Borderline personality disorder: parasuicide

backlitplantIn 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.

14 comments to Borderline personality disorder: parasuicide

  • A strong wish for attention and understanding from others (in this case from a therapist) is one of the underlying reasons for para suicidal behavior. The feeling that most patients struggling with their emotions have is that there is no substantial help and attention from their therapists. Therapists are overwhelmed by the amount of patients and the information which they have to deal with on a daily basis. Parasuicidal person uses actions against himself or herself to say “Hey, I am here, help me, care about me, I am lonely and I am scared. I need somebody to care!”
    The role of psychotherapist is to engage such patient in a constant conversation with the help of an online diary in order to make the patient feel that he/she is getting a constant attention and response. It is like having your therapist 24/7 there for you, because you can pour out your emotions and feel better.

    [Dr. Reidbord replies: I decided to approve this comment even though it’s commercial spam — promoting a site that provides online communication between clients and therapists for a fee (to the therapist), and free private journaling for anyone.

    In my view, no therapist is available 24/7, online or not, and frustration tolerance is one of the treatment goals in BPD. Living with one’s own feelings is one goal of therapy. Dialectical behavior therapy (DBT) does aim to provide 24/7 phone availability for crisis calls, although of course this is never assured. It would be even less assured online. On the other hand, keeping a journal or diary can be therapeutic for some patients, as shown in studies by Pennebaker and others. I personally believe it’s easier to do this on old-fashioned paper, but if an online service helps, great.]

  • tracy

    Dr. Reidbord,
    Thank you for such an informative and understanding explanation of one of the most prominant feartures of Borderline Personality Disorder. (At least, in my situation). i am just barely a week out of the hospital (again!) after another “episode”. My (dear, long suffering) husband and i have noticed that that bad cutting, alohol and meds overdoses seem to happen about every 6 moths…does this make any sense to you? Inpatient treatment does me little good…it is the therapeutic relationship with outpatient paychiatrists who do therapy (i know how fortunate i am!) that seems to keep me, for the most part, “grounded”. i hate the way i have hurt my family and want so badly to overcome these actions, even the minor cutting, in particular.

    Thank you for listening to my ramblings,

    • Hi Tracy,
      I don’t know offhand why your “episodes” seem to happen about every six months. I wonder if they’re related to something that happens those times of the year. Do you have kids who go off to school around then? Do you or your husband have seasonal jobs? Does someone visit (or do you visit your family) twice a year? I’d think about these first. Also, some people have mood swings in the spring and fall, when the seasons change. Bring it up with your outpatient psychiatrist, if you haven’t already, and maybe the two of you can discover a pattern.

  • Lana Lucci

    I like your blog. I don’t know what my diagnosis is really. My T focused a lot on borderline personality but the last year it’s been bipolar II. DBT sent me into a tailspin. He tried it for a few weeks. Having therapy go back to the business-like stuff we started with was not what I wanted.

    It may be helpful to treaters but is not for all patients. What is unfortunate is it seems patients are blamed if DBT doesn’t work for us. I get tired of hearing how difficult we are…

    Is DBT something that I shouldn’t have done with my current T? I’ve been with him four years. Could that have been the issue?

    • You raise a good point. If your therapist of 4 years started acting differently toward you by suddenly becoming a “DBT therapist” this could be disorienting and unhelpful. Therapists should understand that we are not just technicians who pull a canned therapy off a shelf and “apply” it. We have relationships with our patients. Consistency within that relationship is very important, especially for those suffering borderline personality disorder. In general, I think it’s better to do one kind of therapy with any particular patient, and refer him or her to someone else for other type(s) of therapy if needed.

      It’s also a good idea to get DBT, or any kind of therapy, from someone well trained in that approach. It’s unclear from your note if your therapist was trained in DBT, or merely “tried it for a few weeks”.

      The whole question of borderline vs bipolar II is a fascinating one for me. I believe diagnostic errors are made in both directions.

  • Cess

    [Identifying material deleted — SR] My husband seem to have parasuicide episodes only whenever we have marital issues, predominantly his non-recognition of appropriate behavior toward young women. His repetitive behavior of obsessing over young women (no affair or sex, but gets high from their constant attention; euphoric feeling like a drug) has caused strain in our marriage. The latest of which is my husband’s infatuation with [specific person’s description deleted — SR]. It’s like my husband couldn’t get enough of her pretty face and constantly had to look her up on the web, which he had lied about to me time and again. Threatened my husband with exposure of his secret obsession but he pleaded to be spared from embarrassment. When presented with web data hard evidence, he was unable to deny his excessive curiosity over the girl. He claims he knew his behavior was wrong but does not know why he’s doing it. Busted and unable to explain, my husband employed parasuicide to somehow limit our confrontation. This time, more serious than in the past, parasuicide with a very sharp knife and threatened to stab his chest. Of course, I didn’t dare wrestle the knife away because it would only intensify the drama. I called his bluff and said “if you think that’s the solution to your problem, then by all means do it!” I walked away from the scene and the next minute, my husband was just seated on the sofa with knife on coffee table. Nothing happened! It was all for show. Could this mean my husband has BPD?

