AAPEL
BPD and self-injury, self-harm, self-mutilation
Introduction:
Connection between borderline personality and self-mutilation. A lot of BPD people have this addiction. There is a lot of studies about this but once again the goal is not to stigmatize but understand why. You will find on the last part of this document our vision which we hope comprehensive and listening to the suffering
Meme page en Francais / Same page in french
Data, studies
What they say ?
Aapel view
.
Data, studies (statistics, prevalence, comorbidity, co-occurency)
* Starr DL. - North Central Human Services, Gardner, Massachusetts, USA.
Jun 2OO4 J Psychosoc Nurs Ment Health Serv. - Understanding those who self-mutilate.
"Self-mutilating behavior is a symptom seen in both men and women with various psychiatric disorders, but the majority of those who self-mutilate are women with borderline personality disorder. This complex, maladaptive behavior is used by clients as a means of self-preservation and emotion regulation, and is often associated with childhood trauma. Clients who self-mutilate perceive they receive poor care in hospital emergency departments and are retraumatized by these experiences. Clinicians who understand the complexity and purposes of self-mutilating behavior are better able to provide clients with supportive, empathetic care"

* Briere J, Gil E. - Dep of Psychiatry and the Behavioral Sciences, University of Southern California School of Medicine, LA.
1998 Am J Orthopsychiatry. - Self-mutilation in clinical and general population samples
Self-mutilation, examined in samples of the general population, clinical groups, and self-identified self-mutilators, was reported by 4% of the general and 21% of the clinical sample, and was equally prevalent among males and females. Results suggest that such behavior is used to decrease dissociation, emotional distress, and posttraumatic symptoms. Childhood sexual abuse was associated with self-mutilation in both clinical and nonclinical samples.

* Haw C, Hawton K, Houston K, Townsend E. - St Andrew's Hospital, Northampton, UK
2001 Br J Psychiatry - Psychiatric and personality disorders in deliberate self-harm (DSH) patients.
METHOD: A representative sample of 150 DSH patients who presented to a general hospital were assessed using a structured clinical interview and a standardised instrument.
RESULTS: ICD-10 psychiatric disorders were diagnosed in 138 patients (92.0%). Personality disorder was identified in 45.9% of patients.
CONCLUSIONS: Psychiatric and personality disorders are common in DSH patients.

* Raspa RF, Cusack J. - Uniformed Services University of the Health Sciences, Bethesda, Maryland
1990 Am Fam Physician. 1990 - Psychiatric implications of tattoos.
Psychiatric disorders, such as antisocial personality disorder, drug or alcohol abuse and borderline personality disorder, are frequently associated with tattoos. Finding a tattoo on physical examination should alert the physician to the possibility of an underlying psychiatric condition

* Stanley B, Gameroff MJ, Michalsen V, Mann JJ. - Mental Health Clinical Research Center for the Study of Suicidal Behavior, Department of Neuroscience, New York State Psychiatric Institute, NY 10032, USA
2001 - Am J Psychiatry - Are suicide attempters who self-mutilate a unique population ?
Self-mutilators perceived their suicide attempts as less lethal, with a greater likelihood of rescue and with less certainty of death. In addition, suicide attempters with a history of self-mutilation had significantly higher levels of depression, hopelessness, aggression, anxiety, impulsivity, and suicide ideation. They exhibited more behaviors consistent with borderline personality disorder and were more likely to have a history of childhood abuse. Self-mutilators had more persistent suicide ideation, and their pattern for suicide was similar to their pattern for self-mutilation, which was characterized by chronic urges to injure themselves.

* Fowler JC, Hilsenroth MJ, Nolan E. - Erikson Institute for Education and Research, Austen Riggs Center, Stockbridge, Massachusetts, USA.
2000 Bull Menninger Clin - Exploring the inner world of self-mutilating borderline patients
Self-mutilating patients exhibit greater incidence of primary process aggression, severe boundary disturbance, pathological object representations, defensive idealization, devaluation, and splitting than did a matched group of non-self-mutilating borderline patients

* Bohus M, Limberger M, Ebner U, ... - Dept of Psychiatry Psychotherapy, University of Freiburg Freiburg, Germany
2000 Psychiatry Res - Pain perception during self-reported distress and calmness in patients with borderline personality disorder and self-mutilating behavior.
Self-mutilation occurs in 70-80% of patients who meet DSM-IV criteria for borderline personality disorder. Approximately 60% of these patients report that they do not feel pain during acts of self-mutilation such as cutting or burning.
Even during self-reported calmness, patients with BPD showed a significantly reduced perception of pain compared to healthy control subjects

* McKay D, Kulchycky S, Danyko S. - Department of Psychology, Fordham University, Bronx, NY, USA
2000 J Personal Disord - Borderline personality and obsessive-compulsive symptoms.
The findings from this study support the idea that self-mutilation is a more severe form of psychopathology relative to the rest of the BPD population

