Psychiatry Research 285 (2020) 112730

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

Short communication

Bullying and childhood trauma events as predictive factors of suicidal T

behavior in borderline personality disorder: Preliminary findings
⁎
Iñigo Alberdi-Paramoa, , María Dolores Saiz-Gonzaleza, Marina Diaz-Marsaa,b,
Jose Luis Carrasco-Pereraa,b
a
Department of Psychiatry, Hospital Clinico San Carlos, Madrid, Spain
b
Department of Psychiatry, School of Medicine, Universidad Complutense de Madrid. Centro de Investigacion Biomédica en Red de Salud Mental, Cibersam, Spain

A R T I C LE I N FO A B S T R A C T

Keywords: Traumas in childhood could present a significant association with suicidal behavior in BPD. The aim of the report
Borderline personality disorder is to study the link between a traumatic childhood involving school bullying and the different forms and degrees
Bullying of suicidal behavior in BPD. A cross-sectional study was carried out on a sample of 109 BPD patients. It is divided
Suicidal behavior into two groups whether or not there is a history of suicidal behavior. The clinical variables are compared with
Chi square and Student's T tests. Traumatic childhood history and bullying, in particular, showed a statistically
significant association with the incidence of suicidal behaviors.

1. Introduction
Borderline personality disorder (BPD) has a multifactorial etiology
and is characterized by emotional instability, feelings of emptiness and
impulsive behaviors that lead to high dysfunctionality along with great
deterioration of psychosocial functions (Esguevillas et al., 2018;
Paris, 2012; Zlotnick et al., 2003). It is estimated that the prevalence of
BPD is between 1.6 and 5.9% of the general population, 10% of psy-
chiatric outpatients and 20% of hospitalized psychiatric patients
(APA, 2014; Tyrer et al., 2015).
Among the impulsive behaviors associated with BPD, suicidal be-
havior is considered a nuclear issue (Baus et al., 2014;
Gunderson, 2015; Paris, 2012). DSM-5 includes it as one of the 9 di-
agnostic criteria, defining it as "behavior, attitude or recurrent threats
of suicide, or self-injurious behaviors" (APA, 2014). It is considered a
symptom with great clinical relevance and important prognostic value
and is one of the manifestations that most affects functionality
(Hawton and van Heeringen, 2009). Between 40 and 85% of patients
with BPD make suicide attempts, with an average of three suicide at-
tempts per patient (Hawton and van Heeringen, 2009; Jopling et al.,
2016). Rates of completed suicide are between 5 and 10%, being 400
times higher than those estimated for the general population
(Jopling et al., 2016; Oumaya et al., 2008). Mortality attributable to
suicide in BPD is estimated at around 5–10% (50 times higher than in
the general population) (Hawton and van Heeringen, 2009).
Suicidal behavior in BPD is associated with other clinical
characteristics such as certain personality traits but mainly despair and
impulsivity (Dieserud et al., 2001; Doihara et al., 2012). Previous sui-
cide attempts, and comorbidity diagnoses with major depressive dis-
order and substance abuse disorder are indicated as the most important
predictors of suicidal behavior in BPD (Fellows et al., 2014; Links et al.,
2013).
In turn, traumatic background seems to have a special relevance in
the presentation of suicidal behaviors in BPD (de Aquino Ferreira et al.,
2018; Ferraz et al., 2013). All situations of parental neglect or physical,
sexual or emotional abuse in childhood are considered traumatic
(Turecki and Brent, 2016). It is important to consider some of the
characteristics associated with the trauma. In relation to abuse, the type
of abuse, the frequency and the relationship between the victim and the
abuser are presented as decisive in the consequences associated with
the trauma (Brezo et al., 2008).
Literature describes a significant association between history of
trauma in childhood and suicidal behavior in psychiatric population in
general (Bruffaerts et al., 2010; Bruwer et al., 2014; Castellví et al.,
2017; Dube et al., 2001); and in patients diagnosed with BPD in par-
ticular (Ball and Links, 2009; de Aquino Ferreira et al., 2018;
Ferraz et al., 2013; Kaplan et al., 2016; Merza et al., 2017). History of
physical and sexual abuse and parental divorce have been observed to
be significant in this relationship (Bruwer et al., 2014).
Some authors propose, as other possible mediating variables of this
relationship, depression and the abuse of alcohol and other substances
(Dube et al., 2001; Zeng et al., 2015). In addition, there seem to be

