Suicidal urges and attempted suicide at multiple time scales in borderline personality disorder

There is strong evidence for an enduring suicidal diathesis among individuals with a history of suicide attempts, particularly among people diagnosed with borderline personality disorder (BPD). However, the progression of suicidal crises among people predisposed to suicidal behavior remains poorly understood. Via multilevel structural equation modeling we tested the hypothesis that a history of attempted suicide predicts a stronger dynamic link between affect and impulsivity with suicidal ideation (i.e., suicidal urges) — both moment-to-moment and day-to-day. 153 patients diagnosed with BPD, 105 of whom had a history of medically serious suicide attempts completed a 21-day ecological momentary assessment protocol (17,926 total assessments). Individuals with higher average levels of negative affect reported more suicidal thoughts. Moments characterized by more negative affect, hostility, impulsivity, and less positive affect were also characterized by elevated suicidal ideation. For hostility and positive affect, these significant links generalized to the daily level. At the same time, for negative affect and hostility the within-person coupling was stronger among attempters in comparison to non-attempters, and these effects did not significantly differ across timescales. Follow-up studies replicating our findings of the dysregulation-suicidality nexus in clinically more diverse samples are needed. The diathesis for suicidal behavior manifests in tighter dynamic links between negative affect or hostility and suicidal ideation. Because these within-person links were amplified in attempters compared to non-attempters, differential coupling patterns may index potentially lethal processes that generalize beyond BPD reflecting distinct diathesis components. •Assessed the risk for suicidal behavior across timescales in daily life•Used a 21-day ambulatory assessment protocol•Used a case-control design including suicide attempters and non-attempters•Dynamic links between affect and suicidal ideation were tighter among attempters.•Models are useful for identifying who and when is at the highest risk for dying by suicide.