Borderline Personality Disorder (BPD): Symptoms, Causes, Diagnosis and Treatment

Borderline Personality Disorder entails emotional instability, impulsivity, and difficulties in interpersonal relationships. Individuals with BPD often experience intense mood swings and have an unstable self-image, leading to challenges in maintaining healthy relationships. The disorder manifests in early adulthood and can severely impact daily functioning, with symptoms often fluctuating in severity over time.

BPD manifests through symptoms like a pervasive fear of abandonment, unstable relationships that oscillate between idealization and devaluation, rapid changes in self-identity, impulsive behaviors (such as reckless spending or unsafe sex), and recurrent self-harm or suicidal thoughts. 

Genetic, environmental, and neurobiological factors influence the development of BPD. Individuals with a family history of BPD or other mental health conditions are at a higher risk of developing the disorder. Environmental factors such as childhood trauma, neglect, and invalidation can also contribute to the development of BPD. Brain imaging studies have also found differences in the brain structure and function of individuals with BPD, suggesting a neurobiological component to the disorder.

The diagnosis of BPD is made based on clinical interviews and assessments conducted by mental health professionals. The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) outlines specific criteria for diagnosing BPD, including patterns of unstable relationships, intense mood swings, impulsivity, and identity disturbance. 

Treatment for BPD includes psychotherapy, with Dialectical Behavior Therapy (DBT) being one of the most effective approaches. DBT focuses on teaching coping skills, emotional regulation, and interpersonal effectiveness. Medications may also be prescribed to address specific symptoms, such as mood instability or anxiety. While treatment can be challenging, many individuals with BPD experience significant improvements over time, allowing for more stable and fulfilling lives.

In contrast to BPD, Histrionic Personality Disorder (HPD) is characterized by excessive emotionality and attention-seeking behaviors. While both disorders fall under the Cluster B category of personality disorders, individuals with HPD typically exhibit more overtly dramatic behaviors and a strong desire for approval. In contrast, those with BPD may struggle more with emotional regulation and fear of abandonment.

What is BPD?

Borderline Personality Disorder (BPD) is a complex mental health condition characterized by pervasive patterns of instability in mood, self-image, and interpersonal relationships, along with marked impulsivity, according to Leichsenring F & Heim N, Leweke F’s review “Borderline Personality Disorder: A Review” on JAMA Journal 2023

Individuals with this type of personal disorder often struggle with processing and managing their emotions, leading to intense emotional responses that shift rapidly and unpredictably. This emotional instability is distinct from mood disorders, as external events and interpersonal interactions typically influence it. 

BPD is also associated with significant self-image issues, where individuals experience chronic feelings of emptiness and identity diffusion, oscillating between extremes of viewing themselves as “all good” or “all bad” about others. 

Research indicates that BPD frequently co-occurs with other mental health disorders, such as mood and anxiety disorders, complicating diagnosis and treatment. Leichsenring, F’s 2024 World Psychiatry Journal reported that co-occurring lifelong mood disorders (83%), anxiety disorders (85%), substance use disorders (78%), and other personality disorders (53%) are common in people with BPD. 51, 52, and 53.

Therefore, this disorder is linked to high rates of impulsive behaviors, including self-harm and suicidal tendencies, which necessitate comprehensive treatment approaches. 

Early diagnosis and intervention significantly reduce individual suffering and societal costs related to BPD, highlighting the importance of effective therapeutic strategies such as dialectical behavior therapy (DBT) and mentalization-based therapy.

What are the main types of BPD?

The main types of BPD are Impulsive, Petulant, Discouraged, and Self-destructive BPD, according to Kristina Ackerman’s 2024 post in the American Addiction Centers post “What are the main types of BPD?”

The types of BPD are listed below.

• Impulsive BPD: This is BPD characterized by unpredictable behavior, intense emotions, and a tendency to act without considering consequences.
• Petulant BPD: This type of disorder is marked by chronic feelings of emptiness, irritability, and a fear of abandonment, often leading to manipulative behaviors.
• Discouraged BPD: With this BPD, one experiences low self-esteem, feelings of worthlessness, and a tendency to withdraw from social interactions and relationships.
• Self-destructive BPD: Self-destructive BPD is defined by self-harming behaviors, suicidal thoughts, and a pattern of engaging in risky or harmful activities as a coping mechanism.

