Borderline personality disorder (BPD) is characterized by high levels of emotional reactivity and impulsivity, which makes borderline personality disorder treatment a challenge for patients and providers alike. Patients with BPD engage in suicidality – including suicidal ideation and suicide attempts – at higher rates than other mental health disorders. This complicates the situation, and unfortunately, many behavioral health providers turn away people with BPD because of the significant difficulties associated with borderline personality disorder treatment.
Complications with borderline personality disorder treatment result from the nature of the symptoms of BPD. Difficult symptoms include:
- Extreme and excessive efforts to avoid real or imagined abandonment.
- Intense, rocky, and chaotic interpersonal relationships
- Distorted self-image
- Extreme mood swings
- Short-term psychotic symptoms
- Intense, persistent anger
- Tantrums and physical fights
- Suicidality and self-harm
These symptoms often disrupt daily life for people with BPD, making full participation in typical activities problematic, and in some cases, impossible. Negative consequences of untreated BPD and untreated BPD symptoms include:
- Impaired work performance
- Impaired academic achievement
- Legal trouble
- Risky behavior, e.g., substance use, sexual activity, unsafe driving
A typical approach to borderline personality disorder treatment includes a combination of psychotherapy, medication, education about BPD, wraparound support, and adjunct therapies. Psychotherapy helps patients manage symptoms with practical tools. Medication may help to stabilize brain chemistry. Education teaches people with BPD about themselves and their disorder. Wraparound support facilitates reconnection to family and friends, as well as helping patients with BPD access social services and other support that promotes recovery. Adjunct therapies include new approaches to treatment such as transcranial magnetic stimulation (TMS) and others.
There are currently no medications approved specifically for BPD. That’s one thing that makes treatment challenging. However, a study published recently examined the effect of medication for attention-deficit/hyperactivity disorder on patients with BPD.
Borderline Personality Disorder: Facts and Figures
We’ll discuss that study in a moment.
First, we’ll share the latest data on BPD, so we understand the shape and scope of the challenge. National Institute of Mental Health (NIMH), and the peer-reviewed journal article “Chronic Suicidality Among Patients With Borderline Personality Disorder.” We’ll share data on BPD prevalence, BPD and co-morbid mental health disorders (when a person receives a diagnosis of BPD and another mental health disorder), and BPD and suicidality.
Here’s the prevalence data.
Overall Prevalence of BPD in General Population
- Borderline personality disorder (BPD):
- Current diagnosis of BPD: 1.4%
- Ever diagnosed with BPD: 5.9%
Among people with BPD, 42.4% received treatment.
Next, the data on co-morbidity.
BPD and Co-Morbidity With Other Mental Health Disorders
- BPD and co-morbidity with other mental health disorders:
- Anxiety disorders: 88%
- Mood disorders: 80%-96%%
- Substance use disorders: 64%
- Eating disorders: 53%
- Attention deficit hyperactivity disorder (ADHD): 10% – 30%
- Any mental health disorder: 84.5%
People with BPD account for 9% of visits to psychiatric emergency rooms.
Finally, the data on suicidality.
BPD and Suicidality
- BPD with suicidality:
- Suicidal ideation: 85%-50%
- Suicide attempts:
- 30% of patients with BPD report at least one suicide attempt during lifetime
- 75% of BPD patients who engage in inpatient treatment report at least one suicide attempt during lifetime
- BPD patients report an average of 2 suicide attempts during lifetime
- Completed (fatal) suicide: 5% – 10%
- Average age at suicide: 30-40 years old
Before we discuss the study on ADHD medication we mention above, we’ll elaborate on these facts and figures, because BPD is a complex disorder, and a list of statistics does not convey the various issues that arise during the treatment and diagnosis of BPD.
Understanding BPD: Challenges for Treatment and Diagnosis
Here are three key points researchers make about BPD statistics in general:
With regards to prevalence of BPD, data shows that 75 percent of people with BPD are female. However, NAMI indicates that new, preliminary research shows that males may develop BPD at similar rates, but are often misdiagnosed with post-traumatic stress disorder (PTSD) or major depressive disorder (MDD).
With regards BPD, co-morbid mental health disorders, and suicidality, research shows that the presence of any mental health disorder increases risk of suicidality. Patients with co-morbid BPD and MDD show the highest prevalence of suicidal ideation, suicide attempts, and completed suicides.
With regards to BPD and suicidality, researchers over the past several decades reveals a level of complexity that both complicates and informs treatment. Complications include:
- Evidence shows females develop BPD at higher rates than males, but males with BPD commit suicide at higher rates than women.
- Peak suicidal ideation among people with BPD is between ages 18-30, but completed suicides occur most often between age 30-40
- Suicide completers and suicide attempter have different profiles:
- Completers are most often older, male, and die on the first attempt
- Attempters are most often younger, female, and become chronically suicidal
- Chronic attempters/chronically suicidal patients with BPD seek treatment more often than completers
In addition, although BPD is a volatile disorder characterized by a high level of aggression and intensity, research shows that in some cases, hospitalization can exacerbate BPD symptoms and suicidality. In fact, Dr. Marsha Linehan, the founder of dialectical behavior therapy (DBT) – one of the only approaches shown effective for BPD – advises against hospitalization for people with BPD. Apart from acutely suicidal patients and/or those who pose an imminent risk to others, Dr. Linehan advises against stays of over one night. Other researchers find that hospitalization for patients with BPD can be ineffective, and in some cases, counterproductive.
However, the consensus opinion among BPD experts is that serious suicide attempts and acute psychotic symptoms may require hospitalization. At the same time, eminent BPD researchers and clinicians like Dr. Linehan conclude brief stays are more effective than long stays for people with BPD.
