Many men and women with bipolar disorder are familiar with suicidal thoughts—including me.

I can’t even count how many times I’ve thought about suicide, and the reasons have varied.

It is often a familiar feeling and desire for those that experience mental illness.

According to About.com Bipolar Disorder, it is estimated that 20% of those with bipolar will commit suicide. That’s one out of every five. And as many as 50%—half—will attempt suicide at least once in their lives.

The threat is very real.

Because of this reality, it’s important to know the facts and warning signs about bipolar disorder and suicide.

Whether you are someone with the illness, or a caregiver or friend, this educational article is for you.

Causes of Suicidal Thoughts

Suicidal thoughts have numerous causes. Feeling like one can’t cope, or that a situation is much too stressful, can incite thoughts of desperation and suicide. Many bipolar people have issues with coping with stress.

If there’s no hope for the future, it is very possible to resort to suicide as a solution.

A sort-of tunnel vision can ensue, where suicide seems like the only way out.

There is also evidence of genetic links to suicide. People who commit suicide or have suicidal thoughts often have a family history of the same behavior.  I have a history in my family, and this makes sense.

More research is needed on this possible genetic component, but there is research that indicates that there can be a pattern of suicidal behavior in families.

Warning Signs of Suicide

It’s important for both people with bipolar disorder and their loved ones to know the warning signs of suicide.

Since it is easy to get the “tunnel vision” described above, we can become blind to how dangerous the suicidal situation is getting.

Warning signs include:

• Talking about suicide—for example, saying things like, “I wish I was dead”, “I’m going to kill myself”, “I wish I could sleep forever”, or “I wish I had never been born”.
• Acquiring the means to commit suicide, such as stockpiling medication or buying a gun
• Withdrawing from social contact; wanting to be left alone
• Having mood swings, such as being emotionally high one day and being withdrawn and depressed the next
• Preoccupation with death, dying, or violence
• Feeling hopeless or trapped in a situation
• New or increased use of alcohol and/or drugs
• Changing normal routine, including sleeping or eating patterns
• Engaging in self-destructive activities, such as driving recklessly
• Giving away belongings or getting affairs in order when there is no logical reason to be doing so
• Saying goodbye to people as if they won’t be seen again
• Personality changes, including anxiousness and agitation, particularly when engaging in one of the warning signs above.

Remember, these warning signs are not someone’s dramatic cries for attention. They are real and abnormal reactions to stress and should be taken very seriously.

What You Can Do

If you feel like hurting yourself, or are suicidal, get help right now:

• Call 911 or your local emergency number right away.
• Call a Suicide Hotline Number—and they are extremely helpful, just ask me—in the United States, you can call the National Suicide Prevention Lifeline at 1-800-273-TALK. Use that same number, then press 1, to reach the Veteran’s Crisis Line.

If you are feeling suicidal, but are not in immediate danger of hurting yourself:

• Reach out to a close, trusted friend or loved one. It may be hard to talk about your feelings, but it’s worth it.
• Contact a minister, spiritual leader, or someone else in your faith community.
• Call a suicide hotline
• Make an appointment with your doctor or other health care provider.

It’s always good to talk to a professional just in case. Don’t risk your life. And remember, suicide doesn’t get better on its own. Get help.

Call 911 right away if you:

• Think you cannot stop yourself from harming yourself
• Hear voices
• Want to commit suicide
• Know someone who has expressed that they want to commit suicide.

Those that are suicidal and going through severe depression often don’t have the strength, energy, or will to get help, and I’ve been there. If you’re a loved one of someone who is suicidal, being the strong one can pay off and save your friend’s life.