Understanding these types is crucial for developing effective treatment strategies tailored to the specific challenges each faces. With appropriate care, individuals with BPD can lead fulfilling lives despite their struggles.

What are the symptoms of BPD?

The main symptoms of Borderline Personality Disorder (BPD) include emotional instability, impulsive behaviors, dissociative and trust issues, and self-harming and suicidal behaviors, according to an article on Substance Abuse and Mental Health Services Administration titled “Borderline Personality Disorder,.” 

Emotional and Relationship Issues

Emotional instability is marked by intense mood swings and rapidly shifting emotions, including feelings of emptiness, rage, sorrow, shame, panic, and terror. This emotional turbulence often manifests in unstable relationships, where individuals experience intense connections that fluctuate between idealization and devaluation, a phenomenon known as splitting, driven by a profound fear of abandonment and frantic efforts to avoid it.

Impulsive behaviors

Impulsive behaviors encompass a range of reckless actions and self-destructive tendencies that can significantly impact an individual’s life. Reckless actions include dangerous behaviors such as spending sprees, unsafe sex, substance misuse, careless driving, and binge eating, all of which pose serious risks to physical and emotional well-being.

Dissociative and trust issues

Dissociative and trust issues often manifest as a feeling of disconnection from oneself, which can include episodes of depersonalization and transient, stress-related paranoid ideation. These symptoms are frequently exacerbated by stress or reminders of past trauma, leading to paranoid thoughts and severe dissociative experiences. 

Self-Harming and Suicidal Behaviors

Self-harming and Suicidal Behaviors include recurrent thoughts of suicide, as well as actual suicidal behaviors, such as threats and attempts. Self-harm may take various forms, including cutting, burning, or other methods of self-mutilation, reflecting deep emotional distress that warrants attention and support.

These symptoms affect an individual’s ability to manage emotions, maintain stable relationships, and function daily. Effective treatments are available to help manage these symptoms.

What are the complications of BPD?

The complications of Borderline Personality Disorder (BPD) include drug abuse, interpersonal relationship difficulties, depression, thrombus formation, and an increased risk of death, according to a PubMed study titled “Borderline Personality Disorder” by Jennifer Hapman (April 2024).

The complications of BPD are given below.

• Drug abuse
• Interpersonal relationships
• Depression
• Thrombus
• Death

What are the causes of BPD?

The causes of Borderline Personality Disorder (BPD) are genetic predisposition, childhood trauma and adversity,  brain structure and function abnormalities, neurotransmitter imbalances, and environmental factors, according to the NHS publication “Causes – Borderline Personality Disorder”(Nov 2022).

A 2011 study by Gunderson JG and Zanarini MC in the  Gen Psychiatry Journal suggests that people with a first-degree relative (parent or sibling) with BPD are 5 times more likely to develop the disorder, indicating a strong genetic component. 

The main causes of BPD are given below.

• Genetic predisposition: BPD tends to run in families, suggesting a hereditary component. Individuals with close relatives who have BPD are at a higher risk of developing the disorder themselves.
• Childhood trauma and adversity: Early life experiences, particularly abuse, neglect, or unstable family environments, play a significant role in BPD development. Traumatic events during childhood can profoundly impact emotional regulation and interpersonal relationships.
• Brain structure and function abnormalities: Differences in the brains of individuals with BPD, particularly in areas responsible for emotion regulation, impulse control, and decision-making. These include the amygdala, hippocampus, and orbitofrontal cortex.
• Neurotransmitter imbalances: Altered levels of certain brain chemicals, especially serotonin, have been linked to BPD symptoms such as mood instability, aggression, and impulsivity.
• Environmental factors: Growing up in invalidating environments, experiencing long-term fear or distress, or having a family member with a severe mental health condition can contribute to BPD development.

While these factors increase the risk of developing BPD, not everyone exposed to these risk factors will develop the disorder, and individuals develop BPD without experiencing all of these factors. The interplay between genetic vulnerability and environmental stressors likely contributes to the manifestation of BPD symptoms.

What are the significant risk factors associated with BPD?

