Copyright  2008 The Authors

Journal Compilation  2008 Blackwell Munksgaard

Acta Psychiatr Scand 2009: 119: 149155

All rights reserved
DOI: 10.1111/j.1600-0447.2008.01284.x

ACTA PSYCHIATRICA
SCANDINAVICA

Severity of personality disorders and suicide

attempt
Blasco-Fontecilla H, Baca-Garcia E, Dervic K, Perez-Rodriguez MM,
Saiz-Gonzalez MD, Saiz-Ruiz J, Oquendo MA, de Leon J. Severity of
personality disorders and suicide attempt.
Objective: Severity of personality disorders (PDs) may be more useful
in estimating suicide risk than the diagnosis of specic 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 classied using
Tyrer and Johnsons classication of severity (no PD, simple PD,
diuse PD). Severity lethality of attempts was measured with the
Suicide Intent Scale, Risk-Rescue Rating Scale and Lethality Rating
Scale.
Results: Attempters with severe (diuse) PD had more attempts than
the other groups. After controlling for age and gender, this dierence
remained signicant 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.

H. Blasco-Fontecilla1, E. BacaGarcia2,3, K. Dervic4, M. M. PerezRodriguez5,6, M. D. Saiz-Gonzalez7,

J. Saiz-Ruiz5,8, M. A. Oquendo3,
J. de Leon9
1

Dr R. Lafora Hospital, Madrid, Spain, 2Fundacion

Jimenez Diaz University Hospital, Autonoma University
of Madrid, Madrid, Spain, 3Department of
Neurosciences, Columbia University Medical Center,
New York, NY, USA, 4Department of Child and
Adolescent Psychiatry University Hospital, Medical
University of Vienna, Vienna, Austria, 5Department of
Psychiatry, Ramon y Cajal University Hospital, Madrid,
Spain, 6Department of Psychiatry, Mount Sinai School
of Medicine, New York, USA, 7Clinico San Carlos
Hospital, Madrid, Spain, 8University of Alcala, Madrid,
Spain and 9Mental Health Research Center (MHRC) at
Eastern State Hospital, Lexington, KY, USA

Key words: personality disorders; diagnosis; suicide

Enrique Baca-Garcia, Department of Psychiatry, Columbia University Medical Center, 1051 Riverside Drive,
Suite 2719 Unit 42, New York, NY 10032, USA.
E-mail: ebacgar2@yahoo.es; eb2452@columbia.edu
Accepted for publication September 17, 2008

Significant outcomes

Younger female suicide attempters with severe personality disorders are prone to repeated suicide
attempts.
The severity of personality disorders was not related to the severity or the lethality of suicide
attempts.

Limitations

We used a screening questionnaire to diagnose personality disorders.

We did not rule out the possibility that our results are because of impulsivity. That is, impulsivity
might be a confounding factor in the category of diffuse personality disorders.
The subjects were recruited at two emergency rooms. Therefore, there was limited time to perform
the assessments.

Introduction

In an emergency setting, psychiatrists often have

to estimate suicide risk and establish therapeutic
procedures for a number of patients presenting

immediately after a suicide attempt. Many of

them have clinically observable personality psychopathology. Comorbid Axis II personality
disorders (PDs) are a risk factor for suicidal
behavior. After controlling for Axis I diagnoses,
149