⁎
Corresponding author.
E-mail address: inigoalb@ucm.es (I. Alberdi-Paramo).

https://doi.org/10.1016/j.psychres.2019.112730
Received 6 September 2019; Received in revised form 2 December 2019; Accepted 3 December 2019
Available online 04 December 2019
0165-1781/ © 2019 Published by Elsevier B.V.
I. Alberdi-Paramo, et al.
higher rates of abuse and maltreatment in the population with BPD than
in the general population (Ball and Links, 2009; Kaplan et al., 2016).
Likewise, patients with BPD with these antecedents present more sui-
cidal behaviors than patients with BPD without these antecedents
(Ferraz et al., 2013).
One of the proposed models for vulnerability to suicidal behavior of
BPD would be mediated by childhood abuse and impulsivity
(Brodsky et al., 1997). This theory would be framed within the stress-
diathesis model of genetic and environmental interaction
(Brodsky, 2016). In fact, there is increasing evidence of the role played
by trauma in the gene-environment interaction and epigenetic me-
chanisms, such as DNA methylation, and are important in the re-
lationship between childhood trauma and subsequent suicidal behavior
(Brodsky, 2016; Lutz et al., 2015).
A form of abuse that has been especially studied in recent years is
bullying, which has been significantly related to suicidal behavior
(Castellví et al., 2017; Holt et al., 2015; Rivers and Noret, 2013). Ag-
gression can be physical, verbal or gestural, and cyberbullying has
taken center stage, which can be especially traumatic (Dobry et al.,
2013; Kowalski and Limber, 2013; van Geel et al., 2014). In this sense,
the harasser, the bullied and the spectator present more risk of suicidal
behavior in the future than people who have not had contact with si-
tuations of bullying (Brunstein Klomek et al., 2010). In fact, the impact
of bullying on victims is amply demonstrated by different meta-ana-
lyzes in relation to both ideation and suicide attempts (Holt et al., 2015;
van Geel et al., 2014).
The aim of the present report is to study the relation between
traumatic antecedents in childhood and bullying to the intensity and
forms of suicidal behavior in patients with BPD.
2. Methods
2.1. Study design
A cross-sectional, observational and retrospective study is carried
out, which aims to analyze the relationship between the history of
trauma and the subsequent presentation of suicidal behaviors in a
sample of patients with BPD.
2.2. Participants
The sample was composed of 109 patients aged between 18 and 56
years, with a diagnosis of BPD according to DSM-5 criteria, con-
secutively recruited in the process of admission to the Personality
Disorders Day Unit of the San Carlos Clinical Hospital of Madrid. It is a
specific unit for the treatment of patients with this diagnosis, a
Reference Unit that receives patients from the Health Area itself and
from other sources. The sample is divided into two groups according to
whether or not there is a history of suicidal behavior (excluding self-
harm without suicidal intentionality and simple suicidal ideation.
Patients who met criteria for other diagnoses, those with an I.Q
below 85, severe neurological disease, history of head trauma, serious
medical illness, and current abuse of psychoactive substances -except
tobacco- or refusal to participate in the study were excluded. The Ethics
Committee of the San Carlos Clinical University Hospital approved the
evaluation protocol and all the participants signed the informed con-
sent.
2.3. Variables and instruments
Clinical evaluation was carried out with a questionnaire that eval-
uated the existence or not of trauma, dividing traumatic abuse into
physical, sexual, interfamily violence, subjective family violence and
bullying. Likewise, the existence or not of previous suicidal behavior
was collected (excluding self-harm without suicidal intent and patients
presenting suicidal ideation but no actual attempts). The Montgomery
2
Psychiatry Research 285 (2020) 112730
test (MADRS) (Montgomery and Asberg, 1979) was performed to assess
the existence of depression and the Hamilton test (HARS)
(Hamilton, 1959) to assess the existence of anxiety. Patients were
questioned about alcohol consumption.
2.4. Procedure
Subjects were individually evaluated by a psychiatrist and clinical
psychologist for approximately 120 min, in Personality Disorders Unit
of the San Carlos Clinical Hospital in Madrid (Spain). In order to
minimize variability, all tests were performed at similar times (between
10 and 12 a.m.).
2.5. Statistical analysis
The mean and standard deviation were used for the description of
continuous data and the percentages for categorical data. Regarding