The risk factors for Borderline Personality Disorder (BPD) are abandonment in childhood, family disruptions, poor communication in the family, abuse, neglect, exposure to long-term fear or distress, family history of mental illness, and peer rejection or bullying, according to a study titled “Borderline Personality Disorder: Risk Factors and Early Detection by Paola Bozzatello. (Nov 2021).

1. Abandonment in Childhood or Adolescence: Experiences of abandonment, whether real or perceived, significantly impact emotional development and contribute to BPD.
2. Disrupted Family LifeA chaotic or unstable family environment, including frequent changes in caregivers or family structure, increases vulnerability to BPD.
3. Poor Communication in the Family: Families that lack open and healthy communication foster feelings of invalidation and misunderstanding, which lead to emotional dysregulation.
4. Sexual, Physical, or Emotional Abuse: Exposure to any form of abuse during formative years is a strong predictor of developing BPD, as it leads to deep-seated trauma and attachment issues.
5. Neglect: Childhood neglect, including emotional neglect, hinders the development of secure attachments and coping mechanisms, increasing the risk for BPD.
6. Exposure to Long-Term Fear or Distress: Children who grow up in environments characterized by chronic fear or distress may develop maladaptive coping strategies, contributing to BPD symptoms later in life.
7. Family History of Mental Illness: A genetic predisposition to mental health disorders, particularly if a close family member has BPD or related conditions, elevates the risk of developing BPD.
8. Peer Rejection or Bullying: Negative social experiences, such as bullying or rejection by peers, increase feelings of worthlessness and instability, which are characteristic of BPD.

These risk factors interact in complex ways, often leading to the development of BPD during adolescence or early adulthood.

How is the diagnosis of BPD determined?

The diagnosis of Borderline Personality Disorder (BPD) is determined through a comprehensive assessment process that involves clinical interviews and symptom evaluation by qualified mental health professionals such as psychiatrists, psychologists, or clinical social workers, according to a  PubMed study titled “Diagnosing borderline personality disorder” by Robert S. Biskin (Nov 2012).

The diagnosis of Borderline Personality Disorder (BPD) is given below.

• Clinical Interview: A detailed interview is conducted to gather information about the patient’s symptoms, medical history, and the impact of these symptoms on daily life. This process often starts with a visit to a general practitioner (GP), who may refer the patient to a specialist for further evaluation.
• Symptom Criteria: According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), a diagnosis of Borderline Personality Disorder (BPD) requires the presence of at least five of the following nine criteria: efforts to avoid real or imagined abandonment; a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation; identity disturbance with a persistently unstable self-image or sense of self; affective instability due to marked reactivity of mood,  chronic feelings of emptiness; inappropriate, intense anger or difficulty controlling anger; impulsivity in at least two areas that are potentially self-damaging, recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior; and transient, stress-related paranoid ideation or severe dissociative symptoms.
• Assessment Tools: While there are no laboratory tests for BPD, structured interviews and self-report measures can assist in the diagnosis. Tools like the Diagnostic Interview for Borderlines (DIB) are considered gold standards, although they require specialized training to administer.
• Exclusion of Other Conditions: The clinician must also rule out other mental health disorders that may present with similar symptoms, such as mood disorders or anxiety disorders. This is crucial for an accurate diagnosis.
• Contextual Evaluation: Symptoms must be pervasive and present in various contexts, typically beginning in adolescence or early adulthood. The clinician evaluates how these symptoms affect the patient’s relationships and overall functioning.
• Family Involvement: In some cases, involving family members in the assessment process can provide additional insights into the patient’s behavior and relationships, which may aid in the diagnosis.

Diagnosing BPD combines clinical interviews, symptom criteria evaluation, and the exclusion of other mental health conditions, all conducted by trained mental health professionals.

Is there a definitive test for diagnosing BPD?

No, there is no definitive test for diagnosing Borderline Personality Disorder (BPD), according to Leichsenring F & Fonagy P, Heim review  “Borderline personality disorder: a comprehensive review of diagnosis and clinical presentation, etiology, treatment, and current controversies” on World Psychiatry. 2024.

 Diagnosis is primarily conducted through a clinical interview with a licensed mental health professional who evaluates the patient’s history and symptoms.

While various screening tools, such as the McLean Screening Instrument for BPD (MSI-BPD), help identify symptoms consistent with BPD, they are not definitive and cannot replace a professional diagnosis.

What methods are used to treat BPD?

