Deliberately inflicted self-harm in the context of borderline personality disorder (BPD) can be disturbing, frightening, and shame provoking to individuals who engage in it, to their families, and to the clinicians who care for them. This behaviour is particularly confusing because of its seemingly paradoxical nature. On one hand, it causes extraordinary physical and emotional suffering. 

 

Many who commit self-harm describe it as substituting physical suffering for emotional pain and suffering, which is experienced as intolerable and is mostly invisible to others.

Many individuals with BPD experience frequent non-suicidal self-injury along with chronic suicidal ideation, suicide threats, and intermittent nonlethal suicide attempts. This makes prediction of actual suicide risk very difficult (Fine and Sansone 1990).

Although there can be a tendency to hospitalize when it is not clinically indicated, professionals and family members can develop a “boy who cried wolf” reaction to repeated low-lethality suicide attempts, nonsuicidal self-injury, and chronic suicidal ideation. In this scenario, clinicians and family members can become almost immune to concern about the individual’s self-injury and suicidality after repeated episodes accompanied by chronic suicidal ideation and urges. These caregivers can become complacent, underestimating or neglecting genuine suicide risk, and this may contribute to a high rate of suicide completion.

In fact, the population of individuals with BPD is at high risk for completed suicide, with a lifetime suicide rate of about 9%–10%. Relatedly, the low medical lethality and seemingly minor precipitants for many self-injury episodes may contribute to the misperception that self-injury is merely manipulative and attention seeking.

Suicidal and Self-Injurious Behaviour

Its high incidence in BPD presents a formidable challenge to helping individuals with this problem. In fact, some clinicians refuse to treat patients with BPD because of the sense of burden, confusion, stress, and liability in working with such high-risk patients. This is an unfortunate circumstance. Although treating individuals with BPD can be stressful, as is any clinical work with patients who have life-threatening illness, it can also be an extremely rewarding and productive experience. Patients can rid themselves of chronic suicidal ideation and eliminate self-injurious behaviour as a means of coping.

The usual types of nonsuicidal self-injury are cutting the skin (often on the inside of the arms) and burning the skin (arms, legs, and stomach).

Also common are self-hitting, head banging, self-burning, self-biting, hair pulling, and skin picking. Shearer’s (1994) report of the phenomenology of self-injury documented that the most frequent type of nonsuicidal self-injury among BPD inpatients was superficial cutting or scratching (80%), followed by hitting (24%), burning (20%), and head banging (15%).

Self-Injurious Behavior: Reasons

A common belief is that non-suicidal self-injury is attention seeking and manipulative. However, there is both clinical and empirical evidence arguing against this notion. Non-suicidal self-injury is usually an extremely private behaviour; it is often denied and hidden.

Nonsuicidal self-injury is usually an extremely private behaviour; it is often denied and hidden

People who self-injure are often deeply ashamed of their self-injury.

Individuals who self-injure are often deeply ashamed of their self-injury. Shearer (1994) and Brodsky et al. (1995) independently reported that approximately 50% of BPD inpatients hide the fact that they self-injure and do not let anyone know about it.

Suyemoto (1998) reports that isolation from others almost always precedes the actual act of self-mutilation.

For example, individuals with BPD often assume that they cannot handle emotional pain and that physical pain is more tolerable. They believe that they can rid themselves of negative emotions and that self-injury is the only way they can obtain immediate relief from their intolerable emotional states. They believe that by injuring themselves they are more in control than if they were to allow themselves to experience their dysregulated emotions, which they perceive as either coming out of nowhere or triggered by events that they perceive (not always correctly) to be completely out of their control.

Individuals who utilize self-injury as an expression of anger believe that it is better to hurt themselves than to express anger, and they believe that it is “wrong” to express angry feelings toward others, particularly people they care about.

Those who need to self-punish often believe that they deserve to suffer.

The trigger for self-injury is almost always a real or perceived interpersonal loss through separation or abandonment.

The model of suicidal behaviour based on major depression often does not seem to apply to suicide attempts by people with BPD.

The conventional model of suicidal behaviour often does not seem to apply to suicide attempts by persons with BPD.

Another confusing aspect of the clinical picture is that individuals with BPD often describe suicide attempts in the same way that they describe self-injury episodes.

Suicide attempts by individuals with BPD may also serve an emotion-regulation function similar to that of self-injury episodes, because the individuals tend to feel better after making a suicide attempt.

What Families Need to Know

  • Many individuals with BPD engage in non-suicidal self-injuring behaviours (self-harm), have suicidal thoughts, and make suicide threats. This makes it very difficult for their family members and therapists to predict the actual risk for suicide.
  • It is important not to overreact by believing that every act of self-injury (superficial cutting or burning of the skin, head banging, hair pulling, or skin picking) has suicidal intent. Suicide attempts and non-suicidal self-injury are usually quite different in the mind of the person with BPD.
  • It is equally important not to underestimate the risk of suicide in individuals with BPD. Self-mutilation (cutting or burning the skin) is itself a risk factor for suicide: 55%–85% of self-mutilators have made at least one suicide attempt.
  • The risk for completed suicide among individuals with BPD over their lifetimes is about 9%–10%.
  • Rather than using self-injury to manipulate others and seek attention, many individuals with BPD are ashamed of the behaviour and hide it from others.
  • The trigger leading to self-injury in BPD is most often a real or perceived loss of a personal relationship through separation or abandonment.
  • Among its possible functions, self-injury may actually help the person with BPD reduce emotional tension, distract him or her from feeling emotional pain, make the emotional suffering concrete and visible, or act on angry feelings. In other words, self-injury seems to help regulate emotions that are out of control.
  • Many individuals with BPD who self-injure report an immediate sense of relief from emotional pressure afterward.
  • The self-regulation model proposes that suicidal behaviour and self-injury serve a dual function in BPD: to inflict physical harm and to regulate the emotions.
  • During periods of extreme stress that could lead to a suicide attempt or self-injury episode, a stay in the hospital might block the behaviour and help the person with BPD tolerate the emotions until they subside.

This is an exerpt from Understanding and treating borderline personality disorder : a guide for professionals and families, edited by John G. Gunderson and Perry D. Hoffman