Specific Features of Suicidal Behavior in Patients With Narcissistic Personality Disorder
Objective: Suicidal behavior is a clinically significant but underestimated cause of mortality in narcissistic personality disorder. Currently, there are no reliable estimates of suicidal behavior for this population. The main objective of this study was to test whether or not suicide attempters diagnosed with narcissistic personality disorder are different in terms of impulsivity and expected lethality from suicide attempters with other cluster B personality disorders.
Method: In a sample of 446 suicide attempters, patients with cluster B personality disorder diagnoses (n = 254) as assessed by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), version of the International Personality Disorder Examination-Screening Questionnaire (IPDE-SQ) were compared in terms of expected lethality and impulsivity (measured by the Beck Suicidal Intent Scale and the Barratt Impulsiveness Scale, respectively). The subjects were admitted to the emergency departments of the Ramón y Cajal Hospital and the Fundación Jiménez Diaz University Hospital in Madrid, Spain, between January 1999 and January 2003.
Results: Suicide attempts of subjects diagnosed with narcissistic personality disorder had higher expected lethality than those of subjects without narcissistic personality disorder (t = −4.24, df = 439, P < .001). There were no differences in expected lethality of the attempts when comparing subjects with and without histrionic personality disorder (t = 0.28, df = 439, P = .795), antisocial personality disorder (t = 0.66, df = 439, P = .504), and borderline personality disorder (t = 1.13, df = 439, P = .256), respectively. Suicide attempters diagnosed with narcissistic personality disorder did not significantly differ from suicide attempters without narcissistic personality disorder in terms of impulsivity measures (t = −0.33, df = 442, P = .738), while suicide attempters diagnosed with antisocial personality disorder, histrionic personality disorder, and borderline personality disorder were significantly more impulsive than suicide attempters without these diagnoses (t = −3.96, df = 442, P < .001; t = −3.88, df = 442, P < .001; and t = −7.44, df = 442, P < .001, respectively).
Conclusions: Narcissistic personality disorder seems to be a distinct group among cluster B personality disorders with regard to suicidal behavior. In contrast to suicide attempters with other cluster B personality disorders, suicide attempters diagnosed with narcissistic personality disorder are less impulsive and have suicide attempts characterized by higher lethality. These distinctions may offer a basis for targeted therapies aimed at decreasing suicidal risk in patients with narcissistic personality disorder.
J Clin Psychiatry 2009;70(11):1583-1587
© Copyright 2009 Physicians Postgraduate Press, Inc.
Submitted: November 25, 2008; accepted February 4, 2009.
Online ahead of print: July 14, 2009 (doi:10.4088/JCP.08m04899).
Corresponding author: Hilario Blasco-Fontecilla, MD, Department of Psychiatry, Fundación Jiménez Diaz University Hospital, Avenida Reyes Catolicos 2, Madrid, Spain 28040 ([email protected]).
While subjects with cluster B personality disorders other than narcissistic personality disorder are prone to suicidal behavior when depressed, those with narcissistic personality disorder may be prone to suicidal behavior even when not depressed.1 Ego-syntonic suicidal tendencies in narcissistic patients without depressive syndromes can emerge during emotional crises or with the underlying fantasy that suicide reflects triumph over death.2 Narcissism might also contribute to suicide through narcissistic rage secondary to narcissistic injury, real or perceived.3 Suicidal behavior in subjects diagnosed with narcissistic personality disorder may provide an escape from painful feelings, while expressing rage and retaliation with a sense of active mastery.4 These reasons set the stage for a more carefully premeditated (nonimpulsive) suicidal behavior, as opposed to the more impulsive attempts that are more likely among subjects with antisocial or borderline personality disorder. Furthermore, subjects with a combination of affect dysregulation, grandiosity, and narcissistic vulnerability may attempt suicide in response to interpersonal difficulties. Due to limited data, suicide risk assessment in patients with narcissistic personality disorder, compared to other patients, is especially challenging.1,4
Narcissistic personality disorder is uncommon in both community samples and clinical settings.1 The vast majority of information regarding narcissistic personality disorder is based on theoretical formulations and clinical experience rather than on empirical evidence.5
Some authors hypothesize that impulsivity and lethality are inversely associated during suicide attempts.6,7 Suicidal intent entails both a wish to die and the expectation of death (expected lethality). We hypothesized that subjects diagnosed with narcissistic personality disorder are less impulsive and have suicide attempts characterized by greater expected lethality compared to attempters diagnosed with other cluster B personality disorders. If confirmed, this hypothesis may lead to more targeted therapies for suicide-prone subjects diagnosed with narcissistic personality disorder.