Treatment for Borderline Personality Disorder (BPD) employs a variety of methods, primarily focusing on psychotherapy, with some use of medications and hospitalization as well, according to Chapman J, Jamil RT, Fleisher C, et al. Borderline Personality Disorder in StatPearls Publishing; 2024 Psychotherapy: Psychotherapy is the cornerstone of BPD treatment, with several evidence-based therapies proving effective:

• Dialectical Behavior Therapy (DBT): Explicitly developed for BPD, DBT combines individual therapy with group skills training. It focuses on teaching skills in mindfulness, emotional regulation, distress tolerance, and interpersonal effectiveness. DBT has shown significant efficacy in reducing self-harm behaviors and improving emotional regulation.
• Mentalization-Based Therapy (MBT): This therapy aims to enhance individuals’ understanding of their and others’ mental states. It helps improve emotional regulation and interpersonal relationships, making it particularly beneficial for those struggling with BPD.
• Schema-Focused Therapy (SFT): Similar to cognitive behavioral therapy (CBT), SFT focuses on identifying and changing negative thought patterns and beliefs about oneself. It helps in reshaping the individual’s self-image and interpersonal relationships.
• Transference-Focused Psychotherapy (TFP): This therapy emphasizes the relationship between the therapist and the patient, using this dynamic to help patients understand their emotions and behaviors in relationships.
• Systems Training for Emotional Predictability and Problem Solving (STEPPS): This skills-based program combines group therapy with individual therapy, focusing on emotional regulation and interpersonal skills.
• Medication: While psychotherapy is the primary treatment, medications can also play a role in managing specific symptoms associated with BPD, such as depression and anxiety. Although no medication is approved explicitly for BPD, some commonly used types include, antidepressants, antipsychotics and mood stabilizers.
• Hospitalization: In some cases, hospitalization is necessary, especially during acute crises involving self-harm or suicidal ideation. Family therapy and support groups can also be beneficial, helping family members understand BPD and learn how to support their loved ones effectively.

While there is no single cure for BPD, a combination of psychotherapy, medication, and hospitalization can help individuals manage their symptoms and improve their overall functioning. 

What are the differences between BPD and HPD?

The differences between BPD and HPD include differences in core motivation, emotional expression, relationship dynamics, self-image, impulsivity and behaviors, underlying causes, and treatment approaches, according to the Talk Space Journal, “Histrionic vs. Borderline Personality Disorder” by Bisma Anwar (August 2022).

• Core Motivation: Individuals with Histrionic Personality Disorder (HPD) are primarily motivated by a desire for attention, often seeking to be the center of attention through dramatic and exaggerated behaviors. In contrast, those with Borderline Personality Disorder (BPD) are primarily motivated by a fear of abandonment and rejection, leading to intense emotional responses and unstable relationships.
• Emotional Expression: People with HPD typically display shallow, exaggerated emotions that may seem theatrical, while individuals with BPD experience deep, intense emotions that can shift rapidly, often resulting in emotional dysregulation.
• Relationship Dynamics: HPD often leads to superficial relationships, as individuals may engage in flirtatious or provocative behaviors to maintain attention. Conversely, BPD is characterized by intense and unstable relationships driven by fears of being alone or abandoned.
• Self-Image: Those with HPD tend to have a more vivid self-expression with less concern for authenticity. At the same time, individuals with BPD often struggle with a distorted and unstable self-image, leading to significant identity issues.
• Impulsivity and Behaviors: Both disorders can involve impulsive behaviors, but the nature of these actions differs. Individuals with BPD may engage in self-destructive behaviors due to emotional turmoil, whereas those with HPD may act provocatively to gain attention.
• Underlying Causes: BPD is often associated with a history of trauma or neglect, contributing to emotional instability and fear of abandonment. In contrast, HPD is linked to a deep-seated need for approval and reassurance, influencing attention-seeking behaviors.
• Treatment Approaches: While both disorders benefit from psychotherapy, Dialectical Behavior Therapy (DBT) is particularly effective for BPD, focusing on emotion regulation and interpersonal effectiveness. HPD may be treated with psychodynamic therapy or cognitive-behavioral therapy (CBT) aimed at developing healthier communication styles.

Understanding these distinctions is crucial for accurate diagnosis and effective treatment strategies for individuals affected by these personality disorders.