How to Prevent Suicidal Thoughts

You can’t manage suicidal thoughts all on your own. Let’s get that out of the way. You need professional help to combat this. In addition, you should:

• Go to your appointments. Don’t skip a therapy or psychiatric appointment just because you don’t feel like it.
• Take medications as directed. I need this reminder. Even though you’re feeling well, you need to take your meds as prescribed every single day. Don’t stop medications abruptly without talking to your doctor.
• Learn about bipolar disorder. This can empower you and motivate you, helping you stick to your treatment plan and have a better idea of what your thoughts and feelings could mean. Encouraging caregivers to learn as much as they can is extremely helpful as well.
• Pay attention to warning signs. Know them, talk to your doctor about them, and make a plan in case suicidal thoughts return. The best thing is to be prepared.
• Seek help from a support or educational group. A number of organizations in the United States are available to help. They can also help you realize there are others that feel like you and that there are other options than suicide.

Many of us are linked in some way to a survivor of suicide. It is a very real problem in our society, in fact, in the United States in 2009, over 36,000 people chose to end their lives.

We need to keep talking about suicide, educating about suicide, and learning not to be afraid to get help or help someone that is struggling.

I remember helping out at a mental health event at my university in 2008. The American Foundation of Suicide Prevention was there, and they came with fold-out poster boards containing pictures of people that had taken their lives.

Each and every one of them was beautiful, and I wholeheartedly believe that they could have turned their lives around again. People loved them, cared for them, they just couldn’t see it at the time.

Take this to heart.

Many of those that struggle with suicidal thoughts don’t get the help they need. Be courageous, and let’s end the rampant suicide in our society. We have too many people that could be living their lives, spending time with their family, and making the world a better place.

Families are quite unaware of what leads their loved one(s) to consider suicide. Suicidal ideation is the act of entertaining thoughts of taking your life. For the most part, depression alone can leave a detrimental mark on the psyche. Having worked with suicidal and extremely depressed teens, I consider depression a disease of humanity, a human condition of existence. Depression can be a “logical disease,” resulting from realistic thoughts of life. Many depressed teens share stories involving the loss of relationships, death and dying, bullying, and their future. For adults, their depression revolves around finances, stress in relationships, their children, a severe mental illness of a loved one, and aging.

Sadly, many believe suicidal ideation and depression are simply “mood problems” remedied by happiness. The truth is that while depression is a mood disorder, it is far more existential and deep rooted than that. Often, individuals who are intensely affected by reality become suicidal.

Thoughts of suicide often masquerade in the minds of some individuals with depression as a remedy. There are 9 things among adults, children, and adolescents that are essential to pay attention to:

1. Low mood: Someone who is constantly depressed, should be watched with a loving eye of concern.
2. Preparation: Cleaning, giving away items
3. Desire: Preoccupation with death and dying (romanticism)
4. Reminiscing: Thinking about a deceased loved one and desiring to be with them
5. Making statements: Stating “I wish I could leave this earth” should be taken seriously. You also want to determine imminence, stating “I want to take my life in 2015” is not as lethal as “I’m going to kill myself tomorrow.”
6. Verbalizing intent: If a child or adolescent talks about killing him/herself, it is important that an adult follow-up in a calm manner. Determine when thoughts began and specific plans. Be direct (“do you wish you were not born?” “Do you want to die”)
7. Intensity: Ask about thought intensity (mild, moderate, severe)
8. Access: Consider access to things that could be lethal (medication, weapons) and ways to remove/hide them
9. Risky behaviors: Pay attention to increased defiance, promiscuous behaviors, substance/drug abuse, disregarding curfew, and skipping school. All of these behaviors signal that something is wrong.

All of these warning signs can occur in adults, children, and adolescents. It is important to know the signs of someone considering suicide and to be prepared in the event you must act.

Learn more about this at the American Foundation for Suicide Prevention  orHelpGuide.Org

If you or someone you know are having suicidal thoughts, I encourage you to reach out. You can also call the Suicide Prevention Lifeline at 1-800-273-8255 (TALK)

Before deciding upon the most appropriate treatment for a young person who is self-harming or engaging in suicidal behaviours, the management plan should address the young person’s immediate safety, in the context of establishing a therapeutic relationship (1). As part of the development of a safety plan, a decision needs to be made as to whether hospitalisation is required, or if the young person can utilise existing support networks, such as family and friends, in carrying out their safety plan (1). A comprehensive safety plan should cover the following steps:

1. The young person’s early warning signs
2. Coping strategies they could try to feel better
3. People and social settings that provide a distraction
4. People they can contact for help
5. Professionals or agencies they can contact for help, and
6. How they can make the environment safe.

