19 Self-Harm & Borderline Personality Disorder

Foundational Perspectives on Suicide and Self-Harm

• Philosophical Context: The lecture addresses the difficult meaning of life and the taking of life.

• Albert Camus ($1913$–$1960$): Postulated that the "only real philosophical question is that of suicide."

• Survival Instinct: A core question in psychology is why individuals engage in behaviors that directly counter the biological instinct for survival.

Classification of Self-Injurious Thoughts and Behaviors (SITB)

• Self-Harm: Defined broadly as self-inflicted violence.

• Non-Suicidal Self-Injury [NSSI]: Self-inflicted injury performed without the express intent to end one's life.

• Suicidal Intent: Categorized into specific subsets:     - Suicidal Ideation [SI]: Thoughts about suicide.     - Suicide Attempt [SA]: Acts intended to end one's life.

• Developmental Progression: Serious NSSI during teenage years is identified as a significant risk factor for later suicidal behavior.

Epidemiology and Statistics of Suicide

• General Rankings:     - Suicide is the $3^{rd}$ leading cause of death overall (following accidents and homicide).     - It is the $2^{nd}$ leading cause of death among college students.     - It is the $1^{st}$ or $2^{nd}$ leading cause of death among adolescent girls worldwide.

• Demographics in Youth (Aged < $25$):     - Lethality: Males traditionally use more lethal "means," though this trend is beginning to change.     - Attempts vs. Completion: Suicide attempts are more frequent in females, while completed suicides are more frequent in males.

• Risk Factors and Impulse Control:     - Substance Abuse: Increases impulsivity and clouds judgment.     - Bipolar Disorder: Presents an "ultra-high risk" due to mixed-episode energy, impulsivity, despair, and emotion dysregulation.

• The "Impossible Period": Many survivors of suicide attempts report a desire to have simply "gotten through" the temporary, overwhelming period of distress.

• Rational Suicide: Discussed in the context of chronic illness or pain, raising questions about society's role in such choices.

• Key Drivers: Roles of hopelessness and impulsivity.

• Frequency in the U.S.: Approximately $1$ completed suicide occurs every $15$ minutes. This rate is higher than the rate for homicide.

Sociological and Psychiatric Interpretations

• Cognitive Distortions: Suicidal individuals are often utterly convinced that friends and family would be better off without them, leading to the question from outsiders: "How could you do this to friends/family?"

• Inference of Intent: It is difficult to distinguish intent in cases involving substance use, eating disorders, or certain accidents.

• Theories of Causality:     - Sociological: Includes concepts like "anomie."     - Psychiatric: Focuses on high rates within Depression, Bipolar Disorder, Borderline Personality Disorder (BPD), and Obsessive-Compulsive Disorder (OCD).

• Stigma: Suicide is often viewed as the "ultimate mark of shame" for a family.

• Moral Model: Historically views suicide as both immoral and illegal.

Historical Trends and Awareness efforts

• Historical Data (since the $1950$s): Based on the "Triple Bind" lecture series.     - Rates increased by $300\%$ until the year $1988$.     - Rates subsequently decreased, noted as the "role of SSRIs."     - Currently, rates are rising dramatically again, particularly for girls and young women.

• Advocacy and Support Organizations: Including Suicide Hotlines, Active Minds, Bring Change to Mind, Jed Foundation, etc.

• Central Themes: These trends raise intense issues regarding family dynamics, resilience, individual choice, despair, pain, and ethics.

Non-Suicidal Self-Injury (NSSI) Depth and Mechanisms

• Scope of Behavior: Ranges from nail-biting to severe gouging, burning, and head-banging.

• Prevalence: Currently "skyrocketing," especially among girls.

• Clinical Significance: While intent may not be to die, NSSI can result in death if wounds are severe enough. It is a major predictor of adult suicide attempts.

• Functions and Motivations:     - Expression of immense pain when no other outlet exists.     - Relief of Inner Tension: Seeing blood and feeling physical pain can potentially lower emotional pain.     - Emotion Regulation: Indicates major deficits in regulating affect.     - Alexithymia: A Greek-derived term referring to the state of having feelings but lacking the words to describe them.     - Shame: Followed by deep shame and the hiding of marks or scars.     - OCD Elements: Obsession with pain followed by a compulsion to "express" it for temporary relief.

