Modeling the suicidal behavior cycle: Understanding repeated suicide attempts among individuals with borderline personality disorder and a history of attempting suicide

Abstract

Objective: Suicide remains a leading cause of death in the United States and recent reports have suggested the suicide rate is increasing. One of the most robust predictors of future suicidal behavior is a history of attempting suicide. Despite this, little is known about the factors that reduce the likelihood of a re-attempting suicide. This study compares theoretically-derived suicide risk indicators to determine which factors are most predictive of future suicide attempts. Method: We used data from a randomized controlled trial comparing three forms of Dialectical Behavior Therapy (DBT; Linehan et al., 2015). Participants (N = 99, mean age = 30.3 years, 100% female, 71% White) met criteria for borderline personality disorder and had repeated and recent self-injurious behavior. Assessments occurred at four-month intervals throughout one year of treatment and one year of follow-up. Time-lagged generalized linear mixed models (GLMMs) were used to evaluate relationship satisfaction, emotion dysregulation, and coping styles as predictors of suicide attempts. Results: Both univariate and multivariate models suggested that higher between person variance in problem-focused coping and lack of access to emotion regulation strategies were weakly associated with additional suicide attempts over the two-year study. Within person variance in the time-lagged predictors were not associated with subsequent suicide attempts. Conclusions: Among individuals with a recent suicide attempt, problem-focused coping and specific deficits in emotion regulation may differentiate those likely to re-attempt from those who stop suicidal behavior during and after DBT. These results suggest that treatments for recent suicide attempters should target increasing problem-focused coping and decreasing maladaptive emotion regulation skills.