A template of a safety plan is available here.

Currently, there is insufficient research regarding which interventions are most effective for responding to deliberate self-harm behaviours (2). A systematic review evaluated the evidence for interventions with young people at risk of self-harm or suicide and is the only higher-quality evidence available in this area that is youth-specific. While the evidence is extremely limited, cognitive-behavioural interventions (CBT) appeared to show some promise (3). Given that not much is known about the effectiveness of interventions to reduce self-harm (4), it is recommended that any underlying mental health problems, such as depression, are appropriately treated so that the young person may feel more able to cope and therefore less likely to engage in self-harming behaviours (5).

UK Guidelines for Self-Harm (6) suggest the following aims and objectives in the treatment of self-harm:

• Rapid assessment of physical and psychological need
• Effective measures to minimise pain and discomfort
• Timely initiation of treatment, irrespective of the cause of self-harm\
• Harm reduction (from injury and treatment; short-term and longer-term)
• Rapid and supportive psychosocial assessment (including risk assessment and comordibity)
• Prompt referral for further psychological, social and psychiatric assessment and treatment when necessary
• Prompt and effective psychological and psychiatric treatment when necessary
• An integrated and planned approach to the problems of people who self-harm, involving primary and secondary care, mental and physical healthcare personnel and services, and appropriate voluntary organisations
• Ensuring that the special issues that apply to children and young people who have self-harmed are properly addressed, such as child protection issues, confidentiality, consent and competence.

The evidence map provides reference details for studies of prevention and treatment interventions for self harm and suicide behaviours and risk in young people.

Self-harm and suicide are behaviours, not psychiatric disorders, therefore neither is classified in the DSM-IV-TR (1) or the ICD-10 (2). Similarly, suicidal ideation is quite common and in itself is not a psychiatric disorder and therefore, is also not classified in diagnostic systems. However, while self-harm and suicidal behaviour do not constitute psychiatric diagnoses in and of themselves, it is widely recognized that they often occur in the context of a diagnosable mental disorder. Studies consistently report that young people who complete suicide or who make a serious suicide attempt often have a recognisable mental disorder at the time, such as depression, anxiety, conduct disorder and substance misuse (3). Internationally, research suggests that as many as 90% of people who complete suicide have a diagnosable DSM-IV mental disorder at the time of their death (4). Often these disorders are unrecognized and/or untreated.

Assessment Tools

To assess whether a young person is engaging in self-harm or suicidal behaviour, a comprehensive assessment by a mental health professional is required.  As a first step, the assessment involves asking questions about a range of aspects of a person life including their:

• Home and Environment;
• Education and Employment;
• Activities;
• Drugs and Alcohol;
• Relationships and Sexuality;
• Conduct Difficulties and Risk-Taking;
• Anxiety and Eating;
• Depression and Suicide;
• Psychosis and Mania

To assess specifically for the self-harming and suicidal behaviours, a comprehensive assessment by a mental health professional trained in clinical assessment is required. The assessment should comprehensively evaluate the young person’s social, motivational and psychological factors specific to the self-harming behaviour, their current suicidal intent, level of hopelessness, as well as a full assessment of mental health problems (5). The assessment of suicidal risk requires direct questioning of the young person’s wish to die, the frequency and intensity of any suicidal thoughts, if they have any plans to act on these thoughts, if they have access to any means to end their life, and if they have tried previously to end their life (5-7).  Currently, there are no screening tools that are helpful in formulating an assessment of a young person’s level of risk (6).