Blasco-Fontecilla et al.
co-occurrence of PDs in more than one cluster
signicantly elevates suicide risk (1). Furthermore, greater personality disturbance in suicide
attempters is associated with repeated suicidal
behavior (2). There is high comorbidity among
Axis II disorders (39). Thus, a diagnosis of
specic PD might be of limited use in terms of
the estimation of suicide risk.
Tyrer and Johnson (10) developed a simplied
method of rating the severity of PDs, which has
proven to be clinically useful in separating patients
initial assessments and outcomes. This new system
represents an improvement on existing methods
and allows ratings to be made easily from DSM-IV
and ICD-10. With regard to the severity of PD,
Tyrer and Johnson (10) suggested a classication
of PDs that considered comorbidity (or, more
strictly speaking, overlap) of PD as a measure of
severity. This classication is based on four levels
of severity: no PD, personality diculty, simple
PD and diuse PD (Table 1).
The category of simple PD had a correspondence
with either a single PD or multiple PDs within the
same cluster in both DSM-IV and ICD-10 classications. The category of diffuse PD (10) had a
correspondence with two or more PDs from
dierent clusters. Patients with no PD had the
lowest initial symptom scores and the best outcomes, and those subjects diagnosed with a diuse
PD have more severe personality psychopathology,
the highest initial levels of symptoms (by using the
Comprehensive Psychopathological Rating Scale)
and the poorest outcome over a 2 years follow-up
(10).
Aims of the study

We hypothesized that those suicide attempters

diagnosed with a diuse PD would be a specic
subpopulation of suicide attempters who are prone
to suicide attempts of greater severity and lethality,
and engage in suicidal acts more often than
patients with simple PD or non-PD suicide
attempters. If this classication proves to be

useful with regard to suicide attempters, this

could improve triage in emergency settings and
contribute to the assessment of suicide risk.

Material and methods

Sample and procedure

Four hundred and forty-six suicide attempters

were recruited between 1999 and 2003 at the
emergency rooms of two general hospitals in
Spain, which provide free medical coverage to a
catchment area of around 900 000 people. External
funding was available for the rst 235 consecutive
assessments by a research psychiatrist available for
on-call patient recruitment. The remaining nonconsecutive assessments were made by residents in
psychiatry with specic training to assess suicide
attempts. One of the authors taught and trained all
the remaining interviewers. Once weekly, the group
had a consensus meeting to guarantee the interrater reliability. As assessment conditions were
slightly dierent, some dierences could be
expected; however, no signicant dierences were
found with regard to either sociodemographic
parameters or categorical diagnosis of any PD.
After a complete description of the study, subjects
provided written informed consent. The study was
reviewed by the appropriate ethics committee and
was performed in accordance with the ethical
standards laid down in the 1964 Declaration of
Helsinki.
As our group has reported previously (11),
approximately 84% of approached suicide attempters consented to take part in this study. Suicide
attempters who refused study participation did not
signicantly dier in demographics from study
participants. As some of the suicide attempters had
more than one suicide attempt, only the rst
recorded suicide attempt was analyzed. As recommended by the US National Institute of Mental
Health, a suicide attempt was dened as a selfdestructive behavior with the intention of ending
ones life, independent of the resulting damage (12).

Table 1. Classification of the severity of personality disorder by Tyrer and Johnson (10, 24)
Level

Classification

No personality disorder

Personality difficulty*

Simple personality disorder

Diffuse personality disorder

*The category of personality difficulty was not used in our study.

150

Description
Good capacity to form relationships, reasonable personal resources to draw
on in times of adversity
Tendency for enduring patterns of behaviour to interfere with social functioning
in times of particular stress and vulnerability but not at other times
Particular and persistent personality abnormalities that create major problems
in occupational, social and or personal relationships (present cutoff point
for personality disorder in ICD-10 and DSM-IV)
Widespread personality abnormalities covering more than one cluster of personality disorder

