Psychiatry Research ∎ (∎∎∎∎) ∎∎∎–∎∎∎

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Psychiatry Research
journal homepage: www.elsevier.com/locate/psychres

Personality organization in borderline patients with a history

of suicide attempts
Nicole Baus a,n, Melitta Fischer-Kern a, Andrea Naderer a, Jakob Klein a, Stephan Doering a,
Barbara Pastner a, Katharina Leithner-Dziubas a, Paul L. Plener b, Nestor D. Kapusta a
a
Department of Psychoanalysis and Psychotherapy, Medical University of Vienna, Austria
b
Child and Adolescent Psychiatry and Psychotherapy, University of Ulm, Germany

art ic l e i nf o a b s t r a c t

Article history: Suicide attempts (SA) are common in patients with Borderline Personality Disorder (BPD). Recent studies
Received 18 July 2013 focus on aspects of personality associated with risk for SA such as deficits in affect regulation including
Received in revised form impulse control and aggression. The current study examines associations of dysfunctional personality
28 March 2014
organization, psychiatric comorbidities as well as non-suicidal self-injury (NSSI) with SA in a sample of
Accepted 31 March 2014
68 BPD outpatients. Patients with a history of SA yielded higher scores in personality domains of
aggression, especially self-directed aggression. Further, a history of SA was associated with a worse
Keywords: general level of personality organization and a higher prevalence rate of NSSI and substance abuse
Personality functioning disorder. The results demonstrate that SA in BPD patients might be regarded as a manifestation of
STIPO
impaired personality functioning rather than mere state variables and symptoms. Moreover, these
Personality disorders
findings might have implications for indication, treatment, and prognosis of Borderline Personality
Disorder.
& 2014 Elsevier Ireland Ltd. All rights reserved.

1. Introduction Current scientific approaches consider personality organization as

Borderline Personality Disorder (BPD) is a common disorder
with a prevalence of 10–20% in psychiatric populations (Chapman
et al., 2005) causing 30% of inpatient psychiatric healthcare costs
(Bohus and Schmahl, 2007). It is the only mental disorder includ-
ing recurrent suicidal or non-suicidal self-injurious behavior as a
diagnostic criterion (Wittchen et al., 1997).
Suicide attempts (SA), a risk factor for completed suicide (Brent,
2011), are common in BPD with a prevalence of 10–26% (Oldham,
2006). Non-suicidal self-injurious behavior (NSSI) is even more
prevalent in this group with rates up to 50% (Chapman et al.,
2005), and is a risk factor for SA (Brent, 2011). However, even
though NSSI and SA can co-occur, especially among clinical
samples (Soloff et al., 2005; Guertin et al., 2001) both behaviors
seem to constitute different diagnostic categories as suggested in
Section 3 of the 5th edition of the Diagnostic and Statistical
Manual of Mental Disorders (DSM-5).
n
Correspondence to: Suicide Research Group, Department of Psychoanalysis and
Psychotherapy, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna,
Austria.
E-mail address: nicole.baus@web.de (N. Baus).
being strongly related to the severity of personality disorders (Fischer-
Kern et al., 2010; Hörz et al., 2010). According to Rudolf et al. (2008),
personality organization can be seen as the availability of self-
regulating processes which enable an intra-psychical and interperso-
nal balance. Besides identity diffusion and moral decision making,
deficits in affect regulation such as impulse control and aggression are
important aspects of personality organization and are essential in the
development of suicidal behavior (McGirr et al., 2007). In general
psychiatric patients who attempt suicide seem to suffer from a
significantly more severe psychopathology, than patients without SA
(Hamza et al., 2012). In BPD patients there is some evidence regarding
a relation between suicide attempts and impaired impulse control as
well as higher scores on domains of aggression compared to those
who do not attempt suicide (Zouk et al., 2006; Mcgirr et al., 2007). If
affect regulation mechanisms are dysfunctional, a combination of
increased negative feelings like anger, guilt, or self-hatred can cause
aggressive tendencies against oneself (Mangnall and Yurkovich, 2008).
Realizing personality organization as a model to investigate seve-
rity and complexity of personality disorders and regarding suicide
attempts as an important and highly prevalent aspect in BPD, the aim
of the current study was to provide data on personality organization in
BPD patients with SA. We hypothesize a history of SA in BPD patients
to be associated with an impaired personality organization as well as

http://dx.doi.org/10.1016/j.psychres.2014.03.048
0165-1781/& 2014 Elsevier Ireland Ltd. All rights reserved.