People who engage in self-harm deliberately hurt their bodies. The term ‘self-harm’ (also referred to as ‘deliberate self-harm’ or DSH) refers to a range of behaviours, not a mental disorder or illness (1).  At the milder end of the spectrum, these behaviours include mild to moderate self-injury as a response to emotional pain and, at the more extreme end, attempted suicide (1, 2). The most common methods of self-harm among young people are cutting and deliberately overdosing on medication. Other methods include burning or scalding the body, pinching and scratching oneself, self-hitting and hanging(2).

In many cases self-harm is not intended to be fatal (2). It is estimated that the number of young people who have engaged in self-harm is 40-100 times greater than those who have actually ended their lives (3). For many young people self-harm is a coping strategy, however maladaptive and damaging, that allows them to continue to live rather than an attempt to end their life (4).

There is now a general consensus among clinicians and researchers that there is a distinct type of self-harming behaviour, termed non-suicidal self-injury (NSSI) in which the motivation is not intention to die, and that these behaviours should be distinguished from those that are suicidal in nature (5). However research studies typically fail to make this distinction and there is continued debate about terminology and definitions (6). Other terms used to refer to different forms of self-harm include self-injury, cutting, parasuicide and attempted suicide.

Although many young people might try to hide their self-harming behaviour, there are some obvious and less obvious signs that someone might be self-harming (1). These include:

Psychological signs:

• Obvious changes in mood
• Changes in sleeping and eating patterns
• Losing interest and pleasure in activities that were once enjoyed
• Decreased participation and poor communication with friends and family
• Hiding or washing their own clothes and avoiding situations were exposure of arm and legs is required (eg, swimming)
• Problems in social or intimate relationships
• Strange excuses provided for injuries
• Problems with work, school, social or family life

Physical signs:

• Unexplained injuries, such as scratches, cuts or burn marks
• Unexplained physical complaints such as headaches or stomach pains
• Wearing clothes that cover up arms and legs, even in hot weather

Burden of youth suicide and self-harm in young people

The most recent ‘causes of death’ publication from the Australian Bureau of Statistics (ABS) indicates that in 2010, suicide was the leading cause of death for young people aged 15-24, followed closely by road traffic accidents (7). In 2010, 88 males aged 15-19 years and 129 males aged 20-24 years died by suicide (7). For young females, 25 aged 15-19 years and 54 aged 20-24 years died by suicide (7). (These figures should be interpreted with caution as they are subject to an ABS revision process which could see them change, see (8) for further information).

The number of young people who die by suicide in Australia each year is relatively low compared with the number who self-harm. It is difficult to estimate the rate of self harm as evidence suggests that only 10% of young people who self-harm will present for hospital treatment (9). Evidence from Australian studies suggest that 6-7% of Australian youth aged 15-24 years engage in self-harm in any 12-month period (9). Lifetime prevalence rates are higher, with 24% of females and 18% of males aged 20-24 and 17% of females and 12% of males aged 15-19 reporting self-harming at some point in their life (10). While suicide is more common among young men, self-harm is more common among young women.

Taken together, suicide and self-harm account for a considerable portion of the burden of disability and mortality among young Australians. It is estimated that 21% of “years life lost” due to premature death among Australian youth in 2004 was due to suicide and self-inflicted injury (11). In addition, non-fatal suicidal behaviour and self-harm are associated with substantial disability and loss of years of healthy life (11).

Risk factors
Common risk factors or characteristics for those self-harm are similar to those who complete suicide (12). These include (13):

• History of self-harm and/or previous suicide attempt
• Mental or substance use disorders, especially depression
• Physical illness: terminal, painful or debilitating illness
• Family history of suicide, substance abuse and/or other psychiatric disorders
• History of sexual, physical or emotional abuse
• Socially isolated and/or living alone
• Bereavement in childhood
• Family disturbances
• Unemployment, change in occupational or financial status
• Rejection by a significant person eg, relationship breakup
• Recent discharge from a psychiatric hospital

Experiencing a mental health problem is a risk factor for both self-harm and suicide. Evidence suggests that more than 90% of people who present to hospital with self-harm have a mental disorder, the most common being depression (2). A history of mental illness, in particular depression, as well as the presence of more than one mental disorder are also strong predictors of suicide (14-16).

