In my last post, I highlighted diagnostic challenges related to borderline personality disorder (BPD): Sometimes dramatic, self-destructive behavior leads to reflexive, inaccurate use of this label, while other times eagerness to diagnose a medication-responsive illness such as bipolar disorder can lead to overlooking BPD. Naturally, this barely scratches the surface. Thousands of books have been written about BPD. This editorial from the May 2009 issue of the American Journal of Psychiatry provides a concise summary of controversies surrounding the diagnosis. Even the Wikipedia entry on BPD has extensive useful information. Today I’ll focus on another central feature of BPD that has proven challenging to residents I’ve supervised (and me): parasuicide.
Parasuicide refers to self-harming behavior identified by the patient as suicidal but unlikely to actually result in death. Sometimes termed a “suicide gesture,” typical examples include taking a handful of pills, and cutting one’s wrists to draw blood, but not deeply enough to damage veins or arteries. Often the patient realizes later that suicide was not “really” the aim of the behavior. (Aim and intent become complex philosophical issues once the idea of a dynamic unconscious comes into play. Can one intend something without knowing it? Can intent be discerned by a therapist over the patient’s heartfelt disagreement?) Many patients in therapy eventually describe a very unpleasant, difficult-to-name emotional state that is relieved by these activities — especially painful, self-mutilating actions such as cutting or burning oneself. There is a sense of tension release. A communicative aspect is also often apparent, as in showing one’s anger or rage to important others, and eliciting an emotional reaction from them in return.
Parasuicide puts families and therapists, especially beginning therapists, in an uncomfortable position. These actions must be taken seriously, as failure to do so can make the person feel (further) abandoned and even angrier, leading to a spiral of increasingly self-destructive behavior. “Upping the ante” in this way can even lead to accidental death. For example, it is not widely appreciated that even modest overdoses of acetaminophen (Tylenol) can cause lethal liver failure. A seemingly minor overdose can unwittingly prove fatal. On the other hand, parasuicide looks manipulative. It is loudly claimed to be suicidal but isn’t “serious.” Families and therapists become angry themselves, potentially resulting in isolation, retaliation, and further harm to the patient. Patients brought to the emergency room after parasuicidal behavior challenge the on-call psychiatrist, often a resident, to walk a tightrope between dismissing the risk too casually, versus overreacting on the principle of “better safe than sorry.” Patients are sometimes hospitalized unnecessarily. A fascinating theoretical paper on psychiatric risk assessment can be found here.
To its credit, dialectical behavior therapy (DBT) tackles parasuicide head-on, as its top priority. This is wise not only from the perspective of patient safety, but also as a means to contain the anxiety of treatment providers. It is very difficult to work collaboratively with a patient who both scares and angers the therapist. While DBT addresses the problematic behavior itself, the manner in which a patient induces such negative feelings in the therapist is a direct focus of psychodynamic therapies. Transference-focused psychotherapy (TFT), another empirically validated treatment for BPD, was developed by Dr. Otto Kernberg and colleagues at Cornell, and pays particular attention to the communicative aspect of parasuicidal acts.
Parasuicide may look and feel manipulative to observers, but to the person with BPD it is a desperate attempt to secure relief from painful overwhelming feelings. It is both highly characteristic of the disorder, and one of its most challenging clinical features.