Personality and suicide

Measures

The diagnosis of PD was made by using the DSMIV version of the International Personality Disorder Questionnaire Screening Questionnaire
(IPDE-SQ). The DSM-IV version, in contrast to
the ICD-10, includes the diagnoses of narcissistic
and schizotypal PDs. The IPDE-SQ is a brief and
ecient screening questionnaire (13). In order to
increase specicity, we included one or two additional criteria besides those suggested by the IPDE
authors to adjust the rates of PDs in our sample of
controls to the rates of PDs in the general
population (14). We included one more criterion
to diagnose paranoid, schizoid, histrionic, dependent and avoidant PDs (for example, ve out of
seven criteria to diagnose paranoid PD instead of
the four criteria scheduled by IPDE authors), and
two more criteria for the remaining PDs. This
strategy has previously been used by others (15, 16)
with similar results (17).
The patients diagnosed with a PD were then
classied by PD severity into three groups, according to Tyrer & Johnsons classication (10): no PD,
simple PD or diuse PD (the category personality
difculty was not used, as Tyrer and Johnson
considered their ndings to provide little support
for the subclassication of personality diculty).
We compared no PD suicide attempters, simple PD
suicide attempters and diuse PD suicide attempters in terms of suicide intent, risk and rescue
factors, lethality of the suicide attempt and the
number of past suicide attempts. According to the
classication by Tyrer & Johnson (10), 26%
(115 446) of suicide attempters in our sample had
no PD, 36% (161 446) had a simple PD and 38%
(170 446) had a diuse PD.
Severity and lethality of suicide attempts were
measured by the Suicide Intent Scale (SIS), the
Risk-Rescue Rating Scale (RRRS) and the Lethality Rating Scale (LRS). Regarding the SIS (18), in
a previous work (11), we performed an exploratory
factor analysis of SIS. We found two factors:
expected lethality (S1) and planning (S2). The S1
factor was essentially loaded by items 4 (act to get
help), 9 (purpose of attempt), 10 (expectations of
fatality), 11 (concept of lethality), 12 (seriousness),
13 (ambivalence about living) and 14 (concept of
rescuability). The planning subscale (S2) includes
the items comprising the traditional denition of
attempt impulsivity of the SIS items 6 and 15
plus another six items: 1 (isolation), 2 (timing), 3
(precautions), 5 (nal acts), 7 (note) and 8 (communication). Both factors showed a high internal
consistency. The RRRS (19) allows clinicians to
assess suicide risk and rescue expectancies. High

scores are related to an increased risk of suicidal

behavior. The RRRS has two factors: the rst
factor (W1) assesses the suicide risk related to
severity; the second factor (W2) measures the
rescue expectancy, and is associated with a lower
risk of suicidal behavior. The LRS (18) rates the
medical consequences of dierent suicide methods
ranging between 0 (no consequences) and 8
(death). A score >2 suggests a high lethality
attempt and usually indicates the need for major
medical interventions.
We divided our sample of suicide attempters into
four age groups (1835 years, 3650 years, 51
65 years and older than 65).
Control group

We used a healthy control group (n = 515)

blood donors with no previous Axis I or II
diagnosis, no previous suicidal behavior and no
rst-degree familial antecedents of mental illness
to nd the best cut-o point of our diagnostic
instrument by adjusting the rate of PDs in the
control sample to the rates of PDs in the general
population.
Statistical analysis

Chi-square tests were performed to compare the

number of past suicide attempts (none, one or two,
or 3) in suicide attempters without PD, and with
simple and diuse PD. The same analyses were
then performed taking into account the potential
confounding eect of age and gender. Analyses of
variance (anova) were performed to assess the
severity lethality of suicide attempts in suicide
attempters without PD, and with simple and
diuse PD.
Results

The mean age of suicide attempters (n = 434) was

36.6 (SD = 14.24) and 66% were female. Seventyfour per cent had a diagnosis of PD and each
suicide attempter was diagnosed with 0.81 dierent
PDs (SD = 1.07). Rates of specic PD diagnoses
were as follows: paranoid PD (21.5%), schizoid
PD (14.1%), schizotypal PD (5.8%), histrionic PD
(14.8%), antisocial PD (6.1%), narcissistic PD
(3.8%), borderline PD (34.1%), obsessivecompulsive PD (13.5%), dependent PD (17.9%) and
avoidant PD (34.1%).
The proportion of individuals with no past
suicide attempts, 1 or 2, or 3 past suicide attempts
was signicantly dierent in patients with no,
simple or diuse PD. Suicide attempters with
151

Blasco-Fontecilla et al.
diuse PD had more past suicide attempts than
patients with simple or no PD, and attempters with
simple PD had more past suicide attempts than
those without PD (Table 2).
There were no signicant relationships between
the severity of PD according to Tyrer and Johnson
(10) and lethality of the suicide attempt, risk and
rescue scores, and suicide intent (Table 3).
The prevalence of diuse PD among suicide
attempters was lower in the older age groups (41%,
95 229 in those aged 1835; 39%, 50 127 in the
3650 age group; 25%, 12 48 among those aged
5165; and nally, 24%, 5 21 among those older
than 65).