While not all young people who self-harm or contemplate suicide have a mental health problem, these behaviours do suggest the experience of psychological distress.

“The bravest thing I ever did was continuing my life when I wanted to die.”

— Juliette Lewis 

 I feel like it’s completely spot on. Now with the way I view suicide, I can see both sides of the spectrum. Some ignorant people say that committing suicide is cowardly. I disagree. Speaking from someone who has been there a million times, I know what it’s like to fight for so long and so hard that you no longer have the energy to fight anymore. People who are suicidal and those who succeed, they have so much pain inside that living becomes the last thing they want to do, and the saying “People who are suicidal don’t want to die, they just want the pain to stop.” is completely accurate. When you’re in that state it’s like you have blinders on, you can’t see that someday the pain will subside, you feel like you’re going to be in that pain forever and that is unbearable. I don’t necessarily think that people who want to kill themselves or people who do kill themselves are brave, I just think that they can’t stand the pain anymore. Most people spend so much time running from their problems that they never think that they can face them. I’ve been there, running from all the fear, the pain, the sadness, and for people like me, running from the past. This is why I like that quote so much, it takes incredible bravery to stop running and face your problems instead of continuing to run from them. And I truly believe that facing the problems is the only way to get through them, you can’t keep running from them and expect that one day they will all disappear. It just doesn’t work that way. To face them, work through them, and someday be able to look beyond them and find contentedness is the bravest thing you can do. I’ve spend the better part of my life running, but now I’ve finally stopped and basically said “Bring it on”. I’ve been lucky though, if I wasn’t in therapy, and especially if I never met my current therapist, I don’t think I would be at the same place that I am. A lot of hurting people don’t have peoples’ guidance, they don’t  have the opportunity to know the things that I have learned on my journey. I try to put in my two cents on my blogs but I have no way in knowing if I’m actually getting through to people. Sometime I feel like I want to do so much to help people but I can’t do it by myself, there will always be people like the old me, and that is frustrating to me. 

I watched my mom die 6 months ago, it was one of the most horrifying events of my life. That is when I realized the same thing that Susanna Kayson realized in this movie. I’ve tried to kill myself more times than I can count…now it does seem fucking ridiculous. We only have one life to live. I have thought about suicide since but I always come to the same conclusion: we are not promised tomorrow, hell we are not promised to live one second from now. We might as well try to live our lives to the very fullest that we are capable of. I know life is treacherous sometimes, but there is reason behind our pain whether we know what it is or not…

Self-reported nightmares among patients seeking emergency psychiatric evaluation appear to be an excellent forecaster of elevated suicidal symptoms.

Results indicate that severe nightmares were independently associated with elevated suicidal symptoms after accounting for the influence of depression, whereas symptoms of insomnia were not.

These findings suggest that nightmares stand alone as a suicide risk factor.

The sample included 82 men and women between the ages of 18 and 66, who were in a community mental health hospital admissions unit awaiting an emergency psychiatric evaluation. Evaluations determined eligibility for crisis stabilization inpatient admittance.

Patients’ nightmares, insomnia, depression and suicidal tendencies were assessed through several questionnaires, including the Disturbing Dreams and Nightmare Severity Index, Insomnia Severity Index (ISI), Beck Depression Inventory (BDI), and the Beck Scale for Suicide Ideation (BSS).

According to principal investigator Rebecca Bernert, doctoral candidate in clinical psychology at Florida State University, findings of the study emphasize the need for a more thorough assessment ofsleep among acutely ill patients, as it may be an important opportunity for intervention.

“Sleep disturbances, especially nightmares, appear to be an acute warning sign and risk factor for suicide,” said Bernert.

“Given that poor sleep is amenable to treatment, and less stigmatized than depression and suicide, our findings could impact standardized suicide risk assessment and prevention efforts.”