METHOD
Samples and Procedure
Participants were 446 suicide attempters, of whom 254 (56.95%) met criteria for cluster B personality disorders, who were admitted to the emergency departments at the Ramón y Cajal Hospital and the Fundación Jimenéz Diaz University Hospital in Madrid, Spain, from January 1999 to January 2003. All the participants gave written informed consent, and the Institutional Review Boards of the Ramón y Cajal Hospital and the Fundación Jiménez Diaz University Hospital, where the study was conducted, approved the study. Suicide attempt was defined as a self-destructive behavior with the intention of ending one’s life, independent of the resulting damage.8,9 This definition was adopted by the National Institute of Mental Health for research on suicidal behavior.
A healthy control group (n = 515) was used to identify the best cutoff point for the instrument used to diagnose personality disorders. Controls were blood donors with no previous Axis I or II diagnoses, no previous suicidal behavior, and no first degree self-reported familial history of mental illness.
Measures and Statistical Analysis
The diagnoses of personality disorders were made by using the DSM-IV version of the International Personality Disorder Examination-Screening Questionnaire (IPDE-SQ). The IPDE-SQ is a brief and efficient screen.10 We adjusted cutoff points in the healthy control population in order to obtain prevalence for each specified personality disorder similar to those reported in the general population.11 This approach generated criteria for diagnosis at a more stringent level than the DSM requires. For example, we required 1 or 2 more criteria for each personality disorder—eg, to diagnose borderline personality disorder, 7 of 9 items, instead of the 5 of 9 items suggested as necessary to diagnose borderline personality disorder by the IPDE-SQ authors12 were required by us. After finding the best adjusted cutoff point for each personality disorder among the healthy controls, the prevalence of each personality disorder was calculated in the suicide attempters sample. Further information on methods is available in Blasco-Fontecilla et al.13 We used the Mini-International Neuropsychiatric Interview to diagnose DSM-IV Axis I disorders.14
The expected lethality of suicide attempts was measured by the Beck Suicidal Intent Scale (SIS).15 Suicidal intent entails both a wish to die and the expectation of death. In a previous exploratory factor analysis of the SIS, we found 2 factors: expected lethality (S1) and planning (S2).16 The first factor (S1), expected lethality, 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 toward living) and 14 (concept of rescuability). Expected lethality, thus defined, may indicate the seriousness of a suicide attempt better than actual physical consequences or attempt lethality, because attempters are often unaware of medical lethality or choose the method impulsively.
To measure impulsivity, we used the Spanish version of the Barratt Impulsiveness Scale, version 11 (BIS-11).17 The BIS-11 contains 30 self-report items scored 0-4 (range of total score 0-120) divided into 3 subscales. A total score of 75 and above is indicative of highly impulsive behavior.18 The BIS has been extensively used in the study of impulsivity both in suicidal and non-suicidal samples.19
t Tests for independent samples were calculated. Measures of impulsivity and expected lethality were compared among suicide attempters with each cluster B personality disorder versus those subjects without that personality disorder—eg, attempters diagnosed with narcissistic personality disorder versus attempters without narcissistic personality disorder. SPSS statistical software, edition 14.0 for Windows (2005) was used (SPSS Inc, Chicago, Illinois).
