Correlates, stability and predictors of borderline personality disorder among previously suicidal youth

Correlates, stability and predictors of borderline

personality disorder among previously suicidal youth

Brian Greenfield Amir RazMelissa Henry L. Eugene ArnoldEric Lis Londa DanielJosh Slatkoff Brian L. Mishara

Jean-Marc Guile Robert K. KoenekoopGeoffrey Dougherty Filipa de CastroXun Zhang

Brian Greenfield, MD Fifty Shades of Borderline Personality Disorder in Adolescence

ISSPD XIV October 14, 2015

Acknowledgments

Thanks to Hogg Family Foundation

Thanks to NHRDP



Borderline Personality Disorder (BPD)

Somewhat recognized during adolescence : DSM-5 (< 18 years old) (Yen S, Gagnon K, Spirito A, 2013; Miller AL, Muehlenkamp JJ, Jacobson CM, 2008)



How to distinguish adolescent BPD from Hall’s “storm and stress”

o Distresso Fleeting Identity Confusion



G. Stanley Hall 1846-1924

How to distinguish adolescent BPD from Hall’s “storm and stress”

When does “storm and stress” exceed a threshold into an enduring personality disorder?



Gunderson et al. (2011)

Ten year follow-up adult BPD:o 85% remissiono 12% relapseo Severe persistent impairment(Gunderson JG, Stout RL, McGlashan TH, Shea MT, Morey LC, Grilo CM, Zanarini MC, Yen S, Markowitz JC, Sanislow C, Ansell E, Pinto A, Skodol AE, 2011)



Prevalence

o 5.9% non-clinical adult sampleso Community adolescents (15% male; 17.2% female)o 22% adolescent outpatients



Measurement

o Adult-based criteriao Variable measureso Inclusions of “storm and stress”



Distress

o Many BPD sufferers attempt suicide

o 10% commit suicide(Paris J, 2002)

o Attempt during adolescenceo Suicide > 30 years old



American/Canadian suicide rates (2009/2010) ages 15-19 years old:

7.5 / 1000 and 9.0 / 100, 000

(Statistics Canada, 2009; Centre for Disease Control and Prevention, 2012)



What we did

o Large cohorto Vulnerable early adolescent

patientso Followed to late adolescenceo Correlates of BPDo Stability to late adolescenceo Predictors of outcome



Goals

o Early identificationo Distinguish BPD from the

‘condition’



Hypothesis I

Group differences are apparent between previously suicidal adolescents with and without BPD at ages 14 and 18 years with respect to clinical and demographic variables at baseline and follow-up



Hypothesis II

o BPD among suicidal adolescents is heterogeneous• Persisting• Emerging• Remitting

o BPD demonstrates temporal stability



Hypothesis III

Persisting BPD driven by:• Drug use• Prior hospitalization• Mood disorders



Procedure



Sample286 T1

263 (92%) T3 at 6 months

229 (80%) T4

219 (77%) Completed measure

204 (71%)Completed data (T1 &

T4)



34 = n (12%) Attrition

Dropouts similar to participants

o Age (14.6 years)o Female (70.7%)o % BPDo ↓ Depression (34 vs. 53%)o ↓ ETOH (37 vs. 55%)o ↓ IFRo ↑ Suicide (2.7 vs. 2.25)



Measures

o DISC MOOD CD

o Spectrum of Suicide Behavioro CGASo Substance abuseo Coddingtomo IFRo Ab-DIB



Results Hypothesis ISignificant Differences between BPD & Non BPD

Recruitmento Depression ↑o Conduct disorder ↑o CGAS ↓o Drug use ↑o Coddington ↑o IFR ↑o Prior hospitalizations ↑o Previous visits to ER ↑

Follow-Upo Depression ↑o Conduct disorder ↑o CGAS ↓o Suicide ↑



Results Hypothesis II

T1 T4

YES

NO Emerging 3.4% (7/204)



Persisting 76% (155/204)

Never 7.4% (15/204)

Remitting 13.2%

(27/204)

Results Hypothesis III

BPD at follow-up predicted by:Older age at first presentationLower level of functioning



Results

o 17 (7.8%) of 219 patients remained suicidal at T4, 16 (94.1%) meeting BPD criteria

o No sex differences with respect to BPD diagnosis



Discussion

Suicidal adolescents with BPD:o Drug useo Stressful life eventso Family Dysfunctiono Major Depressiono CDo ↓ functioning



EASY TO IDENTIFY

CLINICALLY

Discussion

Like adults with BPD, adolescents CGAS=59 ( ↑ of 20 from T1 but impaired functioning)



Discussion

o BPD stable = 76% (155/204) of suicidal youth over 4 year follow-up

o Compatible with BPD traits in the community (46-73%)

(Wingrad G, Cohen P, Chen H, 2008; Bornovalova MA, Hicks BM, Lacono WG, McGue M, 2009)

o Higher than reports of BPD threshold (14-23%)

(Mattanah JJ, Becker DF, Levy KN, Edell WS, McGlashen TH, 1995; Meijer M, Goedhart AW, Treffers, 1998)



Discussion

o BPD baseline, 8x > non-BPD baseline

→ BPD follow-upo BPD can be diagnosed by age 14o BPD persistent and BPD

emerging may → BPD adulthood



Discussion

o 16.7% BPD only once = o Predictors may distinguish BPD

from conditiono ↓ Function + ↑ Age = Predictors



“storm and stress”

Discussion

No gender differences• Does bifurcation occur > 18

years?• Are measures not discerning

adult male BPD?



Discussion

o Suicide occurs more commonly > 30 o Most adolescent suicidality

associated with BPD – persistingo Help adolescents with suicidality

may ↓ adult BPD suicidalityo Only 7.8% adolescent BPD remain

suicidal but 76% of our sample remain BPD hence, BPD not synonymous with suicide



Limitations

o Only reporting on 71% of original cohort

o Subtract 29% from stability = 48% (still very stable)

o Our subjects did not suicide!o Excluded medically and

surgically unstable suicidal adolescents

o Evaluation = therapyo Used the Ab-DIB



Take home points

o Adolescent BPD may likely be diagnosable by age 14

o Adolescent BPD is highly stableo Adolescents remaining suicidal

are likely to suffer from BPDo Persisting BPD can be predicted

by later age (>14) and by poorer functioning at the time of presentation to emergency



Take home points

o Most suicidal adolescents are no longer suicidal 4 years later

o Adolescent BPD has no gender bias



Health & Medicine

Correlates, stability and predictors of borderline personality disorder among previously suicidal youth