What signs indicate BPD in males versus females?

The presentation of Borderline Personality Disorder in males is explosive anger, impulsivity, substance abuse, antisocial features, and higher novelty seeking. In females, there are affective instability, self-harm behaviors, comorbid disorders, identity disturbance, and higher emotional distress, according to a study titled “Gender Patterns in Borderline Personality Disorder” by Randy A. Sansone(May 2011).

The signs indicating BPD in males versus females are given below.

• Explosive Anger: Men with BPD exhibit intense and inappropriate anger. This explosive temperament is a hallmark of their presentation and manifests as aggressive outbursts or irritability.
• Impulsivity: There is a higher tendency for impulsive behaviors in men with BPD, which include reckless driving, substance abuse, or other high-risk activities. This impulsivity is often due to a desire for novelty and excitement, which is more pronounced in males.
• Substance Abuse: Men with BPD frequently have co-occurring substance use disorders. This behavior is often a coping mechanism for emotional distress or a way to manage their symptoms.
• Antisocial Features: Males with BPD display antisocial personality traits, which include manipulative behaviors and a lack of empathy.
• Higher Novelty Seeking: Men are often characterized by high levels of novelty seeking, which leads to engagement in risky behaviors and contributes to their impulsivity.

• Affective Instability: Women with BPD tend to experience significant mood swings and emotional instability. This includes chronic feelings of emptiness and intense emotional responses to interpersonal situations.
• Self-Harm Behaviors: While both genders engage in self-harm, women are more likely to report such behaviors. This includes cutting or other forms of self-injury as a means of coping with emotional pain.
• Comorbid Disorders: Females with BPD are likely to experience comorbid conditions such as anxiety disorders, depression, and eating disorders. These comorbidities complicate the clinical picture and treatment approaches.
• Identity Disturbance: Women often report more significant issues related to identity disturbance, feeling uncertain about their self-image and personal values.
• Higher Emotional Distress: Women with BPD have higher levels of emotional distress when compared to their male counterparts, influencing their treatment-seeking behavior.

Men are likely to endorse symptoms related to intense anger and impulsivity, while women exhibit more emotional instability and self-harm behaviors.

What signs indicate HPD in males versus females?

Histrionic Personality Disorder (HPD) presents itself in males through attention-seeking behavior, seductive actions, relationship dynamics, and role-playing. In females, there is less aggressive attention-seeking, emotional instability, physical appearance, suggestibility and compliance, and conflict in relationships, according to the Cleveland Clinic article on “Histrionic Personality Disorder” ( April 2022).

The signs indicating HPD in males vs females are given below.

• Attention-Seeking Behavior: Women with HPD often exhibit a strong need to be the center of attention. They may engage in flirtatious or sexually provocative behavior to gain attention from others.
• Emotional Expression: Females typically display intense emotions that shift rapidly. Their emotional expressions may be shallow, and they often dramatize their feelings to impress others.
• Seductive Actions: Women are more likely to use their physical appearance and seductive behavior as tools to attract attention. This can manifest in dressing provocatively or acting in ways that are overtly sexual.
• Relationship Dynamics: Women with HPD interpret relationships as more intimate than they are, leading to conflicts with friends and partners due to their need for constant validation.
• Role Playing: They may adopt roles such as “victim” or “princess” to elicit sympathy and attention from others.

• Less Aggressive Attention-Seeking: While males also seek attention, their methods are less overtly sexual or provocative compared to females. They display attention-seeking behavior through boasting or dramatic storytelling rather than flirtation.
• Emotional Instability: Like females, men with HPD experience emotional ups and downs, but they may express these feelings less exaggeratedly. Their emotional responses might be more subdued, leading to a perception of being less dramatic.
• Physical Appearance: Although both genders may rely on their physical appearance, studies suggest that men with HPD may not emphasize their looks as much as women do. Instead, they might focus on charisma or charm to draw attention.
• Suggestibility and Compliance: Males with HPD may show a high degree of suggestibility, often yielding to the influence of others to maintain social standing or attention, but this may be coupled with a more dominant or assertive demeanor compared to females.
• Conflict in Relationships: Males may struggle with interpersonal relationships, but their disputes might stem more from assertiveness or dominance rather than the seductive or dramatic approaches seen in females.