RESULTS
Among healthy controls, the prevalence of each cluster B personality disorder was as follows: histrionic personality disorder was 2.7% (95% CI = 1.3% to 4.1%), narcissistic personality disorder was 1.6% (95% CI = 0.5% to 2.7%), borderline personality disorder was 0.6% (95% CI = 0% to 1.3%), and antisocial personality disorder was 0.4% (95% CI = 0% to 0.9%). Among suicide attempters, the prevalence of each cluster B personality disorder was as follows: borderline personality disorder was 34.08% (95% CI = 29.7% to 38.5%), histrionic personality disorder was 14.79% (95% CI = 11.5% to 18.1%), antisocial personality disorder was 6.05% (95% CI = 5.6% to 6.5%), and narcissistic personality disorder was 3.81% (95% CI = 2.0% to 5.6%).
Regarding suicide attempters (n = 446), the mean age was 36.6 (SD = 14.24) years; 83.9% lived in an urban area, 66.4% were women, and three quarters were living with a partner (41.5%) or family of origin (35.4%). Each suicide attempter was diagnosed with a mean ± SD of 4.94 ± 2.53 or 0.81 ± 1.07 (SD ± 1.07) personality disorders using the IPDE authors’ cutoff point or our adjusted cutoff point, respectively. Axis I psychiatric disorders were present in 395 patients (90.4% of the 437 patients for whom this information was available). The distribution of Axis I disorders was as follows: major depressive disorder (MDD) (current), 57.30%; major depression (recurrent), 31.34%; dysthymia, 10.06%; manic episode (current), 0.22%; manic episode (past), 2.98%; hypomanic episode (current), 0.45%; hypomanic episode (past), 5.05%; panic disorder without agoraphobia (current), 8.23%; panic disorder with agoraphobia, 5.94%; agoraphobia, 5.26%; social phobia, 8.46%; obsessive-compulsive disorder, 2.97%; generalized anxiety disorder (GAD) (current), 16.93%; alcohol dependence, 12.55%; alcohol abuse (current), 10.73%; substance dependence (current), 8.46%; substance abuse (current), 5.94%; psychotic disorder (current), 3.43%; psychotic disorder (lifetime), 5.48%; anorexia nervosa, 3.43%; bulimia nervosa, 5.94%; and posttraumatic stress disorder, 2.28%. Among suicide attempters diagnosed with narcissistic personality disorder (n = 17), 5 were also diagnosed with substance dependence (current) (Fisher exact test [FET] P = .010). Furthermore, 9 were diagnosed with MDD (current), 4 with alcohol dependence, and 3 with MDD (recurrent), GAD (current), or substance abuse (current), but none of these associations was statistically significant. In addition, we found that, among the 17 patients (12 men and 5 women) diagnosed with narcissistic personality disorder, 7 also were diagnosed with paranoid personality disorder (FET P = .015), 7 with histrionic personality disorder (FET P = .007), and 4 with antisocial personality disorder (FET P = .015).
Suicide attempters diagnosed with antisocial, histrionic, and borderline personality disorder had significantly higher impulsivity than suicide attempters without these diagnoses. The mean ± SD total BIS scores for suicide attempters diagnosed with antisocial personality disorder, histrionic personality disorder, and borderline personality disorder were 70.14 ± 14.0, 65.18 ± 18.2), and 65.66 ± 15.1, respectively. However, suicide attempters diagnosed with narcissistic personality disorder did not significantly differ from suicide attempters without narcissistic personality disorder on impulsivity measures. The mean ± SD total BIS scores for suicide attempters diagnosed with narcissistic personality disorder were 59.17 ± 22.3 versus 57.77 ± 16.7 for suicide attempters without narcissistic personality disorder (P = .738). Conversely, the mean ± SD expected lethality, as measured by the S1 factor of the SIS, was significantly higher in suicide attempters diagnosed with narcissistic personality disorder than in those attempters without narcissistic personality disorder (16.37 ± 34.2 vs 5.03 ± 8.5, P < .001). The mean ± SD expected lethality for attempters diagnosed with antisocial personality disorder, histrionic personality disorder, and borderline personality disorder were 7.11 ± 2.6, 13.83 ± 12.7 and 4.64 ± 8.5, respectively (Table 1).