quantitative variables, its adjustment to normal distribution was de-
termined by the Kolmogorov-Smirnov test. The sample was divided into
two groups according to the existence or not of previous suicidal be-
havior (excluding self-harm). Variable comparisons were realized using
Chi-squared test and Student's T test. Association between variables was
analyzed through a logistic regression model. Data analysis was per-
formed using the SPSS statistical package, version 19.0. The sig-
nificance level for all hypothesis contrast tests was 0.05.
3. Results
The 109 patients participating in the study were divided into 36
men (33%) and 73 women (67%). The average age of these patients is
30 years, in an age range between 17 and 56 years. 77.5% were single,
19.1% were married or matched and 3.4% were divorced or separated.
Regarding the level of education, 58.7% had completed primary or
secondary education, 14.7% had professional training and 26.6% had
higher education (diploma, degree or postgraduate studies). At work
level, 65.1% of the sample was unemployed / unemployed, 11% were
active in work, 14.7% were students and 9.2% were in temporary or
permanent leave.
78% of the sample had history of suicidal behavior (excluding self-
harm without suicidal intent and simple suicidal ideation.) with a mean
of 2.53 attempts (SD: 1.69). Women had more suicidal behavior history
without a statistically significant difference (χ2 = 1.038; p = 0.308).
Table 1 shows the scores in the Montgomery test (MADRS)
(Montgomery and Asberg, 1979) to assess the existence of depression
and the Hamilton test (HARS) (Hamilton, 1959) to assess the existence
of anxiety in patients presenting or not history of suicidal behavior
(excluding self-harm without suicidal intent). A statistical significance
is observed in both for those who present this antecedent (MADRS
p = 0.051; HARS p = 0.018), as shown in Table 1. Likewise, alcohol
consumption was significantly associated with the existence of a history
of suicidal behavior (excluding self-harm without suicidal intent)
(χ2 = 4.526; p = 0.033). Neither the scores in MADRS and HARS tests
nor alcohol consumption were significantly associated with the ex-
istence of suicidal behavior history (excluding self-harm without sui-
cidal intentionality) in univariate and multivariate analysis.
Table 1
Scores in Montgomery test (MADRS) and Hamilton test (HARS) in patients
presenting or not history of suicidal behavior.
Suicidal behavior N Mean SD p value
MADRS Yes 63 27.52 12.00 0.05
No 13 20.00 14.50
HARS Yes 64 29.45 11.15 0.02
No 13 20.54 16.37
SD: standard deviation.
I. Alberdi-Paramo, et al.
History of childhood trauma, including traumatic physical abuse,
sexual abuse, interfamily violence, subjective family violence and bul-
lying; they are significantly related to the existence of a history of
suicidal behavior (excluding self-harm without suicidal intent)
(χ2 = 3.916; p = 0.048) according to the univariate analysis.
According to multivariate analysis through logistic regression, it is
observed how the history of school bullying / bullying in childhood is
related to the personal history of suicidal behavior (excluding self-harm
without suicidal intent) (p = 0.021; CI: 1175 −10,318).
4. Discussion
This paper tries to deepen in the analysis of the association between
history of school bullying and childhood trauma, and its relationship
with suicidal behavior in BPD. The data from this study are consistent
with the literature reviewed, and those expected in this subpopulation
(Ball and Links, 2009; Ferraz et al., 2013; Kaplan et al., 2016;
Merza et al., 2017). Higher rates of abuse and mistreatment are found
in the present sample, compared to general population. It should be
taken into account that our study is a cross-sectional study of a sample
of patients with BPD who have been treated for several years and who
have exceeded the onset and early stages of the disease in their teens.
The average age is thirty years, with an age range between seventeen
and fifty-six years. In literature, studies predominate in patients with
BPD who have been treated fewer years and with age averages closer to
adolescence (du Roscoät et al., 2016; Jacobson et al., 2008).
The debate about the role of childhood trauma in the etiology of
BPD has been going on for decades (Ball and Links, 2009). About 20
years ago, Brodsky et al. (1997) pointed out the possible importance of
major trauma such as child sexual abuse, as predictive variables of in-
creased risk of suicidal behavior in patients with BPD. These data have
been replicated in the study described, finding a significant association
between traumatic background and suicidal behavior in BPD.