After stratication by age groups, the association between PD severity and number of past
suicide attempts remained signicant only in the
youngest age group (1835 years). The results for
those older than 65 years should be interpreted
with caution, as there were no cases in certain
categories (Table 4).
After gender stratication, we found that the
relationship between the severity of PD and the
number of past suicide attempts remained significant only in women (Table 5).
We observed that the rates of Axis I diagnoses
were signicantly dierent among subjects without
PD (85%, 95 112), with simple PD (87%,

Table 2. Number of past suicide attempts and severity of personality disorder

according to Tyrer and Johnson (10, 24)

Table 4. Number of past suicide attempts in suicide attempters without personality disorder (PD), with simple and diffuse PD across age groups

No PD

Simple PD*

Number of past suicide attempts

None
225
77 (69)
1 or 2
120
22 (20)
3
92
13 (11)
Total
437
112 (100)

Diffuse PD
Age

82
38
37
157

(52)
(24)
(24)
(100)

66
60
42
168

(39)
(36)
(25)
(100)

3650

Values in parenthesis represent the percentages.

PD, personality disorder.
*1 PD of the same cluster.
2 PDs of different clusters.
v2 = 25.08, d.f. = 4, P < 0.001.

5165

Table 3. Severity and lethality of suicide attempts among suicide attempters

without PD, with simple* and diffuse PD
n

Median

SD

Lethality Rating Scale (n = 412)

No PD
108
1.4
1.5
Simple PD
148
1.4
1.6
Diffuse PD
156
1.3
1.3
Risk-Rescue Rating Scale (W1 suicide risk) (n = 443)
No PD
114
5.9
1.5
Simple PD
160
7.6
16.5
Diffuse PD
169
6.8
10.2
Risk-Rescue Rating Scale (W2 rescue expectancy) (n = 443)
No PD
114
13.0
8.9
Simple PD
160
16.8
35.1
Diffuse PD
169
13.2
14.7
Suicide Intent Scale (SIS) (total) (n = 441)
No PD
114
20.6
32.8
Simple PD
159
16.7
20.6
Diffuse PD
168
18.9
29.5
SIS (factor S1 = expected lethality) (n = 441)
No PD
114
6.2
12.9
Simple PD
159
5.5
11.3
Diffuse PD
168
4.9
8.1
SIS (factor S2 = planning) (n = 441)
No PD
114
14.4
29.7
Simple PD
159
11.2
17.0
Diffuse PD
168
14.0
28.4
PD, personality disorder.
*one PD from the same cluster.
two PDs from different clusters.

152

1835

>65

P (ANOVA)

Number of past
suicide attempts
None
1 or 2
3
Total
None
1 or 2
3
Total
None
1 or 2
3
Total
None
1 or 2
3
Total

No PD
34
7
3
44
20
7
9
36
10
6
1
17
12
1
0
13

(77)
(16)
(7)
(100)
(56)
(19)
(25)
(100)
(59)
(35)
(6)
(100)
(92)
(8)
(0)
(100)

Simple PD*
45
26
19
90
24
8
9
41
11
4
4
19
1
0
2
3

(50)
(29)
(21)
(100)
(59)
(19)
(22)
(100)
(58)
(21)
(21)
(100)
(33)
(0)
(67)
(100)

Diffuse PD
37
33
25
95
19
18
13
50
4
4
4
12
3
2
0
5

(39)
(35)
(26)
(100
(38)
(36)
(26)
(100)
(34)
(33)
(33)
(100)
(60)
(40)
(0)
(100)

Total
116
66
47
229
63
33
31
127
25
14
9
48
16
3
2
21

(51)
(29)
(20)
(100)
(50)
(26
(24)
(100)
(52)
(29)
(19)
(100)
(76)
(14)
(10)
(100)

0.506

Values in parenthesis represent the percentages.

