Suicidal Self-Injurious Behavior in People With BPD

Borderline personality disorder (BPD) is characterized by unstable relationships, self-image and affect, as well as impulsivity, that begin by early adulthood. Patients with BPD make efforts to avoid abandonment. They often exhibit recurrent suicidal and/or self-injuring behavior, feelings of emptiness, intense anger, and/or disassociation or paranoia. Suicidal and non-suicidal self-injury are extremely common in BPD. Zanarini et al. (1990) found that over 70% of patients with BPD had self-injured or made suicide attempts, as compared to only 17.5% of patients with other personality disorders. Nevertheless, clinicians consistently misunderstand and mistreat this aspect of BPD.

There has been considerable controversy surrounding the diagnosis of BPD, ranging from a sense that the term itself is misleading and frightening, to the fact that the diagnosis is often made in an inconsistent manner (Davis et al., 1993), to a lack of clarity about whether the diagnosis should be Axis I or Axis II (Coid, 1993; Kjellander et al., 1998). Furthermore, these patients are often excluded from clinical trials due to perceived risk.

More important, however, is the fact that suicidal self-injurious behavior is usually understood within the context of major depressive disorder, while the phenomenology of this behavior within BPD is quite different. In addition, self-injurious non-suicidal behavior is often understood by clinicians to be synonymous with suicidal behavior, but again, it may be distinguished separately, particularly within the context of BPD. It is possible that, although self-injury and suicidal behavior are distinct, they may serve similar functions. This phenomenon has important implications for treatment recommendations.

Suicidality in BPD Versus Major Depression

In traditional conceptualizations developed from suicidality seen as an aspect of major depression, suicidal behavior is usually understood to be a response to a deep sense of despair and desire for death, which, if unsuccessful, typically results in a persistence of depression. Vegetative signs are prominent, and the suicidal feelings subside when the major depression is successfully treated with antidepressants, psychotherapy or their combination. In contrast, suicidality in the context of BPD seems to be more episodic and transient in nature, and patients often report feeling better afterward.

Risk factors for suicidal behavior in BPD show some differences, as well as similarities, with individuals who are suicidal in the context of major depression. Brodsky et al. (1995) noted that dissociation, particularly in patients with BPD, is correlated with self-mutilation. Studies of comorbidity have produced unclear results. Pope et al. (1983) found that a large number of patients with BPD also display a major affective disorder, and Kelly et al. (2000) found that patients with BPD alone and/or patients with BPD plus major depression are more likely to have attempted suicide than patients with major depression alone. In contrast, Hampton (1997) stated that the completion of suicide in patients with BPD is often unrelated to a comorbid mood disorder (Mehlum et al., 1994) and to degree of suicidal ideation (Sabo et al., 1995).

Conceptualizing Self-Harm

Suicidal behavior is usually defined as a self-destructive behavior with the intent to die. Thus, there must be both an act and intent to die for a behavior to be considered suicidal. Non-suicidal self-harm generally implies self-destructive behavior with no intent to die and is often seen as being precipitated by distress, often interpersonal in nature, or as an expression of frustration and anger with oneself. It usually involves feelings of distraction and absorption in the act, anger, numbing, tension reduction, and relief, followed by both a sense of affect regulation and self-deprecation. Confusion in the field regarding the definition of the term parasuicide can lead to a misunderstanding of the differences in function and danger of suicidal and non-suicidal self-injury. Parasuicide, or false suicide, groups together all forms of self-harm that do not result in death--both suicide attempts and non-suicidal self-injury. Many people who engage in non-suicidal self-harm are at risk for suicidal behavior.

We propose that non-suicidal self-injury in BPD uniquely resides on a spectrum phenomenologically with suicidality. Perhaps the most distinguishing factor, as pointed out by Linehan (1993), is that self-injury may help patients to regulate their emotions--an area with which they have tremendous difficulty. The act itself tends to restore a sense of emotional equilibrium and reduces an internal state of turmoil and tension. One striking aspect is the fact that physical pain is sometimes absent or, conversely, may be experienced and welcomed, as validation of psychological pain and/or a means to reverse a sense of deadness. Patients often report feeling less upset following an episode. In other words, while the self-injury is borne out of a sense of distress, it has served its function and the patient's emotional state is improved. Biological findings pointing to relationships among impulsivity and suicidality support the notion that suicidality and self-mutilation, particularly within the context of BPD, may occur on a continuum (Oquendo and Mann, 2000; Stanley and Brodsky, in press).