• Contagion: "Copycat" behaviors occur within schools and across society via the internet.     - Sites can provide great support (reducing stigma) but can also serve as "how-to" manuals for cutting.

Risk Factors for NSSI

• Impulsivity: A heritable history of impulsive behavior.

• Family Environment: History of non-affirming, non-validating, emotionally intense, and coercive interactions.

• Trauma: History of maltreatment.

• ADHD Correlation (Referencing the ADHD Lecture):     - High rates observed in girls with ADHD.     - Interaction Effect: Girls with ADHD plus a history of maltreatment have a risk of suicide attempt by early adulthood that jumps from $14\%$ to $35\%$ (more than double).

• Parallels: Similarities are drawn to Bipolar Disorder.

BGALS Follow-up Study Findings (Hinshaw et al., 2012)

• Study Demographics: Follow-up at Wave $3$ ($W3$) with a Mean age ($M$) of $19.5$ years.

• Comparative Data:     - ADHD Combined Type (ADHD-C): Highest rates of both suicide attempts (approaching $20\%\text{-}25\%$) and NSSI (over $50\%$).     - ADHD Inattentive Type (ADHD-I): Elevated rates compared to the control group, but lower than ADHD-C.     - Comparison Group: Significantly lower levels of both behaviors.

Mitigating Factors and Antidotes

• Communication: Developing the ability to express pain verbally.

• Stigma Reduction: Normalizing the expression of emotional distress.

• Stress Management: Lowering the "impossible" stressors faced by modern youth (referencing the "Triple Bind").

• Validation: Ensuring individuals feel valued as people rather than "commodities."

• Social Media Impact: Managing the constant social comparisons provoked by "impossible" digital images.

Borderline Personality Disorder (BPD)

• Terminology: Historically viewed as traversing the "border" between neurosis and psychosis.

• Classification: Organized within the DSM-5 into three clusters based on shared features.

• Core Clinical Features:     - Affective instability and emotion dysregulation.     - Splitting: Idealization and demonization (black and white thinking).     - Brief periods of psychosis or dissociation.     - High impulsivity.     - Major identity disturbance.     - Intense and unstable interpersonal relationships.     - Self-Injurious Behavior: NSSI is a marker of BPD, though NSSI occurs without full BPD symptomatology.

Developmental Psychopathology (DP) Model of BPD

• Genetic Risk: Heritable traits including impulsivity and affective instability.

• Neurobiology: Genetically vulnerable individuals may have an "over-reactive" amygdala, poor frontal lobe regulation, and low serotonin regulation.

• Environmental Triggers: Extremely low validation of emotions by caregivers, coercion, and abuse (noting discrepancies between retrospective and prospective research).

• Interaction: The combination of genetic vulnerability and childhood devaluation/lack of validation can result in BPD.

• Prevalence Note: NSSI is described as "pandemic" today; authors argue it cannot all be attributed to individual psychopathology like BPD.

Treatment and Dialectical Behavior Therapy (DBT)

• Professional Stigma: Individuals with BPD are often shunned even by mental health professionals and face high rates of ridicule.

• Nomenclature: Suggestions to rename it "Unstable P.D." to reduce stigma.

• Medical Intervention: Use of antidepressant or antipsychotic medications.

• Dialectical Behavior Therapy (DBT):     - Origin: Developed as a revolutionary approach.     - Components: Involves individual therapy, group support, family involvement, and phone coaching.     - Core Principles: Balance of acceptance and limits; therapist validates the client unconditionally while pointing out maladaptive behaviors.     - The Dialectic: Can a therapist value the client yet set limits? Can a client try their hardest yet still need to try harder?     - Themes: Mindfulness, distress tolerance, and emotion regulation.

Crisis Resources

• National Suicide Prevention Lifeline: $1\text{-}800\text{-}273\text{-}TALK$ ($8255$).