The study states that sleep complaints are now listed among the top 10 warning signs of suicide by the Substance Abuse and Mental Health Services Administration (SAMHSA).

Objective: Severity of personality disorders (PDs) may be more useful in estimating suicide risk than the diagnosis of specific PDs. We hypothesized that suicide attempters with severe PD would present more attempts and attempts of greater severity/lethality. Method: Four hundred and forty-six suicide attempters were assessed. PD diagnosis was made using the International Personality Disorder Questionnaire – Screening Questionnaire. PDs were classified using Tyrer and Johnson’s classification of severity (no PD, simple PD, diffuse PD). Severity/lethality of attempts was measured with the Suicide Intent Scale, Risk-Rescue Rating Scale and Lethality Rating Scale. Results: Attempters with severe (diffuse) PD had more attempts than the other groups. After controlling for age and gender, this difference remained significant only for the younger age group and women. There was no relationship between severity of PDs and severity/lethality of attempts. Conclusion: Younger female attempters with severe PD are prone to repeated attempts. However, the severity of PD was not related to the severity/lethality of suicide attempts. [ABSTRACT FROM AUTHOR]

Blasco-Fontecilla, H., Baca-Garcia, E., Duberstein, P., Perez-Rodriguez, M., Dervic, K., Saiz-Ruiz, J., & … Oquendo, M. A. (2010). An exploratory study of the relationship between diverse life events and specific personality disorders in a sample of suicide attempters. Journal of Personality Disorders, 24(6), 773-784. doi:10.1521/pedi.2010.24.6.773

Personality disorder (PD) increases risk for suicidal behavior. Certain life events (LE) can precipitate suicidal behaviors in patients with PD. A fundamental question is whether specific combinations of LE and PD increase suicidal risk. Four hundred forty-six suicide attempters (SA) were recruited from emergency rooms. We used a healthy control group ( n = 515) to identify the best cut-off point for the instrument used to diagnose PD. We used the DSM-IV version of the International Personality Disorder Questionnaire-Screening Questionnaire, the Mini International Neuropsychiatric Interview, and the Social Adjustment Scale to assess PD, Axis I disorders, and LE, respectively. After controlling for Axis I disorders, we found that ‘Death of spouse’ preceded suicidal acts in those with antisocial PD (FET p = 0.024) and patients with narcissistic PD attempted suicide after being Fired at work (FET p = 0.002), among others. Our data suggest the presence of particular LE-PD associations in suicide attempters. Some LE-PD relationships appear independent of Axis I disorders in suicide attempters. This may offer a basis for specific targeted therapies or prevention programs aimed at decreasing suicidal risk. [ABSTRACT FROM AUTHOR]

Lamis, D. A., Langhinrichsen-Rohling, J., & Simpler, A. H. (2008). The associations among personality disorder symptoms, suicide proneness and current distress in adult male prisoners. Personality and Mental Health, 2(4), 218-229. doi:10.1002/pmh.52

Suicide is the 11th leading cause of death in the United States, and the third leading cause of death in US jails and penitentiaries. Research has shown that the presence of an Axis II personality disorder (PD) increases the risk for suicidal behaviour. While many correctional institutions screen inmates for suicidal ideation upon intake, they can neglect to assess for the presence of PD symptoms other than those associated with criminality such as Antisocial PD. The current study examined whether symptoms of various PDs were associated with self-reports of current suicide proneness and distress in a small sample of adult male inmates residing in a medium or a maximum security facility. As hypothesized, elevated scores on numerous PD Millon Clinical Multiaxial Inventory-III scales (e.g. Schizoid, Depressive, Sadistic, Schizotypal, Borderline) were significantly associated with both self-reports of current suicide proneness and psychological distress. Once the nature of these associations in inmates is better understood, more effective suicide prevention programs can be designed and implemented in correctional facilities. (PsycINFO Database Record (c) 2010 APA, all rights reserved)

Leichsenring, F., Leibing, E., Kruse, J., New, A. S., & Leweke, F. (2011). Borderline personality disorder.Lancet, 377(9759), 74-84. Retrieved from EBSCOhost.