Click figure to enlarge
DISCUSSION
Suicidal behavior is a clinically significant but underestimated cause of morbidity and mortality in subjects diagnosed with narcissistic personality disorder. Currently, there are no reliable estimates of suicidal behavior for this population.20 The vast majority of information is based on theoretical formulations and clinical experience.5 There are virtually no empirical data on narcissistic personality disorder in suicide attempters. According to the psychological autopsy method, narcissistic personality disorder is also an infrequent diagnosis among those who completed suicide.1 However, in a 15-year follow-up of hospitalized patients with borderline personality disorder, those diagnosed with comorbid narcissistic personality disorder or with narcissistic traits had a higher probability of death by suicide than those without such comorbid diagnoses or traits.21
Our finding that 90.3% of patients who attempted suicide had at least 1 Axis I disorder is in accordance with the literature.22 Hawton et al22 suggested that comorbidity of Axis I and Axis II disorders is increasingly recognized as a major factor in both suicide attempters and suicide. They also stressed that the impact of comorbidity on risk of suicidal behavior may be attributable to specific characteristics (eg, aggression and impulsivity) that increase the likelihood of suicidal behavior as well as the deleterious effects that personality disorders may have on the nature of psychiatric disorders. Another factor is likely to be the poorer social adjustment and capacity for function conferred by personality disorders when comorbid with Axis I disorders.
Narcissistic personality disorder was present in 17 patients (12 men and 5 women, 3.81%) in our sample of suicide attempters. Several studies investigating suicide attempters or completers used instruments assessing Axis II disorders, including narcissistic personality disorder or similar diagnoses,23,24 but failed to find relevant results. This discrepancy may be explained by methodological differences between our study and those finding no relevant results or by the low prevalence of narcissistic personality disorder both in the general population and in samples of suicide attempters or completers. In addition, narcissistic personality disorder is not assessed in all studies. In some countries, such as those in the United Kingdom, the DSM classification is not widely used, and thus the diagnosis of narcissistic personality disorder may not have been included in some of the studies.
Subjects with narcissistic personality disorder are characterized by a pathologically grandiose self-view, grandiosity, lack of empathy with others, self-involvement, unintegrated object relations, inconsistent superego functioning, and impaired affect regulation, among others.25 Furthermore, clinicians have long known that such patients are emotionally fragile and prone to suicidal crises. Suicidal behavior may be a way to raise the fragile self-esteem of narcissistic subjects3 as such behavior could give them the feeling that they have active mastery over their own lives.21 In our study, among suicide attempters with a diagnosis of cluster B personality disorder, those diagnosed with narcissistic personality disorder appear to be a specific subpopulation, which, in contrast to the remaining cluster B personality disorder sample, is not characterized by impulsivity and whose suicidal acts are characterized by higher expected lethality. Indeed, narcissistic personality seems to be a clinical marker of elevated suicide risk, at least among depressed older adults.26
In addition, our results may help in understanding the complex relationship between impulsivity and lethality in suicidal subjects. Some authors aver that impulsivity and lethality are inversely associated during suicide attempts.6,7 However, there is disagreement on this point. In a study with bipolar patients, Swann et al.27 found that impulsivity was highest in subjects with the most medically severe suicide attempts. As hypothesized, we found that suicide attempters diagnosed with narcissistic personality disorder did not significantly differ from suicide attempters without narcissistic personality disorder on impulsivity measures, while attempters diagnosed with the remaining cluster B personality disorders did differ significantly on impulsivity measures from suicide attempters without the remaining cluster B personality disorders. Furthermore, the suicide attempts of subjects with narcissistic personality disorder were characterized by greater expected lethality than those of attempters without narcissistic personality disorder. The concept of expected lethality might be a better index of the seriousness of a suicide attempt than medical lethality, because suicide attempters are often unaware of medical lethality or choose the method impulsively. Thus, impulsivity and expected lethality may better inversely correlate than impulsivity and (medical) lethality.