Please cite this article as: Baus, N., et al., Personality organization in borderline patients with a history of suicide attempts. Psychiatry
Research (2014), http://dx.doi.org/10.1016/j.psychres.2014.03.048i
2 N. Baus et al. / Psychiatry Research ∎ (∎∎∎∎) ∎∎∎–∎∎∎

with higher scores of aggression. Further we examine comorbid ever hurt yourself on purpose without wanting to die?”). The present study focuses
on lifetime NSSI and SA. Further, the frequency of NSSI and SA was assessed (“How
psychopathology in suicide attempters on Axis I and II as well as in
often have you intentionally injured yourself/attempted suicide?”), with the
terms of NSSI. answers ranging from “1” to “4 times or more”. The SHBQ allows to specify the
methods of past SA (intake of drugs, physical harm and hanging, choking, shooting
oneself, or intended accident). The German version of the SHBQ has been
2. Methods previously validated in a patient sample showing satisfying reliability and con-
vergent validity (Fliege et al., 2006).
2.1. Participants

2.2.2. Structured Interview of Personality Organization

All women and men fulfilling the diagnostic criteria for Borderline Personality
Disorder (DSM-IV-TR) at the age of 18–60 years, who were in a position to
understand the information of the study and gave personal consent, were included
into the study. A total number of 71 patients from the outpatient unit of the
Department of Psychoanalysis and Psychotherapy of the Medical University of
Vienna referred to the study investigators with 68 meeting diagnostic criteria of
BPD according to SCID-II. Hence, the examination of personality organization and
self-harm behaviors was offered to 68 patients diagnosed with BPD. Exclusion
criteria were lack of German language skills and acute mental health conditions,
like psychotic episodes, acute suicidal crises or severe depressive episodes;
however, no patients needed to be excluded. The diagnostic interviews were
administered by an exercised and trained psychologist.
The study protocol was approved by the Ethics Committee of the Medical
University of Vienna. Written informed consent was obtained from the study
subjects after a complete description of the study.
2.2. Assessment measures
Personality organization was measured by the German version of the Struc-
tured Interview of Personality Organization (STIPO-D; Clarkin et al., 2004). This
interview reflects a psychodynamic concept of personality organization, measured
by seven dimensions of personality: (1) identity consolidation, (2) quality of object
relations, (3) use of primitive defenses, (4) quality of aggression, (5) adaptive
coping versus character rigidity, (6) moral values, and (7) reality testing (Clarkin et
al., 2004). One-hundred items in total are rated on a three-point scale, each, the
domains are assessed on a five-point scale from one (no pathology) to five (severe
pathology). Finally, the level of personality organization is scored on one of six
levels: normal, neurotic I, neurotic II, borderline I, borderline II, and borderline III.
An examination of the psychometric qualities of the German Version of the STIPO
(Doering et al., 2013) showed satisfying interrater reliability with intraclass
correlations ranging from 0.72 for reality testing and 0.97 for primitive defenses.
They reported generally high internal consistency for the seven STIPO domains
with Cronbach's alphas ranging from 0.69 (Reality Testing) to 0.86 (Identity).
Psychometric values of the STIPO in the current study showed a satisfying internal
consistency with Cronbach's Alpha ranging from 0.87 for identity to 0.68 for reality
control.

Each patient completed one self-report questionnaire and received three

structured clinical interviews for the purpose of the study.
2.2.1. Self-harm behavior questionnaire
The Self-Harm Behavior Questionnaire (SHBQ; Gutierrez et al., 2001) contains
subscales that assess non-suicidal self-injury (NSSI), suicide attempts (SA), suicidal
ideation and suicide threats (e.g. “Have you ever attempted suicide?”; “Have you
2.2.3. Structured Clinical Interviews for Axis I and Axis II disorders
The German version of the Structured Clinical Interview for DSM-IV, Axis I and
the Structured Clinical Interview for DSM-IV, Axis II (Wittchen et al., 1997, Fydrich
et al., 1997) were used to assess psychiatric diagnoses and personality disorders.
2.3. Statistics