The article offers clinical information on borderline personality disorder. Characteristics of this disorder include severe functional impairments, a high risk of suicide and a negative effect on the course of depressive disorders. It says that genetic factors and adverse life events seem to interact to lead to the disorder. Information on its epidemiology, treatment and diagnosis is provided. INSET: Search strategy and selection criteria.

Lentz, V., Robinson, J., & Bolton, J. (2010). Childhood adversity, mental disorder comorbidity, and suicidal behavior in schizotypal personality disorder. Journal of Nervous & Mental Disease, 198(11), 795-801. doi:10.1097/NMD.0b013e3181f9804c

Schizotypal personality disorder (SPD) is a serious and relatively common psychiatric disorder, yet remains understudied among the personality disorders. The current study examines the psychiatric correlates of SPD in a representative epidemiologic sample, utilizing data from the National Epidemiological Survey on Alcohol and Related Conditions (N = 34,653). Multiple logistic regression compared people with SPD to the general population across a broad range of childhood adversities, comorbid psychiatric disorders, and suicidal behavior. SPD was strongly associated with many adverse childhood experiences. After adjusting for confounding factors, SPD was independently associated with major depression and several anxiety disorders, including post-traumatic stress disorder. Interestingly, SPD was more strongly associated with borderline and narcissistic personality disorders than cluster A personality disorders. Individuals with SPD were also more likely to attempt suicide. As a whole, these results suggest that individuals with SPD experience significant morbidity and may be at increased risk of mortality.

Loza, W., & Hanna, S. (2006). Is schizoid personality a forerunner of homicidal or suicidal behavior?: A case study. International Journal of Offender Therapy and Comparative Criminology, 50(3), 338-343. doi:10.1177/0306624X05285093

The authors believe that a relationship exists between schizoid personality disorder and violent acts. The following case study is presented to contemplate such a possible relationship. There is a paucity of research on this topic. The authors suggest that further research closely examine the relationship between violent behavior and those character traits associated with schizoid personality disorder. If such a relationship is found, these character traits could be integrated with other risk factors known to predict violence. (PsycINFO Database Record (c) 2010 APA, all rights reserved)

McGirr, A., Paris, J., Lesage, A., Renaud, J., & Turecki, G. (2007). Risk factors for suicide completion in borderline personality disorder: A case-control study of cluster B comorbidity and impulsive aggression.Journal of Clinical Psychiatry, 68(5), 721-729. doi:10.4088/JCP.v68n0509

Background: Borderline personality disorder is a major risk factor for suicidal behavior, yet prediction of suicide completion remains unclear. It has been proposed that impulsivity and aggression interact to increase suicide risk. Death by suicide in borderline personality disorder, then, may be the result of impulsivity, a core feature of the disorder, interacting with violent-aggressive tendencies. Using a case-control design, this study investigated clinical and behavioral risk factors for suicide completion in borderline personality disorder. Method: One hundred twenty subjects meeting DSM-IV criteria for borderline personality disorder, 50 controls and 70 who died by suicide between 2001 and 2005, were investigated by means of proxy-based interviews using structured diagnostic instruments and personality trait assessments. Results: Borderline personality disorder suicides had fewer psychiatric hospitalizations and suicide attempts than borderline personality disorder controls. Borderline personality disorder suicides were also more likely to meet criteria for current and lifetime substance dependence disorders. They had higher levels of current and lifetime Axis I comorbidity, novelty seeking, impulsivity, hostility, and comorbid personality disorders, while exhibiting lower levels of harm avoidance. Most importantly, borderline personality disorder suicides were more likely to have cluster B comorbidity. Impulsivity and aggression interacted to predict suicide, though not after controlling for cluster B comorbidity. Conclusions: Borderline personality disorder individuals who die by suicide differ from those borderlines typically encountered in acute psychiatric settings. Our results suggest that the lethality of borderline personality disorder suicide attempts results from an interaction between impulsivity and the violent-aggressive features associated with cluster B comorbidity. Further, the anxious trait of harm avoidance appears to be protective against suicidal behavior resulting in death. (PsycINFO Database Record (c) 2010 APA, all rights reserved)

McGirr, A., Paris, J., Lesage, A., Renaud, J., & Turecki, G. (2009). An examination of DSM-IV borderline personality disorder symptoms and risk for death by suicide: A psychological autopsy study. Canadian Journal of Psychiatry, 54(2), 87-92. Retrieved from EBSCOhost.

