Psychiatric Times.
No. 13
Suicidal Self-Injurious Behavior in People With BPD
By Jessica Gerson, Ph.D., and Barbara Stanley, Ph.D.
|
December 1, 2003
Dr. Gerson is a research scientist in the department of neuroscience at the New York State Psychiatric Institute, an assistant project director at Safe Horizon and in private practice in Brooklyn, N.Y.
Dr. Stanley is a research scientist in the department of neuroscience at the New York State Psychiatric Institute, professor in the department of psychiatry at Columbia University and professor in the department of psychology at the City University of New York.
It is crucial to recognize, however, that even if patients with BPD self-mutilate and attempt suicide for similar reasons, death may be the accidental and unfortunate result. Because patients with BPD try to kill themselves so often, clinicians often underestimate their intent to die. In fact, individuals with BPD who self-injure are twice as likely to commit suicide than others (Cowdry et al., 1985), and 9% of the 10% of outpatients who are diagnosed with BPD eventually commit suicide (Paris et al., 1987). Stanley et al. (2001) found that suicide attempters with cluster B personality disorders who self-mutilate die just as frequently but are often unaware of the lethality of their attempts, compared to patients with cluster B personality disorders who do not self-mutilate.
Treatment of Suicidal Behavior and Self-Injury
While non-suicidal self-harm can result in death, it is more likely not to and, in fact, only occasionally leads to serious injury such as nerve damage. Yet, patients are often hospitalized on a psychiatric unit in the same way that they would be for a frank suicide attempt. In addition, while the intent is most often to alter the internal condition, as opposed to an external condition, clinicians and those in relationships with self-injurers experience this behavior as manipulative and controlling. It has been noted that self-injury can elicit quite strong countertransference reactions from therapists.
Although there is clearly a biological component to this disorder, the results of pharmacologic interventions have been inconclusive. Different classes and types of medications are often used for different aspects of the behavior (e.g., sadness and affective instability, psychosis and impulsivity) (Hollander et al., 2001).
One class of psychological intervention has been cognitive-behavioral therapy (CBT), of which there are a few models, e.g., Beck and Freeman (1990), cognitive-analytic therapy (CAT) developed by Wildgoose et al. (2001), and an increasingly well-known form of CBT called dialectical behavior therapy (DBT), developed by Linehan (1993) specifically for BPD. Dialectical behavior therapy is characterized by a dialectic between acceptance and change, a focus on skill acquisition and skill generalization, and a consultation-team meeting. In the psychoanalytic arena, there is controversy as to whether a confrontative, interpretative approach (e.g., Kernberg, 1975) or a supportive, empathic approach (e.g., Adler, 1985) is more effective.
Concluding Thoughts
This paper addresses contemporary conceptual and treatment issues that come into play in understanding suicidal and self-injuring behavior in the context of BPD. Diagnostic issues and the phenomenology of self-injurious behavior are important to consider. Treatment approaches include pharmacologic interventions, psychotherapy and their combination.
References
1. Adler G (1985), Borderline Psychopathology and Its Treatment. New York: Aronson.
2. Beck AT, Freeman A (1990), Cognitive Therapy of Personality Disorders. New York: The Guilford Press.
3. Brodsky BS, Cloitre M, Dulit RA (1995), Relationship of dissociation to self-mutilation and childhood abuse in borderline personality disorder. Am J Psychiatry 152(12):1788-1792 [see comment].
4. Coid JW (1993), An affective syndrome in psychopaths with borderline personality disorder? Br J Psychiatry 162:641-650.
5. Cowdry RW, Pickar D, Davies R (1985), Symptoms and EEG findings in the borderline syndrome. Int J Psychiatry Med 15(3):201-211.
6. Davis RT, Blashfield RK, McElroy RA Jr (1993), Weighting criteria in the diagnosis of a personality disorder: a demonstration. J Abnorm Psychol 102(2):319-322.
7. Hampton MC (1997), Dialectical behavior therapy in the treatment of persons with borderline personality disorder. Arch Psychiatr Nurs 11(2):96-101.
8. Hollander E, Allen A, Lopez RP et al. (2001), A preliminary double-blind, placebo-controlled trial of divalproex sodium in borderline personality disorder. J Clin Psychiatry 62(3):199-203.
9. Kelly TM, Soloff PH, Lynch KG et al. (2000), Recent life events, social adjustment, and suicide attempts in patients with major depression and borderline personality disorder. J Personal Disord 14(4):316-326.
10. Kernberg OF (1975), Borderline Conditions and Pathological Narcissism. New York: Aronson.
11. Kjellander C, Bongar B, King A (1998), Suicidality in borderline personality disorder. Crisis 19(3):125-135.
12. Linehan MM (1993), Cognitive-Behavioral Treatment for Borderline Personality Disorder: The Dialectics of Effective Treatment. New York: The Guilford Press.
13. Mehlum L, Friis S, Vaglum P, Karterud S (1994), A longitudinal pattern of suicidal behavior in borderline disorder: a prospective follow-up study. Acta Psychiatr Scand 90(2):124-130.
14. Oquendo MA, Mann JJ (2000), The biology of impulsivity and suicidality. Psychiatr Clin North Am 23(1):11-25.
15. Paris J, Brown R, Nowlis D (1987), Long-term follow-up of borderline patients in a general hospital. Compr Psychiatry 28(6):530-535.
16. Pope HG Jr, Jonas JM, Hudson JI et al. (1983), The validity of DSM-III borderline personality disorder. A phenomologic, family history, treatment response, and long-term follow-up study. Arch Gen Psychiatry 40(1):23-30.
17. Sabo AN, Gunderson JG, Najavits LM et al. (1995), Changes in self-destructiveness of borderline patients in psychotherapy. A prospective follow-up. J Nerv Ment Dis 183(6):370-376.
18. Stanley B, Brodsky B (in press), Suicidal and self-injurious behavior in borderline personality disorder: the self-regulation model. In: Borderline Personality Disorder Perspectives: From Professional to Family Member, Hoffman P, ed. Washington, D.C.: American Psychiatric Press Inc.
19. Stanley B, Gameroff MJ, Michalsen V, Mann JJ (2001), Are suicide attempters who self-mutilate a unique population? Am J Psychiatry 158(3):427-432.
20. Wildgoose A, Clarke S, Waller G (2001), Treating personality fragmentation and dissociation in borderline personality disorder: a pilot study of the impact of cognitive analytic therapy. Br J Med Psychol 74(pt 1):47-55.
21. Zanarini MC, Gunderson JG, Frankenburg FR, Chauncey DL (1990), Discriminating borderline personality from other axis II disorders. Am J Psychiatry 147(2):161-167.
|
Five Steps to Improving Patient Access Judy Capko, May 21, 2013 Patient access is getting increased attention through reform initiatives. Here are five steps you can take to make sure patients get appropriate access to care in your office.
SearchMedica SEARCH RESULT
Find peer-reviewed literature and websites for practicing medical professionals
|