Dealing with suicidal patients is a challenging task for clinicians.18 Our findings indicate specific characteristics of suicidal behavior in suicide attempters with narcissistic personality disorder and may offer a basis for targeted therapies aimed at decreasing suicidal risk. A therapeutic approach like dialectical behavior therapy, which is useful for suicidal behavior in patients with borderline personality disorder,28 remains unexplored in patients with narcissistic personality disorder. Such patients might benefit from help in learning to regulate their emotions and development of distress tolerance and interpersonal skills. In addition, clinicians should routinely incorporate discussions of life transitions into therapeutic work with those at risk for suicide.21
The main limitation of this study is the fact that we used a screening questionnaire to diagnose personality disorders. The IPDE-SQ was selected over other screening instruments because it is simple to use, places low burden on the patient, and training on its use is straightforward, which makes it suitable for an emergency department setting.10 Furthermore, to increase specificity, we used an adjusted cutoff point, a strategy previously used by others. In one study,29 the authors considered 6 items to diagnose each personality disorder using the IPDE-SQ. In another, the authors added 1 more criterion to the ones specified by the authors of the SCID-SQ.30 They found good concordance between the results of the adjusted cutoff of the SCID-SQ, the full SCID interview, and the diagnosis of personality disorder made by clinicians. Finally, we could control neither for Axis I nor for Axis II comorbidity. We found that narcissistic personality disorder was significantly associated with substance dependence and with antisocial, histrionic, and paranoid personality disorder. However, since the narcissistic personality disorder group was very small (N = 17), we lacked statistical power to control for potential confounders, eg, Axis I psychiatric disorders or personality disorders. In addition, we did not use "pure" personality disorder categories (comprising attempters diagnosed with just 1 personality disorder) because individuals diagnosed with a personality disorder often and even usually have at least 1 comorbid personality disorder.31-34
On the other hand, our study has several strengths. First, all personality disorders naturally presenting among suicide attempters evaluated at a general hospital emergency department were analyzed together. Second, a large population of patients was recruited. However, even larger samples are necessary for a comprehensive evaluation of the characteristics of suicide behavior in subjects with narcissistic personality disorder.
Author affiliations: The Department of Psychiatry, Fundación Jiménez Diaz University Hospital, Autonoma University of Madrid, Spain (Drs Blasco-Fontecilla and Lopez-Castroman); Instituto de Salud Carlos III (Centro de Investigación Biomédica En Red de Salud Mental [CIBERSAM]), Madrid, Spain, and the Molecular Imaging and Neuropathology Division, New York State Psychiatric Institute and Columbia University, New York (Dr Baca-Garcia); the Department of Psychiatry, Faculty of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates (Dr Dervic); the Department of Psychiatry, Mount Sinai School of Medicine, New York, NY (Dr Perez-Rodriguez); the Department of Psychiatry, Ramón y Cajal University Hospital, Alcalá de Henares University, Instituto de Salud Carlos III (CIBERSAM), Madrid, Spain (Dr Saiz-Ruiz); and the Molecular Imaging and Neuropathology Division, New York State Psychiatric Institute and Columbia University, New York (Dr Oquendo).
Financial disclosure: Dr Baca-Garcia is the Lilly Suicide Scholar at Columbia University. Dr Oquendo has received funding from the National Institute of Mental Health, the National Institute on Alcohol Abuse and Alcoholism, the American Foundation for Suicide Prevention, the Moody’s Foundation, and unrestricted educational grants from Eli Lilly, Pfizer, AstraZeneca, and Janssen and has served as a consultant to Pfizer. Drs Blasco-Fontecilla, Dervic, Perez-Rodriguez, Lopez-Castroman, and Saiz-Ruiz report no financial or other relationship relevant to the subject of this article.
