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.
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.]
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,
tracy
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.
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.