While both males and females with HPD share core symptoms such as attention-seeking and emotional instability, the expression of these symptoms differ significantly based on gender. Females tend to be more overtly seductive and dramatic, while males may exhibit less aggressive but still attention-seeking behaviors.

Are there any differences between BPD and bipolar disorder?

Yes, there are significant differences between Borderline Personality Disorder (BPD) and Bipolar Disorder, despite some overlapping symptoms such as mood swings and impulsive behavior, according to Paris J’s 2004 review “Borderline or bipolar? Distinguishing borderline personality disorder from bipolar spectrum disorders” in Harv Rev Psychiatry Journal.

BPD is a personality disorder characterized by ongoing instability in self-image, mood, and behavior, often leading to impulsive actions and tumultuous relationships. Mood changes in BPD are typically rapid and intense, often triggered by external factors like stress in relationships or work, and last for a few hours to a few days.

In contrast, Bipolar Disorder is a mood disorder marked by distinct periods of high (mania or hypomania) and low (depression) moods that can last for days to months. These mood episodes are more prolonged and less frequently triggered by external events compared to BPD. Bipolar Disorder includes Bipolar I, characterized by full manic episodes, and Bipolar II, which involves hypomanic episodes and more severe depressive episodes. 

Is splitting a common symptom in individuals with borderline personality disorder?

Yes, splitting is a common symptom in individuals with borderline personality disorder (BPD), as suggested by Chapman J, Jamil RT, Fleisher C, et al. Borderline Personality Disorder (2024).  Splitting is a defense mechanism where a person with BPD views people, situations, or objects in black-and-white terms, categorizing them as entirely good or entirely bad with no middle ground. This extreme form of thinking helps individuals with BPD manage intense emotions and fears, particularly fears of abandonment and instability.

Does the DSM-5 provide criteria for diagnosing borderline personality disorder?

Yes, the DSM-5 provides specific criteria for diagnosing borderline personality disorder (BPD), as reviewed by Biskin, R. S., & Paris, J. (2012). Diagnosing borderline personality disorder. CMAJ : Canadian Medical Association Journal. According to the DSM-5, BPD is characterized by a pervasive pattern of instability in interpersonal relationships, self-image, and affects, as well as marked impulsivity. 

To receive a diagnosis, an individual must meet at least five out of nine criteria, which include frantic efforts to avoid abandonment, unstable and intense interpersonal relationships, identity disturbance, impulsivity in potentially self-damaging areas, recurrent suicidal behavior or self-harm, affective instability, chronic feelings of emptiness, inappropriate or intense anger, and transient stress-related paranoid ideation or dissociative symptoms. 

What happens if BPD is left untreated?

If left untreated, Borderline Personality Disorder (BPD) leads to severe and long-term consequences that significantly impair an individual’s quality of life, according to Biskin, R. S. (2015). “The Lifetime Course of Borderline Personality Disorder in the Canadian” Journal of Psychiatry. Individuals with untreated BPD often experience chronic emotional turmoil, which results in a poor quality of life and physical health issues due to risky behaviors, self-harm, and substance misuse. 

The disorder’s inherent instability strains relationships, leading to frequent breakups, conflicts with family and friends, and eventual social isolation. Untreated BPD also causes significant employment instability, making it difficult for individuals to maintain steady jobs due to impulsivity and mood swings. 

Are there effective strategies to prevent suicide in individuals with BPD?

Yes, there are effective strategies to prevent suicide in individuals with Borderline Personality Disorder (BPD), according to Mann, J. J., Michel, C. A., & Auerbach, R. P. (2021) in The American Journal of Psychiatry. One of the most effective approaches is psychotherapy, particularly Dialectical Behavior Therapy (DBT), which has been shown to reduce suicidal behavior by teaching patients skills to manage emotional distress and improve interpersonal relationships. 

DBT includes techniques such as behavioral analysis, validation of distress, and development of alternative solutions to problems, which help patients cope with suicidal thoughts. 

Creating a self-soothing plan with a therapist is beneficial, as it provides patients with tools to manage overwhelming emotions and suicidal ideation. Speaking with someone, such as a trusted therapist, support group, or confidant, is crucial to avoid isolation and obtain appropriate responses to suicidal thoughts.