Funding/support: This study was supported by NARSAD, the Spanish Ministry of Health (Fondo de Investigacion Sanitaria, FIS PI060092 to the Fundación Jiménez Diaz University Hospital, Dr Baca-Garcia, principal investigator [PI] and RD06/0011/0016 to Fundación Jiménez Diaz University Hospital and Ramón y Cajal Hospital, Dr Saiz-Ruiz, PI); Instituto de Salud Carlos III, CIBERSAM, the Conchita Rábago Foundation, and the Harriet and Esteban Vicente Foundation.
REFERENCES
1. Links PS, Gould B, Ratnayake R. Assessing suicidal youth with antisocial, borderline, or narcissistic personality disorder. Can J Psychiatry. 2003;48(5):301-310. PubMed
2. Kernberg OF. Aggressions in Personality Disorders and Perversions. New Haven, CT: Yale University Press; 1992.
3. Perry C. Personality disorders, suicide and self-destructive behavior. In: Jacobs D, Brown H, eds. Suicide: Understanding and Responding. Madison, CT: International Universities Press; 1990.
4. Rothstein A. The Narcissistic Pursuit of Perfection. New York, NY: International Universities Press; 1980.
5. Links PS, Stockwell M. The role of couple therapy in the treatment of narcissistic personality disorder. Am J Psychother. 2002;56(4):522-538. PubMed
6. Baca-Garcia E, Diaz-Sastre C, Basurte E, et al. A prospective study of the paradoxical relationship between impulsivity and lethality of suicide attempts. J Clin Psychiatry. 2001;62(7):560-564. PubMed
7. Baca-Garcia E, Diaz-Sastre C, Garcia Resa E, et al. Suicide attempts and impulsivity. Eur Arch Psychiatry Clin Neurosci. 2005;255(2):152-156. PubMed doi:10.1007/s00406-004-0549-3
8. O’ Carroll PW, Berman AL, Maris RW, et al. Beyond the Tower of Babel: a nomenclature for suicidology. Suicide Life Threat Behav. 1996;26(3):237-252. PubMed
9. Silverman MM, Berman AL, Sanddal ND, et al. Rebuilding the Tower of Babel: a revised nomenclature for the study of suicide and suicidal behaviors, pt 2: Suicide-related ideations, communications, and behaviors. Suicide Life Threat Behav. 2007;37(3):264-277. PubMed doi:10.1521/suli.2007.37.3.264
10. Egan V, Austin E, Elliot D, et al. Personality traits, personality disorders and sensational interests in mentally disordered offenders. Legal Criminological Psychol. 2003;8:51-62. doi:10.1348/135532503762871237
11. Cooke D, Hart S. Personality disorders. In: Johnstone E, ed. Companion to Psychiatric Studies. Edinburgh, Scotland: Churchill Livingstone; 2004:502-526.
12. Loranger A. International Personality Disorder Examination: ICD-10 Module. Washington, DC: American Psychiatric Press; 1995.
13. Blasco-Fontecilla H, Baca-Garcia E, Dervic K, et al. Severity of personality disorders and suicide attempt. Acta Psychiatr Scand. 2009;119(2):149-155. PubMed doi:10.1111/j.1600-0447.2008.01284.x
14. Sheehan DV, Lecrubier Y, Sheehan KH, et al. The Mini-International Neuropsychiatric Interview (M.I.N.I.): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. J Clin Psychiatry. 1998;59(suppl 20):22-33. PubMed
15. Beck RW, Morris JB, Beck AT. Cross-validation of the Suicidal Intent Scale. Psychol Rep. 1974;34:445-446. PubMed
16. Diaz FJ, Baca-Garcia E, Diaz-Sastre C, et al. Dimensions of suicidal behavior according to patient reports. Eur Arch Psychiatry Clin Neurosci. 2003;253(4):197-202. PubMed doi:10.1007/s00406-003-0425-6
17. Oquendo MA, Baca-Garcia E, Graver R, et al. Spanish adaptation of the Barratt Impulsiveness Scale (BIS-11). Eur J Psychiatry. 2001;15:147-155.