Table 1
Data were analyzed using IBM SPSS Statistics 20.0. Descriptive Statistics give
Characteristics of Borderline patients with suicide attempts and without (N ¼ 68).
demographic information using arithmetic means, standard deviations and fre-
quencies. Differences in demographic variables, Axis I and Axis II diagnoses
Variables Suicide attempt Test p
between attempters and non-attempters were tested using Student's t-test and
Chi-Square (Fisher's Exact Test) depending on the structure of the data. Student's
No Yes
t-test was conducted to assess differences in personality domains. Two-sided
(N ¼ 47) (N ¼ 21)
statistical analyses were performed with significance level set at p o0.05. Char-
acteristics which differed between the groups were analyzed to predict suicide
Age (mean7 S.D.) 26.6 75.39 28.197 7.45 T¼  1.050 0.315
attempts by a binary logistic regression model.
Sex (%)
Female 73.9 85.7 χ2 ¼ 0.46 0.740
Male 26.1 14.3

Marital status (%)

3. Results
Unmarried 93.5 81.0 χ2 ¼ 3.91 0.141
Married 4.3 4.8 Participants were on average 27.1 (S.D. ¼6.1) years old. Fifty-
Divorced 2.2 14.2 three (78%) subjects were female, the majority (90%) was unmar-
Educational status (%) ried. Two-thirds of the subjects had at least an university entrance
Required schooling 32.6 33.3 χ2 ¼ 0.14 0.933 qualification, including 46.8% reporting an university degree.
University entrance diploma 18.6 22.2
Detailed information about the demographic characteristics of
University 48.8 44.4
the subgroups is presented in Table 1. In the whole sample 21
NSSI (%) 46.8 76.2 χ2 ¼ 5.08 0.024 (31%) patients reported a history of attempted suicide and 47
Disorders Axis I (%) (69%) patients did not. Only one patient of those reporting SA did
Affective disorders 51.1 71.4 χ2 ¼ 2.53 0.283 not report NSSI at any time in the past.
Anxiety disorders 59.1 61.9 χ2 ¼ 0.47 0.976
According to items of the SHBQ, suicide was most often
Substance abuse disorders 47.7 66.7 χ2 ¼ 12.55 0.014
Eating disorders 15.9 28.6 χ2 ¼ 2.18 0.337 attempted by the intake of two or more drugs simultaneously
(67%) and immediate physical harm, such as self-cutting (48%),
Disorders Axis II (%)
Avoidant 40.4 47.6 χ2 ¼ 0.31 0.385
followed by the intake of more than 10 pills of one drug (33%), and
Dependent 10.6 14.3 χ2 ¼ 0.19 0.474 by violent methods, such as hanging, self-suffocating or shooting
Obsessive-compulsive 46.8 28.6 χ2 ¼ 1.99 0.126 (19%). One third (29%) of the subjects with SA reported one past
Negativistic 40.4 38.1 χ2 ¼ 0.03 0.537 attempt, 33% reported two and 38% three or more attempts.
Depressive 42.6 42.9 χ2 ¼ 0.00 0.594
Within our BPD sample, suicide attempters did not differ
Paranoid 46.8 38.1 χ2 ¼ 0.45 0.345
Schizoid 14.9 23.8 χ2 ¼ 0.79 0.286 significantly from those who did not attempt suicide with regard
Schizotypal 19.1 9.5 χ2 ¼ 0.99 0.269 to age (t(64) ¼  1.05, p ¼0.315), sex (χ2(1)¼0.46, p¼ 0.740), mar-
Histrionic 17.0 19.0 χ2 ¼ 0.04 0.544 ital status (χ2(2)¼3.91, p ¼ 0.141) and educational status (χ2(2) ¼
Narcissistic 40.4 33.3 χ2 ¼ 0.31 0.391 0.14, p ¼0.933). Suicide attempters significantly more often
Borderline 100 100
Antisocial 19.1 23.8 χ2 ¼ 0.19 0.445
engaged in NSSI (χ2(1)¼5.08, p¼ 0.024), but did not show any
other significant differences in terms of Axis-I and Axis-II

Please cite this article as: Baus, N., et al., Personality organization in borderline patients with a history of suicide attempts. Psychiatry
Research (2014), http://dx.doi.org/10.1016/j.psychres.2014.03.048i
 N. Baus et al. / Psychiatry Research ∎ (∎∎∎∎) ∎∎∎–∎∎∎ 3