Those are the primary factors that make borderline personality disorder treatment a significant challenge, particularly around suicidality.
Borderline Personality Disorder and Suicide
Published in June 2023 in the Journal of the American Medical Association (JAMA), researchers who designed the study “Comparative Effectiveness of Pharmacotherapies for the Risk of Attempted or Completed Suicide Among Persons With Borderline Personality Disorder” asked a simple, direct, and important question:
What is the comparative effectiveness of pharmacological treatments on the risk of suicidal behavior among individuals with borderline personality disorder (BPD)?
To explore this question, the research team analyzed data from a nationwide database in Sweden on mental health outcomes for 22,601 patients diagnosed with BPD and treated between 2006 and 2021. They calculated hazard ratios for two outcomes: attempted and completed suicide over the 16 years of study data. They connected these hazard ratios to the various medications patients took during the course of their treatment. Medications included:
- Antidepressants (10): Vortioxetine, Bupropion, Citalopram, Escitalopram, Sertraline, Fluvoxamine, Mirtazapine, Moclobemide, Amitriptyline, Venlafaxine
- Antipsychotics (4): Clozapine, Quetiapine, Levomepromazine, Olanzapine
- Mood stabilizers (5): Lithium, Valproic acid, Lamotrigine, Carbamazepine, Topiramate
- ADHD medication (5): Lisdexamphetamine, Methylphenidate, Atomoxetine, Dexamfetamine
Let’s take a look at what they found.
ADHD Medication for Borderline Personality Disorder Treatment: The Results
At the 16-year follow-up, researchers observed:
- 8513 hospitalizations due to attempted suicide
- 316 completed (fatal) suicides
Statistical analysis associated treatment with attention-deficit/hyperactive disorder (ADHD) medication with a decreased risk of attempted or completed suicide. Researchers reported their results by calculating the hazard ratio (HR). In behavioral health research, a hazard ratio (HR) describes the probability an individual with one specific condition will experience one specific outcome after exposure to one specific intervention.
In this case, they calculate the probability and individual with BPD would commit suicide after taking antidepressant medication, antipsychotic medication, mood stabilizing medication, or medication for ADHD.
A hazard ratio (HR) of 1 means no increase or decrease in risk. An HR below 1 means decreased risk, and an HR over 1 means increased risk. For instance, an HR of 0.70 means a 30% reduced risk, while an HR of 1.70 means a 70% increased risk.
Here are the results.
BPD, Psychiatric Medication, and Suicide Risk
Analysis associated treatment with attention-deficit/hyperactive disorder (ADHD) medication with a decreased risk of attempted or completed suicide:
- ADHD medication, average hazard ratio: 0.83, or a 17% reduced risk of suicide
- Hazard ratio by ADHD medication type:
- Polytherapy (treatment with more than one ADHD medication): 0.75, or 25% reduced suicide risk
- Lisdexamphetamine: 0.78, or 22% reduced suicide risk
- Methylphenidate: 0.84, or 16% reduced suicide risk
- Atomoxetine: 0.86, or 14% reduced suicide risk
Treatment with mood stabilizers did not have a statistically significant association with the main outcome:
- Mood stabilizers: 0.97, or a 0.03% reduce risk of suicide
- Antidepressants: 1.38, or a 38% increased risk of suicide
- Antipsychotics: 1.18, or an 18% increased risk of suicide
The research team found that among the medications used to treat BPD, benzodiazepines were associated with the highest risk of suicide, with a hazard ratio of 1.61, or a 61% increased risk of suicide.
Here’s how the study authors describe these results:
“In this comparative effectiveness research study, ADHD medication was the only pharmacological treatment associated with reduced risk of suicidal behavior among patients with BPD. The findings suggest that benzodiazepines should be used with care among patients with BPD due to their association with increased risk of suicide.”
We’ll discuss the implications of these findings below.
How This Helps Borderline Personality Disorder (BPD) Treatment
The data we report above describes risks of both attempted and completed suicide. ADHD medication was superior to all other pharmacological treatments for this combined metric. The results show ADHD medication reduced likelihood of completed suicide by 48 percent, while treatment with benzodiazepines increased risk of completed suicide by 323 percent.
That’s invaluable data. It tells providers right away that they need to reconsider treating any BPD patient with benzodiazepines, as it dramatically increases risk of suicide attempts and fatal suicides. It also tells providers that ADHD medication can reduce suicide risk in BPD patients.
That’s a big deal.
The research team indicates that to the best of their knowledge, this was the first study to examine the differential effects of pharmacotherapies on borderline personality disorder treatment outcomes. Therefore, it’s also the first one to identify an association between decreased suicide risk and ADHD medication.
It bears repeating: that’s a big deal.
Since impulsivity and emotional dysregulation are symptoms common to both BPD and ADHD – and ADHD medication is not contraindicated for BPD treatment – it’s a logical choice to treat those components of BPD with ADHD medication. The fact that impulsivity and emotion dysregulation are associated with increased suicide risk supports considering ADHD medication as a borderline personality disorder treatment. Finally, the data showing decreased suicide risk after exposure to ADHD medication makes considering ADHD medication for BPD treatment more than logical: if additional studies confirm these results, then this means that for the first time, we’ll have a pharmacotherapy that effectively and significantly reduces suicide risk in patients with BPD.
If that happens, it can give people with BPD – and their friends and families – hope for the future, and instill optimism that risk of one of the most feared outcomes associated with BPD – a suicide attempt or completed suicide – can be effectively managed with medication that’s readily available.