18. Zouk H, Tousignant M, Seguin M, et al. Characterization of impulsivity in suicide completers: clinical, behavioral and psychosocial dimensions. J Affect Disord. 2006;92(2-3):195-204. PubMed doi:10.1016/j.jad.2006.01.016
19. Baca-Garcia E, Oquendo MA, Saiz-Ruiz J, et al. A pilot study on differences in aggression in New York City and Madrid, Spain, and their possible impact on suicidal behavior. J Clin Psychiatry. 2006;67(3):375-380. PubMed
20. Pompili M, Ruberto A, Girardi P, et al. Suicidality in DSM IV cluster B personality disorders: an overview. Ann Ist Super Sanita. 2004;40(4):475-483. PubMed
21. Stone MH. Long-term follow-up of narcissistic/borderline patients. Psychiatr Clin North Am. 1989;12(3):621-641. PubMed
22. Hawton K, Houston K, Haw C, et al. Comorbidity of Axis I and Axis II disorders in patients who attempted suicide. Am J Psychiatry. 2003;160(8):1494-1500. PubMed doi:10.1176/appi.ajp.160.8.1494
23. McGirr A, Turecki G. The relationship of impulsive aggressiveness to suicidality and other depression-linked behaviors. Curr Psychiatry Rep. 2007;9(6):460-466. PubMed doi:10.1007/s11920-007-0062-2
24. Brezo J, Paris J, Barker ED, et al. Natural history of suicidal behaviors in a population-based sample of young adults. Psychol Med. 2007;37(11):1563-1574. PubMed
25. Ronningstam EF, Maltsberger JT. Pathological narcissism and sudden suicide-related collapse. Suicide Life Threat Behav. 1998;28(3):261-271. PubMed
26. Heisel MJ, Links PS, Conn D, et al. Narcissistic personality and vulnerability to late-life suicidality. Am J Geriatr Psychiatry. 2007;15(9):734-741. PubMed
27. Swann AC, Dougherty DM, Pazzaglia PJ, et al. Increased impulsivity associated with severity of suicide attempt history in patients with bipolar disorder. Am J Psychiatry. 2005;162(9):1680-1687. PubMed doi:10.1176/appi.ajp.162.9.1680
28. Linehan MM, Comtois KA, Murray AM, et al. Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder. Arch Gen Psychiatry. 2006;63(7):757-766. PubMed doi:10.1001/archpsyc.63.7.757
29. Perez Urdaniz A, Vega Fernandez FM, Martin Navarro N, et al. Diagnostics discrepancies between ICD-10 and DSM-IV in personality disorders. Actas Esp Psiquiatr. 2005;33(4):244-253. PubMed
30. Ekselius L, Lindstrom E, von Knorring L, et al. SCID II interviews and the SCID Screen questionnaire as diagnostic tools for personality disorders in DSM-III-R. Acta Psychiatr Scand. 1994;90(2):120-123. PubMed doi:10.1111/j.1600-0447.1994.tb01566.x
31. Lewin TJ, Slade T, Andrews G, et al. Assessing personality disorders in a national mental health survey. Soc Psychiatry Psychiatr Epidemiol. 2005;40(2):87-98. PubMed doi:10.1007/s00127-005-0878-1
32. Oldham JM, Skodol AE, Kellman HD, et al. Diagnosis of DSM-III-R personality disorders by two structured interviews: patterns of comorbidity. Am J Psychiatry. 1992;149(2):213-220. PubMed
33. Pilkonis PA, Heape CL, Proietti JM, et al. The reliability and validity of two structured diagnostic interviews for personality disorders. Arch Gen Psychiatry. 1995;52(12):1025-1033. PubMed
34. Watson DC, Sinha BK. Comorbidity of DSM-IV personality disorders in a nonclinical sample. J Clin Psychol. 1998;54(6):773-780. PubMed doi:10.1002/(SICI)1097-4679(199810)54:6<773::AID-JCLP3>3.0.CO;2-I
