Self-harm and suicidal thoughts are a troubling part of many mental illnesses, but for those struggling with borderline personality disorder (BPD), the risk is extreme.
In fact, self-harm and suicide attempts are so prevalent in BPD that it is the only mental disorder that includes such behaviors as part of its diagnostic criteria. Almost 80% of those with BPD report a history of suicide attempts, and suicide deaths range between 8-10%. This rate is 50 times greater than that found in the general population, according to a 2014 analysis of BPD research by the Substance Abuse and Mental Health Services Administration (SAMHSA).
Then there is self-destructive behavior—cutting, burning, hitting, hair-pulling, head-banging, and skin-picking. More than three-quarters of those with BPD engage in at least one of these actions, with a 2008 study putting the number closer to 90%. The reasons vary and can overlap but most commonly include:
- An attempt to shift the pain from the mental to the physical;
- To feel something or “more real”;
- To express anger or frustration or, conversely, to keep emotions in check;
- As self-punishment;
- As a plea for attention or help.
Such self-harm classifies as nonsuicidal self-injury and doesn’t usually involve an intent to die. Instead, it becomes an attempt to use pain to deal with pain.
Living Life at Extremes
A look at the realities of BPD sheds light on its ability to fuel such destructive reactions. Characterizing this complex illness are an intense fear of abandonment, impulsivity, risk-taking, an unstable sense of self, angry outbursts and overreactions (especially to criticism), and emotions that move from one extreme to another. This can set the stage for volatile personal relationships in which the people in their lives (including themselves) are on pedestals at one moment and then off in the next.
BPD can also bring feelings of emptiness and detachment, as well as paranoia, especially in times of stress.
Estimates on the prevalence of BPD vary, but we now know it to be more common than we once realized. Some researchers put the number at almost 6% of the population. It often, but not always, comes with a history of childhood trauma such as early neglect or physical or sexual abuse.
Though women more often receive diagnoses than men, research now suggests it occurs in the male and female populations in equal measure. The past tendency to view BPD as a women’s issue is likely due to the fact that it seems to hit women harder, with higher levels of mental and physical disability, and to come with different co-occurring conditions. For example, research shows that women with BPD more often have eating disorders, anxiety, major depression and post-traumatic stress disorder. Men with BPD, on the other hand, have higher instances of drug and alcohol addiction and antisocial personality disorder, and are more likely to show explosive anger and have higher levels of risk seeking. These traits—along with gender bias—may have led to a mischaracterization of such males as having personality problems other than BPD.
It’s because BPD shares such links and commonalities with other issues that people often misunderstand it, making it important to turn to a licensed mental health professional for a diagnosis.
The Silver Lining
Despite this grim portrait of BPD, there is an encouraging side to the illness. Many do respond well to appropriate treatment, and psychologists no longer assume it to be the chronic illness they once thought.
As SAMHSA noted in a 2011 report on BDP to Congress:
“BPD symptoms can be severe, debilitating, and isolating, and individuals with this disorder suffer discrimination and bias. However, despite its severity and burden, BPD has a surprisingly good long-term prognosis with a high rate of recovery.”
This is especially true when the treatment and education extend beyond the sufferer to include his or her family, friends, employer, and community.
Though there is no targeted FDA-approved BPD treatment as of yet, there is help for those with the disorder through several avenues. Dialectical behavior therapy, for example, can teach skills for dealing with distress, regulating emotions, and relating more effectively with others. A 2004 study found it helped participants improve in a variety of areas, including anxiety, depression, global psychopathology, interpersonal functioning, self-harm and social adjustment. It can also help the person reduce behaviors that get in the way of change, such as alcohol and drug use. Medications such as antidepressants are also an option in some cases and doctors may prescribe them to help lift mood and lessen anger, impulsivity and irritability.
When seeking treatment, look for mental-health professionals experienced in dealing with BPD. They will know, for example, that BPD patients often bond strongly with their therapist, which can cause them to fear abandonment and lash out. Some patients will even sabotage recovery—sometimes consciously, sometimes not—to keep the therapeutic relationship from ending. In short, the person providing treatment must fully understand and be willing to manage the inherent challenges of committing to someone whose personality is geared for volatility.
At our BPD treatment center in California, we recognize that co-occurring conditions are common with BPD. We must be treating them along with the disorder to maximize chances of a successful recovery. One study found, for example, that 62% of those in treatment for BPD also met the criteria for a substance-use disorder. Such drug and alcohol abuse not only interferes with the work of therapy and is dangerous in its own right, but it can also boost the impulsivity, risk-taking, and suicide risk that comes with BPD.
Because those dealing with BPD are sometimes unaware that their emotions and behaviors fall outside the norm, or are reluctant to admit they are struggling, family members are often the ones who reach out for help. No matter who makes the first move, it’s important to make it. The disorder’s destructive power is real. We shouldn’t ignore it, nor the possibility of healing.
David Sack, MD, is board certified in psychiatry, addiction psychiatry and addiction medicine. He is Chief Medical Officer of Elements Behavioral Health, a network of mental health and addiction treatment centers that includes the Malibu Vista women’s mental health center and Lucida Treatment Center in Florida.