Table 2 individuals who die by suicide differ from BPD patients who
Comparison of STIPO domains regarding suicide attempters (N ¼21) and non- do not commit suicide in terms of violent-aggressive behavior.
suicide attempters (N¼ 47).
Our results add to the line of evidence, that features of self-
MeanSA (S.D.) MeanNSA (S.D.) T p directed aggression increase the risk of suicide attempts in border-
line patients. Self-directed aggression such as neglecting physical
Identity 3.62 (0.92) 3.45 (0.83)  0.77 0.447 health, engaging in sexual behavior that could hurt oneself, and
Object relations 3.57(1.03) 3.45 (0.95)  0.49 0.628 other potentially harmful risky behavior should raise concern
Use of primitive defenses 3.95(0.87) 3.91 (0.97)  0.15 0.880
Coping/rigidity 3.81 (1.07) 3.51 (1.02)  1.10 0.276
about SA in therapeutic settings.
Aggression (self-directed) 4.24 (1.34) 2.94 (1.21)  3.98 o0.001 In addition to aggression, the structural level of personality
Aggression (other-directed) 3.00 (1.30) 2.66 (1.20)  1.05 0.297 organization summarizing the seven domains of personality orga-
Aggression 4.19 (1.03) 3.21 (0.93)  3.87 o0.001 nization according to the STIPO is associated with an increased risk
Moral values 2.90 (1.26) 2.40 (1.12)  1.64 0.106
of suicide attempts. Hence, suicide attempts seem to be signifi-
Reality testing 2.76(0.89) 2.53 (1.02)  0.89 0.375
Organization level 3.95 (0.81) 3.51 (0.83)  2.05 0.045 cantly related to more severe impairments in personality function-
ing. This is in line with several previous studies focusing on suicide
Note: MeanSA ¼mean of the domains considering patients with past suicide attempts as an indicator of the severity of mental health problems
attempts; MeanNSA ¼ mean of the domains considering patients without past (Larsson and Sund, 2008; Asarnow et al., 2011; Hamza et al., 2012).
suicide attempts.
Significant results are emphasized in bold font.
Hö rz et al. (2010) identified personality organization to be linked
to the severity of BPD as well as to the frequency of SA in patients
with BPD. According to Lowyck et al. (2013) lower levels of
Table 3 personality functioning are related to general psychopathology,
Risk factors for past suicide attempts in Borderline Personality Disorder. such as depression, symptomatic distress, self-harm and interper-
sonal problems in inpatients with various personality disorders.
B SE Wald d.f. OR p
Hence the assessment of personality organization as a clinical tool
Aggression (self-directed)  0.30 0.81 0.14 1 131.19 0.001
appears to be helpful for the estimation of the risk for SA in
Aggression  1.31 2.06 0.41 1 0.27 0.524 patients with BPD.
Level of personality organization 0.96 1.75 0.30 1 2.60 0.583 In addition to the investigation of suicidal tendencies, person-
NSSI 0.92 0.94 0.96 1 0.40 0.327 ality organization seems to give important information on general
Substance abuse disorders  0.30 0.81 0.14 1 0.74 0.709
psychopathological characteristics and allows having a more
Constant  4.85 1.57 9.52 1 0.01 0.008
detailed impression of the patient's deficits and resources. Current
Significant results are emphasized in bold font. research identifies personality organization as being strongly
associated with the diagnosis of DSM-IV personality disorder, as
comorbidity, apart from substance abuse disorders (χ2(1)¼12.55, well as with personality disorder comorbidity (Bender et al., 2011;
p ¼0.014), as shown in Table 1. Morey et al., 2011). Sollberger et al. (2012) found significantly
Regarding the personality organization, suicide attempters higher levels of psychiatric symptoms, as well as higher anxiety,
showed significant differences compared to non-attempters in anger, and depression scores in BPD patients with severe identity
terms of higher self-directed aggression, total aggression and a diffusion, as one part of personality organization, compared to
worse overall level of personality organization (Table 2). patients with less severe identity diffusion. Moreover, they suf-
In a binary logistic regression model we considered NSSI, fered more frequently from concurrent personality disorders.
substance abuse disorders, self-directed aggression as well as total BPD patients with SA and those without showed differences in
aggression to predict suicide attempts as they significantly differed substance abuse disorders, with suicide attempters. These results
between the groups. Self-directed aggression predicted SA with are in line with Csorba et al. (2009) examining high rates of
OR¼ 131.19 (p ¼0.001), however none of the other characteristics addictive features in adolescent inpatients with suicide attempts.
predicted SA (Table 3). The model reveals a satisfying coefficient of Consistently McGirr et al. (2007) reported an association between
determination (Nagelkerke R² ¼0.57). substance-abuse disorders and completed suicides in an autopsy
study of BPD. According to recent studies several psychopatholo-
gical characteristics are associated with suicidal behavior, such as
4. Discussion major depressive disorder (Soloff and Fabio, 2008), substance use
disorders (Black et al., 2004) and affective instability (Soloff and
The current study examined the relation between suicide Fabio, 2008; Yen et al., 2005).
attempts in borderline patients and domains of personality orga- Besides diagnostic options the consideration of personality
nization as well as psychopathological aspects. A group of 47 organization has been shown to be beneficial in the consideration
borderline outpatients without SA were compared to 21 with SA of efficiency of therapeutic treatment (Doering et al., 2010). Higher
regarding structural as well as psychopathological differences. initial levels of personality organization seem to be moderately to
Investigations on the structural differences between the two strongly associated with better treatment outcome (Koelen et al.,
groups indicated that BPD patients reporting SA in the past, are 2008), indicating the importance of including personality organi-
characterized by more self-directed aggression and aggression in zation in psychotherapeutic considerations. On the other hand the
general than BPD patients without SA. lower levels of personality organization as present in BPD patients
The results show associations between aggression and suicidal with SA according to the current study might relate to higher
behavior. Brent and Melhem (2008) hypothesized that aggression drop-out rates in therapeutic processes (Wnuk et al., 2013; De
is an important predictor of suicidal behavior and that aggression Panfilis et al., 2012).
and impulsivity act as a link between suicide and family history of Taking into account recent discussions on differences between
suicide. Renaud et al. (2008) showed that aggression poses a suicide attempts and non-suicidal self-injury (De Leo, 2011;
reason for completed suicide in children and adolescents. There Kapusta, 2012), and its inclusion as two different conditions for
is evidence that the relation between aggression as a personality further study in the recent 5th edition of the Diagnostic and
trait and completed suicide can also be found in BPD patients Statistical Manual of Mental Disorders (DSM-5), we distinguished
(Zouk et al., 2006). Recently, Mcgirr et al. (2007) showed that BPD between both self-harm behaviors during the assessment. Within

