such as BPD requires consideration of the psychological, social, environmental, and neural components that lead to the disorder. While it is difficult to suggest clinical applications for these findings, they do open the door to further studies that will allow us to better understand how BPD affects patients’ ability to mediate their most dangerous impulses. By better understanding the mechanisms of the disorder, we can hope to discover more effective treatments that will ultimately save lives.