Objective: To clarify whether certain Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), borderline personality disorder (BPD) symptoms are more prevalent among people who die by suicide, and thereby better predict suicide risk. Method: A psychological autopsy method with best informants was used to investigate DSM-IV BPD symptoms and suicide risk among people who died by suicide and met criteria for BPD (n = 62), and BPD control subjects (n = 35). Results: BPD symptoms in people who died by suicide were less likely to include affective instability and paranoid ideation-dissociative symptoms. The negative association between paranoid ideation-dissociative symptoms and suicide was independent of all other BPD symptoms, Cluster B comorbidity, and alcohol dependence. Conclusions: We found that discrete DSM-IV BPD symptoms differentiate people with BPD who die by suicide and those who do not. People with BPD who go on to die by suicide appear to constitute a specific subgroup of those who meet criteria for BPD, characterized by different general clinical presentation, but also by different characteristics within BPD. [ABSTRACT FROM AUTHOR]

Pompili, M., Girardi, P., Ruberto, A., & Tatarelli, R. (2005). Suicide in borderline personality disorder: A meta-analysis. Nordic Journal of Psychiatry, 59(5), 319-324. Retrieved from EBSCOhost.

Suicide is the major cause of death among patients with borderline personality disorder; however, the literature on completed suicides in such disorder is inconclusive, as suicide rates vary greatly among cohorts of patients. We searched MedLine , Excerpta Medica and PsycLit from 1980 to 2005 to identify papers dealing with suicide in borderline personality disorder. We also searched the World Health Statistics Annual to ascertain the suicide rate in the age groups for specific years and country. We selected eight studies comprising 1179 patients with a diagnosis of borderline personality disorder. Of these patients, 94 committed suicide. Results obtained for each study were processed together to calculate the mean figure for each year of suicides for 100,000 individuals suffering from borderline personality disorder. Our meta-analysis shows that suicide among patients with borderline personality disorder is more frequent when compared with the general population. All study analyses reported that patients with borderline personality disorder committed suicide more often than their counterparts in the general population. Suicide seems more alarming in the first phases of follow-up than during chronic phases of illness

I stitch myself one piece at a time that’s
what I’ve done for all my life.
I’ve stitched my life thus far and I am fine.

Whoa slow down I think I’m going to fast again.
Whoa writing my words with the vengeance of
someone who wants to run away.

So I:

Replace the razor with my pen
The noose becomes my thoughts
My words the pills swallow em down swallow em down.

Replace the razor with my pen
The noose becomes my thoughts
My words the pills swallow em down swallow em down.

I never thought that broken glass, spilt milk, my life
would make me cry.
I never thought my life would be just fine.

Whoa, hold on I’m getting ahead of myself again.
Whoa, rethinking my words with conviction and
the faith of one who wants to stay.
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So I:

Replace the razor with my pen
The noose becomes my thoughts
My words the pills swallow em down swallow em down.

Replace the razor with my pen
The noose becomes my thoughts
My words the pills swallow em down swallow em down.

When I don’t see you don’t think I don’t care.
When I’m not with you believe me I am scared.
Whoa slow down I think I’m going to fast again.
Whoa writing my words with the vengeance of
someone who wants to run away.

Replace the razor with my pen
The noose becomes my thoughts
My words the pills swallow em down swallow em down.

Replace the razor with my pen
The noose becomes my thoughts
My words the pills swallow em down swallow em down.