‘Compelling evidence’
“Our epidemiological sample has much broader generalizability and fewer potential confounds than the clinical treatment-seeking sample,” said Dr. Grilo.
However, he noted that the two studies “converge strongly and provide compelling evidence that BPD is associated with substantially heightened risk for suicide attempts over the lifetime.”
The two studies “also converge in finding that the presence of symptoms such as repeated self-harm and feelings of chronic emptiness are also associated with risk for suicide attempts.”
The new findings highlight the need to ask potentially at-risk patients about feelings of emptiness as well as self-injurious behaviors. Clinicians could, for example, ask: “Have you often felt like your life had no purpose or meaning?” or “Have you often felt empty inside?”
Limitations of the study include reliance on retrospective self-reports and use of lay interviewers, although these interviewers were trained and had an average of 5 years of experience conducting health-related surveys.
Although the study included a representative sample of U.S. adults, the sample did not include groups known to have high rates of suicide and self-harm behaviors, such as institutionalized, incarcerated, or homeless individuals.
In addition, the study did not evaluate severity and duration of BPD, although the authors noted they did adjust for age at BPD onset, this did not alter the findings.
Often misdiagnosed
Commenting on the study, John M. Oldham, MD, Distinguished Emeritus Professor, Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, and past-president, American Psychiatric Association, and an expert on BPD, had high praise for the research.
BPD is often misdiagnosed, Dr. Oldham said in an interview. Many patients seek help from primary care doctors who may label the symptoms as an anxiety disorder or a mood disorder, he said.
Although medications can help treat some BPD symptoms, “the primary, core evidence-based treatment for BPD is psychotherapy,” said Dr. Oldham, who some years ago helped develop evidence-based practice guidelines for BPD.
“It’s a clear and very well-designed study, and I don’t see any major limitations or problems with it,” he said. “The authors kept their focus rigorously on their goals and they used really careful methodology.”
He noted the “huge” numbers of patients included in the data and the relatively large percentage of men (43.7%).
“There’s a general belief that it’s mostly females who have BPD, but that’s not true; it’s females who come to treatment,” said Dr. Oldham.
Requiring that all five criteria lead to seriously impaired functioning “is a much more rigorous diagnostic methodology” than requiring only one or two criteria to lead to such impairment, said Dr. Oldham. “This is really important” and makes it “a much stronger study.”
The finding that self-harm behavior was linked to suicide attempts isn’t that surprising as this association has been well documented, but the finding that chronic emptiness is also predictive of future suicide attempts “is news,” said Dr. Oldham.
“We have not paid enough attention to this criterion in the clinical world or in the research world.”
Dr. Oldham said one patient with BPD gave him an ideal metaphor for emptiness. “She said it’s like there’s just nobody home. Think of it as an empty house that may look fine on the outside but you go inside and nobody lives there; there’s no furniture; no favorite things; no photos; no possessions.”
The authors have “important messages we need to pay attention to, and the main one is to explore this sense of chronic ‘nobody home’ emptiness,” said Dr. Oldham.
Dr. Grilo has reported receiving research grants from the National Institutes of Health; serving as a consultant for Sunovion and Weight Watchers; receiving honoraria for lectures, continuing medical education activities, and presentations at scientific conferences; and receiving royalties from Guilford Press and Taylor & Francis, all outside the submitted work.
A version of this article first appeared on Medscape.com.