* Wilhelm S, Keuthen NJ, ... - Dept of Psychiatry, Massachusetts Hospital, Harvard Medical School, Boston, USA.
1999 J Clin Psychiatry - Self-injurious skin picking
31 DSM IV patients with Self-injurious skin picking, 26% had a borderline disorder

* Briere J, Gil E. - Dept of Psychiatry and Behavioral Sciences, University of Southern California, Los Angeles, USA.
1998 Am J Orthopsychiatry - Self-mutilation in population samples: prevalence, correlates, and functions.
Self-mutilation, examined in samples of the general population, clinical groups, and self-identified self-mutilators, was reported by 4% of the general sample, and was equally prevalent among males and females.
Results suggest that such behavior is used to decrease dissociation, emotional distress, and posttraumatic symptoms. Childhood sexual abuse was associated with self-mutilation in both clinical and nonclinical samples.

* Dubo ED, Zanarini MC, Lewis RE, ... - Dept. of Psychiatry, Sunnybrook Health Science Centre, North York, Ontario
1997 Can J Psychiatry - Childhood antecedents of self-destructiveness in borderline personality disorder.
In the borderline group, parental sexual abuse was significantly related to suicidal behaviour and both parental sexual abuse and emotional neglect were significantly related to self-mutilation.
CONCLUSION: Both parental sexual abuse and emotional neglect appear to play a role in the etiology of self-destructive behaviour in BPD

* Kemperman I, Russ MJ, Clark WC, Kakuma,... - New York Hospital, Cornell Medical Center, White Plains, USA
1997 Psychiatry Res - Pain assessment in self-injurious patients with borderline personality disorder using signal detection theory.
These findings suggest that 'analgesia' during self-injury in patients with BPD is related to both neurosensory and attitudinal/psychological abnormalities.

* Brodsky BS, Cloitre M, Dulit RA. - Dept. of Psychology, Cornell University Medical Center, New York, USA.
1995 Am J Psychiatry - Relationship of dissociation to self-mutilation and childhood abuse in borderline personality disorder.
RESULTS: The subjects who dissociated were more likely than those who did not to self-mutilate and to report childhood abuse
CONCLUSIONS: Female inpatients with borderline personality disorder who dissociate may represent a sizable subgroup of patients with the disorder who are at especially high risk for self-mutilation, childhood abuse, depression, and utilization of psychiatric treatment.

* Zweig-Frank H, Paris J, Guzder J. - Institute of Community and Family Psychiatry, Jewish General Hospital, Montreal, Quebec.
1994 Can J Psychiatry - Psychological risk factors for dissociation and self-mutilation in female patients with borderline personality disorder.
Subjects who mutilated themselves had higher rates of both childhood sexual abuse and dissociation in univariate analyses. However, in multivariate analyses only diagnosis was significant
The findings do not support theories that dissociation and self-mutilation in borderline personality disorder are associated with childhood trauma.

* Ghaziuddin M, Tsai L, Naylor M,... - Dept. of Child and Adolescent Psychiatry, University of Michigan Hospital, Ann Arbor.
1992 Acta Paedopsychiatr - Mood disorder in a group of self-cutting adolescents.
Although self-cutting is generally said to be associated with borderline personality disorder, a substantial number of patients who cut themselves in our study were clinically depressed

* Burgess JW. - Stanford University Medical Center, CA.
1991 Psychiatry Res - Relationship of depression and cognitive impairment to self-injury in borderline personality disorder, major depression, and schizophrenia.
Self-injury was not significantly correlated with acute or chronic depression in any group, but self-injury was correlated with neurocognitive deficits in borderline and schizophrenic groups.

* Favazza AR, DeRosear L, Conterio K. - University of Missouri, Columbia.
1989 Suicide Life Threat Behav - Self-mutilation and eating disorders.
Patients with eating disorders are at high risk for self-mutilation (e.g., skin cutting and burning), and vice versa. Even if the self-mutilation in these patients is regarded as a Borderline Personality Disorder symptom, DSM-IV should list it as an associated feature or a complication of Anorexia Nervosa/Bulimia Nervosa. In lieu of a dual diagnosis, we postulate that the combination of self-mutilation, anorexia, bulimia, and other symptoms (such as episodic alcohol abuse and swallowing foreign objects) may be manifestations of an impulse control disorder known as the "deliberate self-harm syndrome."

* Hawton K, Rodham K, Evans E, Weatherall R. - Centre for Suicide Research, Warneford Hospital, Oxford. UK
2OO2 BMJ - Deliberate self harm in adolescents: self report survey in schools in England.
PARTICIPANTS: 6020 pupils aged 15 and 16 years.
RESULTS: 398 (6.9%) participants reported an act of deliberate self harm in the previous year that met study criteria.
Deliberate self harm was more common in females11.2%than it was in males3.2%.
In females the factors included for deliberate self harm were recent self harm by friends, self harm by family members, drug misuse, depression, anxiety, impulsivity, and low self esteem.
In males the factors were suicidal behaviour in friends and family members, drug use, and low self esteem. .


