Suicidality, Self-Injury, and Borderline Personality Disorder
Suicidal behaviour is often associated with Borderline Personality Disorder (BPD). Although the presence of suicidal and self-injurious behaviour is not required to establish a diagnosis of BPD, this is commonly regarded as a key feature of the disorder (See page on Key Features). The rate of completed suicide amongst patients with BPD is estimated to be between 8 – 10%, which is considerably higher than in the general population, particularly for young women who tend to have lower suicide rates (Gunderson, 2011; Oldham, 2006). Many more patients make unsuccessful attempts at suicide. Thus, awareness of suicide risk is an important task in any clinical encounter with individuals who have BPD.
Consideration of suicide risk in BPD is complicated by the tendency of many patients with BPD to engage in nonlethal self-injurious behaviour. Where suicidality involves at least a partial intent to die, nonlethal self-injury – also known as parasuicidal behaviour – does not (Oldham, 2006). Self-destructive behaviour without suicidal intent may take many forms, including deliberate self-mutilation such as cutting or burning, engaging in high-risk sexual activity, and exposure to potential violence. The motivations for engaging in such behaviour likely vary among patients, and remain only partially understood.
A common clinical error is to consider nonlethal self-injury as being willful and manipulative. Although these behaviours may involve an interpersonal context, they may be fuelled by other motivations such as self-punishment or relief from acute dysphoria (Oldham, 2006). For many patients with BPD, self-injury can serve as a means – albeit a costly one – of emotional regulation, with potentially multiple factors contributing to its occurrence. Repeated engagement in self-injury does not lessen suicide risk. Suicide ideation / intent may stem from different psychological concerns and motivations than nonlethal self-injury. Therefore, clinicians must remain alert to suicide potential when working with patients with BPD, regardless of the presence of chronic self-injury.
Several risk factors for suicidal behaviour have been identified among patients with BPD. These include a history of previous suicide attempts, co-morbid mood disorder or substance use disorder, hopelessness, family history of suicidality, history of sexual abuse, and high levels of impulsivity or antisocial traits (Black, Blum, Pfohl, & Hale, 2004; Oldham, 2006). One study found that the odds of attempting suicide was 10 times more likely for BPD patients with a history of childhood sexual abuse over BPD patients without such a history (Soloff, Lynch, & Kelly, 2002). Although it may be useful for clinicians to understand such risk factors, the prediction of whether or not a particular patient with BPD will proceed with a lethal suicide attempt remains difficult (Paris, 2008). There is no substitute for a thorough, individualized assessment of suicide risk.
The management of suicidal behaviour will depend upon the assessed acuity and level of risk. Patients with BPD may also suffer from episodes of major depression, with accompanying suicidality that requires active management. For some patients with BPD, hospitalization may be necessary in the management of acute suicide risk. In general, however, recommendations in the literature suggest that management of suicidal behaviour may be best handled within a structured psychotherapy (McMain, 2007; Oldham, 2006; Paris, 2008; See section on Psychotherapy for BPD). Suicidal behaviour should be prioritized as a target of treatment interventions (McMain, 2007), and patients should be encouraged to explore the meaning of their suicidal and self-injurious behaviours in order to develop alternative coping strategies (Oldham, 2006).
Wherever possible, clinicians should aim to prevent suicidal ideation and behaviour from altering the structure of therapy; patients should be encouraged to bring up such issues during therapy sessions rather than frequent crisis calls between sessions (Paris, 2008). On the other hand, allowing limited availability for crisis calls may promote the patient’s trust in their therapist and reinforce the coping strategies developed during therapy session, particularly during early phases of treatment. Therapists’ emotional reactions to suicidal behaviour – which may range from rejecting to rescuing responses – may potentially interfere with overall treatment goals. Consultation and supervision are therefore strongly recommended for therapists working with patients who engage in self-destructive behaviours. Ideally, addressing suicidality for patients with BPD should consist of a structured, long-term psychotherapy approach (See section on Psychotherapy for BPD), based on a comprehensive and theoretically coherent model (McMain, 2007).