*1 PD from the same cluster.
2 PDs from different clusters.
v2 = 18.0, d.f. = 4, P = 0.001.
Non-significant.
v2 = 16.4, d.f. = 4, P = 0.002, note that some categories have 0 cases.

0.299

Table 5. Number of past suicide attempts in attempters without PD, and with
simple and diffuse PD in females and males

0.949

Sex

Number of past
suicide attempts

No PD

Simple PD*

Diffuse PD

Total

0.514
Female

0.571
Male

0.504

None
1 or 2
3
Total
None
1 or 2
3
Total

56
14
8
78
21
8
5
34

(72)
(18)
(10)
(100)
(62)
(23)
(15)
(100)

57
32
24
113
25
6
13
44

(50)
(28)
(2)
(100)
(57)
(14)
(29)
(100)

Values in parenthesis represent the percentages.

*1 PD from the same cluster.
2 PDs from different clusters.
v2 = 25.8, d.f. = 4, P = 0.001.
v2 = 5.7, d.f. = 4, P = 0.217.

34
40
27
101
32
20
15
67

(34)
(40)
(26)
(100)
(48)
(30)
(22)
(100)

147
86
59
292
78
34
33
145

(50)
(30)
(20)
(100)
(54)
(23)
(23)
(100)

Personality and suicide

138 158) and with diuse PD (97%, 162 167)
(v2 = 14.1, d.f. = 2, P = 0.001). The rates of
major depressive disorder were signicantly higher
among subjects with diuse PD (66%, 111 168)
than among those without PD (52%, 58 111) or
with simple PD (52%, 82 159) (v2 = 8.6, d.f. = 2,
P = 0.014). Furthermore, we observed that the
rates of paranoid, schizoid, schizotypic, borderline,
dependent and avoidant PDs were signicantly
higher among patients with diuse PD than among
those with simple PD (data not shown). The rate of
borderline PD was three times higher among
patients with diuse PD (69%, 117 170) than
among those with simple PD (22%, 35 161)
(Fishers exact test P < 0.001).
Discussion

We observed a signicant association between the

number of past suicide attempts and PD severity
according to Tyrer and Johnson among young (18
35 years) female attempters. This is consistent with
previous reports that co-occurrence of PDs in more
than one cluster signicantly elevates suicide risk
(1). Repeated suicidal behavior is associated with
more severe personality psychopathology proles
among suicide attempters (2). Alternatively, the
higher impulsivity level in younger populations
could be related to a higher risk for suicidal acts
(2023).
We could not nd any association between the
severity of PD and severity lethality of suicide
attempts in our sample of suicide attempters.
Therefore, our ndings do not support the assumption that the severity of PD is an indicator of
severity lethality of suicide attempts. Most studies
have reported that the diagnosis and severity of
PDs seem to discriminate between suicide attempters and non-attempters (20, 2428), although
negative results have also been reported (21). In
contrast, the ndings of studies that have analyzed
the relationship between PDs and suicide intent
and lethality severity of suicide attempts have been
inconsistent so far. Several studies have not been
able to nd any association between PDs and
suicide intent (25, 2931) or lethality (32). Other
authors have observed that suicidal subjects with
PDs had lower suicidal intent than suicidal subjects
with depressive disorders (33, 34). Solo et al. (20)
found that a mixed subtype of borderline PD plus
schizotypal PD and paranoid ideation was associated with a low intent to commit suicide. Furthermore, the presence of obsessivecompulsive PD
associated with mood disorders may increase the
severity of the suicide attempt (35). However, the
results of these studies should be interpreted with