Self-mutilation and BPD, what they say
" An estimated 2 million Americans purposely cut or burn themselves. 90% of self-injurers begin cutting as teenagers. The average self-injurer starts at age 14 and continues with increasing severity into her late 20's. The most common professions are: teacher, nurse and manager. More than half of self-injurers are victims of sexual abuse, and most report emotionally abusive or neglected childhoods. Self-injury is prevalent in ALL races and economic backgrounds." (deb.arneson.net)

"Patients who self mutilate tend to be infantile, narcissistic, and “as if” personalities functioning in an overt borderline level" (Kernberg)

"Self mutilation occurs in response to fear of fragmentation and that is represents an abortive (and sometimes sexualized) attempt to restore the cohesion and stability to a fragmenting self-representation" (Stolorow and Lachmann)

"Self-mutilation has become a major public health concern as its incidence appears to have risen since the early 1990s. One source estimates that 0.75% of the general American population practices self-mutilation. The incidence of self-mutilation is highest among teenage females, patients diagnosed with borderline personality disorder, and patients diagnosed with one of the dissociative disorders. Over half of self-mutilators were sexually abused as children, and many also suffer from eating disorders" (Rebecca J. Frey PhD, "Self-mutilation", Medical Network Inc)

"Self-mutilation may be a symptom that is part of an underlying psychiatric disorder such as depression, obsessive-compulsive disorder, Gilles de la Tourette syndrome, psychosis, borderline personality disorder, trichotillomania, eating disorder, or body dysmorphic disorder" ("Bio-Behavioral Institute Disorders Self-mutilation", biobehavioral)

"69-75% of BPD sufferers resort to self mutilation" (Colleen Sullivan, "borderline", bipolarworld.net)

"Under stress borderlines experience a horrible neurological sensation called "dysphoria". Borderlines desperately try to find ways for it to go away... Some borderlines discover that scratching or cutting the skin in a linear manner doesn't hurt, but stops the dysphoria.  Interestingly all of us employ this technique when we have an unbearable neurological sensation that responds to this treatment - scratching insect bites. The treatment is medication.  Borderlines need to use medication that works in 10 minutes (Haldol) rather than self-mutilating.  Self mutilation causes fear in others and borderlines recognize that it's not good for them.  I share their belief that they need relief, and that's what medication is for." (Leland M. Heller, MD, “What Causes Self Mutilation And Can It Be Cured”, www.biologicalunhappiness.com)
 


Aapel view of Self-injury and Borderline Personality Disorder
Here is our feeling.

Do BPD people use self-mutilation ?
yes, it is a common behavior, to the extent that it is one of the points in the DSM "recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior"

Do they ALL (bpd) use self-mutilation ?
No, some data suggest that 70% of bpd people self-mutilate, but we think that this number is excessive. BPD people with impusive or suicidal behaviors are much more inclined to consult that "high functioning" peoples.
In that way stigmatize a borderline saying for example that "the borderline peoples cut themselves" is stupid, even if self-mutilation is an extreme warning sign !

What kind of mutilation are they using ?
A lot, like cuting, burning, scratching. If you want no know more please read data on some dedicated web sites.
Once again, we don't care "how", but "why". (how is only important to explain why)

When a people self-mutilate, can we then say that he / she is borderline ?
Of course not. Even if a lot of them have bpd, some may have other disorders.
We can find self-mutilation in neurological, biological, genetic disorders like autism, mental retardation, Prader-Labhart-Willi syndrome (obesity), ...
... and in psychological disorders like Post Traumatic Stress Disorder, Schizophrenia, Obsessive compulsive disorder, eating disorder,...

What about drugs influence ?
Some medications may help to reduce and or prevent self-injury but in the opposite, some medications can induce or amplify phenomenon
It is obvious that in front of such problem, the first investigation is to verify if self-injury could be induced by drugs

Which treatment ?
The first part of the treatment is to understand the cause, especially for a borderline disorder
Effective medical treatment should involve a combination of psychotherapy and possibly medication

Why borderline peoples are acting like this ?
Keep in mind that the main problem of a borderline people is to deal with emotions and then impulsivity
Borderline peoples are like everyone but "more"
When they are happy, it is more than us, when they suffer it is more than us.
Another problem is the duration, they have to deal, almost all their life with their pain. It is why each of them looks for a way to calm their suffering, and why there is a lot of addictions linked between BPD (eating disorder, alcohol, drugs, suicide, ...)


Please read page
BPD and post traumatic stress disorder
BPD and dissociation
 


AAPEL - Back to BPD summary page
 

,
Warning:
All the informations on this site are with an aim of helping to understand a "particular" disease at the very least and puzzle
But more especially to support peoples who suffer, sick or not.  In all cases, it is ESSENTIAL to have recourse to a therapist specialized in the disease to confirm or to cancel a diagnosis
Though it is the name doesn't much matter, which is important, it is to apply "the right" treatment to each patient
 

last update august 2007
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Author, Alain Tortosa, psychotherapist, founder president of the Aapel
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