Please cite this article as: Baus, N., et al., Personality organization in borderline patients with a history of suicide attempts. Psychiatry
Research (2014), http://dx.doi.org/10.1016/j.psychres.2014.03.048i
4 N. Baus et al. / Psychiatry Research ∎ (∎∎∎∎) ∎∎∎–∎∎∎
the relatively homogenous BPD sample, NSSI appeared to be
predictive for SA as 76% of the suicide attempters also engaged
in NSSI, compared to 47% in the group without SA. Similarly,
Asarnow et al. (2011) found NSSI to be related to suicide attempts
in a sample of depressive adolescents and Wilkinson et al. (2011)
identified NSSI to be strongly associated with future suicide
attempts than previous suicide attempts during major depressive
episodes. Thus NSSI needs to be taken seriously in BPD and has to
be considered as an important risk factor for suicide attempts.
However, considering overall aggression, self-directed aggression,
level of personality organization and substance abuse disorders to
predict SA, only self-directed aggression is significant, which
might be due to high correlation between NSSI and self-directed
aggression causing a loss of significance of NSSI.
Studies on the interaction of NSSI and suicide attempts are still
very rare and our results highlight, that even though this condi-
tions might be distinct in adolescents (Plener et al., 2012), there is
a strong relationship between both conditions in BPD patients.
4.1. Limitations
Several limitations of this study must be considered. First the
analyzed sample was an outpatient sample, which consisted
primarily of young, unmarried, and well educated patients.
Assuming that personality organization may differ in a sample of
suicide attempters without borderline personality disorder,
further studies in non BPD samples would be necessary to confirm
that a low personality organization is associated with SA. Further-
more, there was no assessment of psychotherapeutic or psycho-
pharmacological treatment, which could influence the severity of
symptoms and the deficits in personality domains. Furthermore
the cross-sectional design of the study does not allow to draw
conclusion on the predictive role of STIPO domains with respect to
SA. Finally, the sample size might contribute to the lack of
significant differences in psychiatric comorbidities and domains
of personality organization. Even though, despite of the relatively
homogeneous sample differences in personality organization as
well as in psychopathological features could be identified.
4.2. Conclusion
Our findings indicate that aggression and particularly self-
directed aggression might be an important aspect of personality
functioning which needs to be addressed in the treatment of
borderline patients with a history of suicide attempts. It is also of
special interest that BPD patients with past SA have a more
severely impaired personality organization in general. In addition
to this, NSSI and addictive features seem to be associated with
suicide attempts.
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Please cite this article as: Baus, N., et al., Personality organization in borderline patients with a history of suicide attempts. Psychiatry
Research (2014), http://dx.doi.org/10.1016/j.psychres.2014.03.048i