Understanding the causes of suicide in BPD
The affect, mood, and behavior of patients with BPD can suddenly switch and appear contradictory, causing bewilderment and frustration for their health care providers. Patients can appear very depressed and suicidal at one moment and appear angry and entitled the next. Indeed, affective instability is the feature of BPD most closely associated with attempted suicide.6
Many clinicians have found the states of being model of dynamic deconstructive psychotherapy helpful for understanding affective instability in BPD and how it increases suicide risk.7 According to this model, patients with BPD can be triggered to switch between different states of being, or pseudo-personalities. In a matter of days, hours, or even minutes, patients can alternately appear helpless and childlike (helpless victim state), angry and self-righteous (angry victim state), or depressed and suicidal (guilty perpetrator state). These states are not methods of manipulation, but rather represent different sets of polarized and poorly integrated attributions of self and others.
When in the angry victim state, patients see themselves as heroic victims. They accept no responsibility for failures and instead blame others for their difficulties. They can become angry, manipulative, or violent in this state, since they perceive their actions as totally justified. This state is a defense against feelings of shame or humiliation and is triggered by situations that provoke such feelings. For example, Ms A reacted with rage when the consultant questioned the seriousness of her condition and the legitimacy of her suicide attempt. Patients are at low risk for suicide while in this state because they see the source of their difficulties as outside of themselves.
On the other hand, when in the guilty perpetrator state, patients with BPD are at significantly increased risk for suicide, especially when there are other risk factors, such as poor social supports, co-occurring alcohol(Drug information on alcohol) misuse, or poor physical health.3 When in the guilty perpetrator state, patients take on total responsibility for every bad thing that has ever happened to them. They see their lives as a series of failures and bad decisions; they feel ugly, worthless, and evil—a pest that deserves to be exterminated.
In the guilty perpetrator state, the patient preserves an idealized image of others by taking all the badness onto himself or herself. This state is usually triggered by perceived rejection, abandonment, or separation anxiety, but it can also be triggered by any situation that causes the patient to become ambivalent toward major attachment figures. For example, Ms A’s initial presentation of having had a “bad day” was triggered by her therapist’s vacation. Instead of being able to acknowledge anger toward her therapist for abandoning her, Ms A maintained a positive image of her therapist by devaluing herself instead. During that day, Ms A’s self-image was the unlovable and difficult patient who was beyond help and who deserved to be “abandoned.” Despite Ms A’s later protestations, her overdose most likely included some suicide intent, in addi-tion to self-directed anger.
The states of being and rapidity of switching can be exacerbated by circumstances that intensify attachment wishes and fears, such as abusive relationships, prolonged hospital stays, or poor patient-therapist boundaries (physical touching, multiple contacts per week, extended sessions, etc). Patients can regress and become moody and childlike under these conditions: they react strongly to minor provocations and alternate rapidly between different states of being; their risk of suicide varies as well. The childlike qualities and sudden fluctuations in states contribute to health care providers’ confusion and skepticism.