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.
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.
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