    • Sorry about editing your comment, but it seemed to me you were “exposing your husband’s secret obsession” right here. It’s impossible to interpret his parasuicidal behavior over the internet. It could be “all for show” as you say. Or it could be a desperate attempt to avoid the shame of exposure, or something else. It isn’t necessarily diagnostic of BPD.

      One reason I published your comment is to warn you and others not to “call the bluff” of people who threaten suicide. This dares the person to “up the ante”, i.e., act more dangerously self-destructive next time, so you’ll take him seriously. People die that way. A better approach is to take seriously the feeling behind the behavior, whether that is despondency, shame, angry retaliation, or whatever.

      Your husband’s behavior obviously troubles you. Ideally, he would agree to go to therapy himself, to address his parasuicidal behavior, and also his preoccupation with young women. I would also advise couples therapy (marriage counseling) for both of you, as the two of you have a destructive pattern: he misbehaves, you threaten to shame him, he harms himself. It’s a cycle that can and should be broken. But even if he refuses therapy, you might get something out of it yourself, i.e., how to deal with your own feelings about what he does, and whether it is worth pushing him to the point of acting like this. Take care.

  • Jakabird

    I just recently became aware of the term parasuicide, and searching he web has led me here. Everything else I’ve read has made me feel defensive, angry…but I can relate to this. I hate the way my behavior effects those closest to me. I always thought the motivation for SELF harm was to keep from hurting others…I was never one who would ‘wear my pain on my sleeve’ (or under it, as the case may be). Everything was hidden…but the feeling if having people walk a tightrope hit uncomfortably close.
    I feel I would like to get help…but I’m terrified of bringing this up to anyone in authority (a therapist, for example). I have children, and don’t want to say anything that could have then taken away…I don’t know where to go from here.

    • I’m sorry you face the dilemma of wanting help but fearing the consequences if you seek it. In an ideal world, you would speak to a therapist, secure in the knowledge that your words would not be misinterpreted or used against you. However, the reality is that self-harming behavior can — very rarely in my experience — potentially harm one’s children as well. In such cases, a therapist may rightfully involve Child Protective Services. Unfortunately, a therapist may also overreact and call CPS when there is no harm to the child. As a first step, you might call an anonymous suicide hotline and see if talking to someone briefly helps you feel better. Then consider seeking out a psychotherapist recommended by a friend or relative you trust, and/or one with an excellent reputation in the community. Good therapists don’t have knee-jerk overreactions, and your wish not to hurt others is a positive factor as well. Take care.

  • erika

    I think I have this . I don’t know what to do anymore. I feel like nobody cares and I’m always trying to get attention and by that people think I’m annoying which makes me feel like I’m worthless and stupid and that causes me to cut. I don’t cut deep enough though. I cut my wrist with tweezers. I use to do it with a razor but only at the sides of my wrist. Then I moved the the actually wrist part and now I just leave welts with the hurts but I don’t know it helps me. people always tell me I act like the world revolves around me but I just want to be noticed I don’t know…. I usually get upset about boys and that’s when I cut my self really badly because they always end up using me and not liking me. I recently lost my virginity to a guy who hates me now. It was 3 weeks ago that I thought I was fine. Then now he talks bad about me. I’ve been crying ever since he stopped talking to me. I don’t feel safe anymore.

    • Erika,
      Many people have found help for similar problems through psychotherapy. I hope you’ll give it a try if you haven’t already. There are many schools of therapy that could help; Dialectical Behavior Therapy or DBT is especially suited to people who cut or do other parasuicidal behaviors. If you have health insurance, therapy should be covered. If you don’t, there may be low-fee therapy clinics in your area. It sounds as though you have some insight about your emotional sensitivity, which is a good start. The next step is to access the help that is available to you. Take care.

  • paula

    I think self-harm can be a way to communicate need for people who have no words or the ability to effectively ask for help.

  • Sara

    To be perfectly honest, when everything goes haywire, parasuicide gives you a sense of control… somehow. I know that it is not right and that (or perhaps survival instincts, who am I kidding?) is why I never carry on to finish the job. It’s a burden, yes, knowing how deep to cut or how many pills to take but you’re in control. You choose to be in pain, you choose to live and you can choose to die. It can be addictive. Whenever things go anywhere near that way again, you yearn for the control.

  • Lizzy

    Dr. Reidbord,

    My mom is para-suicidal and we have been dealing with it since I was 12 and now am 31. Its usually triggered by her compulsive desire to gamble and when she uses money that can be needed somewhere else she attempts suicide. She has taken pills, rat poison, household pesticides you name it. But she always cries out for help after the action and we rush her to hospital. It has taken its toll on us as her children and made us have a very strained relationship with her as we cannot trust her with money and this makes her even more isolated.

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