Kaplan et al. (2016), in a recent cross-sectional study highlights the
increased risk of suicide in BPD in patients who have been physically
and/or sexually abused, aspects that are studied and replicated in this
study. According to this study, childhood sexual abuse predicts suicidal
ideation and planning, but not the attempt (Kaplan et al., 2016). In-
stead, the data analyzed find a link between the traumatic childhood
background and bullying with suicide attempts. Ferraz et al. (2013),
expose that hostility and sexual abuse in childhood, predict suicidal
behavior rather than impulsivity or other traits of temperament. In this
same line, Soloff et al. (2002) find in past and long-term outcome, that
the presence and severity of sexual abuse in childhood, but not physical
abuse, predict sympathic behavior in BPD independently to another
known suicide risk factor. It is important to note that suicidality in BPD
and its association with sexual abuse in childhood is a multivariate and
highly complex relationship.
Likewise, the study of bullying is being emphasized as a variable
related to the diagnosis of BPD and repeated suicidal behaviors, an
aspect that this analysis also suggests (Jopling et al., 2016). Further-
more, children with an abnormal temperament are often chosen pre-
ferentially by bullies (Farrell and Vaillancourt, 2019; Frizzo et al., 2013;
Nocentini et al., 2019). BPD is a population especially vulnerable to
adverse events in childhood. The data studied found a significant re-
lationship between bullying and suicidal behavior in BPD. These data
are in line with what has been described in recent meta-analysis
(Holt et al., 2015; van Geel et al., 2014).
Different authors propose depression and substance abuse as a
mediator in the relationship between the history of childhood trauma
and suicidal behavior in BPD (Baus et al., 2014; Black et al., 2004;
Links et al., 2013; Turecki and Brent, 2016). The exposed study finds a
significant relationship in the scores on the MADRS and HARS tests, as
well as alcohol consumption (no other drugs have been evaluated), with
the autolytic attempts at BPD in the Chi square analysis, but not on the
univariate nor the multivariate analysis. Other authors describe BPD
3
Psychiatry Research 285 (2020) 112730
symptomatology as a mediator between the different subtypes of
childhood trauma (physical abuse, emotional abuse and neglect) and
suicide (Allen et al., 2013). This model would partially fit with our
observations, in the case of a sample of special clinical severity, where
symptoms such as affective dysregulation, identity problems and the
brief psychotic clinic could act as mediators between childhood trauma
and suicidal behavior in Adulthood.
The risk factors for suicide in BPD are quite stable over time, with
the history of childhood trauma being an important predictor of suicide
(Gunderson, 2015; Links et al., 2013). BPD is about 50% genetic in twin
studies, so it is important to be advised to consider gene-environment
interactions (Cattane et al., 2017; Leichsenring et al., 2011; Martín-
Blanco et al., 2015). Although the different specific forms of treatment
in BPD can be effective in modifiable risk factors, but hardly anything
in non-modifiable factors (Links et al., 2013), it is important to identify
this subgroup of patients and carry out an integral approach to them
(Lana et al., 2015).
This study has several limitations. The main one is the study design
(cross-sectional measurement approach), which clouds inferences about
directionality. Furthermore, this data was retrospectively self-reported,
and may be subject to bias.
In summary, traumatic history in general and bullying in childhood
in particular appeared related to suicidal behavior in BPD. More studies
are needed to specify the mediating elements between the incidence of
these childhood events and suicidal intent in BPD patients.
CRediT authorship contribution statement
Iñigo Alberdi-Paramo: Conceptualization, Methodology, Software,
Formal analysis, Data curation, Writing - original draft, Writing - review
& editing. María Dolores Saiz-Gonzalez: Conceptualization,
Methodology, Validation, Visualization. Marina Diaz-Marsa:
Investigation, Resources, Supervision. Jose Luis Carrasco-Perera:
Validation, Investigation, Resources, Project administration,
Supervision.
Declaration of Interest statement
Each named author has substantially contributed to conducting the
underlying research and drafting this manuscript. Additionally, to the
best of our knowledge, the named authors have no conflict of interest,
financial or otherwise.
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