caution because of methodological and sample

disparities. First, some of the ndings have been
reported only in subjects diagnosed with borderline
PD (29, 33). Second, some of the studies focus on
specic groups such as adolescents (34). Finally,
the rate of comorbid DSM Axis I disorders varies
widely across the studies.
With regard to the prevalence of PD among
suicide attempters across dierent age groups, we
found that the diagnosis of severe PD was more
frequent among people aged 50 or younger. This is
in agreement with data by Brieger et al. (35), who
found that subjects diagnosed with more than one
PD are younger than those diagnosed with one PD.
Suicide rates generally increase with age, but this is
not always true for several countries (36).
There are several other factors, such as specic PD
diagnoses and Axis I psychiatric diagnoses, which
may confound the association between PD severity
and suicide attempts. We found that the rate of
major depressive disorder, one of the most important risk factors for suicide attempts, was signicantly higher among subjects with diuse PD than
among those without PD or with simple PD.
Impulsivity is positively correlated with immature
and neurotic styles in depressive patients (37).
Moreover, melancholic major depression is associated with more serious past suicide attempts than
non-melancholic major depression (38). Those
suicide attempters diagnosed with bipolar disorder
have suicide attempts with a higher lethality and
report higher levels of aggression and impulsivity
but less hopelessness than attempters with major
depression, particularly among males. Males with
bipolar disorder make more lethal suicide attempts
than bipolar females (39). We also found that several
PDs, including borderline PD, were overrepresented
among patients with diuse PD. The rate of
borderline PD is linked to increased risk of suicide
attempts (40). Thus, both Axes I and II comorbidities might help to explain the increased impulsivity
among suicide attempters with a diuse PD.
In conclusion, our results suggest that the
presence of PD diagnoses from more than one
cluster should be considered in the assessment of
risk for suicidal behaviors. However, suicidal
behavior is a complex phenomenon and multiple
other factors, such as Axis I diagnoses, age and
gender, should be considered in the assessment of
suicide risk.
Our study has several strengths. First, a large
population of patients was recruited, thus providing sucient statistical power to test the hypothesis. Second, all PDs naturally presenting among
suicide attempters evaluated at a general hospital
emergency room were analyzed together.
153

Blasco-Fontecilla et al.
The main limitation of our study is the use of a
screening questionnaire to diagnose PDs. The
IPDE-SQ is not recommended for making PD
diagnoses because of the lack of specicity and the
high rate of false positives typical of screening
questionnaires (14). In order to increase specicity,
we used an adjusted cut-o point. This strategy has
previously been used by others (15, 16). Perez et al.
(16) used a cut-o point of six criteria to diagnose
each PD. Ekselius et al. (15) added one more
criterion to the diagnosis of each PD when using
the structured clinical interview for DSM-III-R
personality disorders-screening questionnaire.
They found good concordance between the results
of the adjusted cut-o screening questionnaire, the
full interview and the diagnosis made by clinicians.
Moreover, the percentages of PDs we found in our
sample of suicide attempters are slightly lower than
those reported by Dirks (17) using the Standardized
Assessment of Personality in a sample of 120
consecutive in-patients evaluated in the emergency
room after parasuicide, suggesting that we may
have used more stringent criteria for diagnosing
PDs.
Another limitation is that we did not control for
the levels of impulsivity, which might be a confounding factor in the association between PD
severity and suicidal behaviors.

7.

8.

9.

10.
11.

12.

13.

14.

15.

16.

Acknowledgements
This article was supported by the National Alliance for Research
on Schizophrenia and Aective Disorders (NARSAD), the
Spanish Ministry of Health (Fondo de Investigacion Sanitaria,
FIS, PI060092 and RD06 0011 0016; Instituto de Salud Carlos
III, CIBERSAM), the Conchita Rabago Foundation, and the
Harriet and Esteban Vicente Foundation. Dr Baca-Garcia is the
Lilly Suicide Scholar at Columbia University.

17.

18.
19.
20.

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