Reasons for suicide attempts and non suicidal self-injury in women with Borderline Personality Disorder

Article (PDF Available)inJournal of Abnormal Psychology 111(1):198-202 · March 2002with1,990 Reads
DOI: 10.1037/0021-843X.111.1.198 · Source: PubMed
Abstract
Self-reported reasons for suicide attempts and nonsuicidal self-injury were examined using the Parasuicide History Interview within a sample of chronically suicidal women meeting criteria for borderline personality disorder (N = 75). Overall, reasons given for suicide attempts differed from reasons for nonsuicidal self-injury. Nonsuicidal acts were more often reported as intended to express anger, punish oneself, generate normal feelings, and distract oneself, whereas suicide attempts were more often reported as intended to make others better off. Almost all participants reported that both types of parasuicide were intended to relieve negative emotions. It is likely that suicidal and nonsuicidal parasuicide have multiple intents and functions.
Joumal
of
Ahnomal
PsYchok)g)
2002.
Vol. I 11. No.
I. I98-202
Parasuicidal
helnvior
(deliberate
self-injury
or
imminent risk
of
death,
with or
without
the
intent
to die)
is the single best
predictor
ol death
by suicide
(see
Gunnell
& Frankel,
1994, for a
review).
Parasuicidal
acts can
be divided
into roughly
three
cate-
gories:
sriclde
attempts, ambivalent
suicide
attempts,
and nonsui-
ciclal
self-injury
(Linehan,
1986).
The
categories
dift'er
on the
relative
intensity
and clarity
of
the intent
to
die and
expectation
of
death.
It
is not
known,
however.
whether
nonsuicidal self-injury
(comrnonly
self-mutilation)
difi'ers
frorn
suicide
atternpts on other
motives.
Motives
for
parasuicide
have been
studied
by examining
how individuals
explain
their
own
parasuicitie.
It
is important
to
know
the reasons
given for
parasuicide because
they
provide
important
clues
to its
function
and
thereby may
clarity ways to
change
the behavior.
The most
comlnon
reason
given
fbr suicide
attempts
is
to escape
or
get
relief
from situations
causing extreme
distress
(Boergers,
Spirito,
&
Donaldson,
1998:
Varadaraj,
Men-
donca,
&
Rauchenberg,
1986).
The most
colnmon
reasons reported
for nonsuicidal
self-injury
also
often
involve
emotional distress,
but another
common
reason
is to end
dissociation
(.e.g.,
Parker,
1981;
Roy, 1978).
A small
number
of
studies
have
used
the same
.
assessment
methodology
to
contpare
reasons
for
parasuicide
with
high versus
low
suicicle
intent.r
These
conrparisons
suggest
that reasons tbr
Milton Z.
Brown and
iUarsha
M. Linehan,
Departnlent
of Psychology,
University
of
Washington;
Katherine
Anne
Conrtois,
Department of
Psy-
chiatry
and Behavioral
Sciences,
University
of
Washington.
This
research
was
presented
in
part at Lhe
annual
meeting
of the
Association
tbr the
Advancement
of
Behavior
Therapy,
Novernber 1996.
This
researcb
was supported
by
National
Institute ol
lvlental
Health
Grant
MH34486
to N4arsha
M. Linehan.
We thank
Angela
lvlurray,
Ikis Adarns,
Shari Fox,
Evelyn lV{ercicr,
Debbie McGhee,
Heidi Heard,
antl
Henry Schrnidt
ibr
helping collect and
cocle
the data.
and Sarah
K. Reynolds
and Linda
Dimeff
for valuable help
in revising
the article.
Correspondence
concerning
tlris
article
should be
addressed tcr
Marsha
M.
l-inehan,
Department
of
Psychology,
University of Wash-
ington,
Box
351525,
Seattle,
Washington 98195-l-s2-5.
E-mail:
linehan @u.rvashingtotr.edu
Copyrighr
2002
bv the American Psychological
Assc-.iatjon.
lnc.
0021
-841xi02l$5.00
DOI:
10. 10,37l/002 I -843X.
I
I
l. l. I
98
suicide
attempts more often
reflect
high
emotional
distress
(Hol-
den,
Kerr, Mendonca, &
Velamoor, 1998) and the
intent to make
things better
for others
(Bancroft,
Skrimshire, & Sin*in,
i976);
reasons
more common
for less suicidal
parasuicide
are tension
relief
(Jones,
Congiu, Stevenson,
Strauss, & Frei,
1979), ange at
others,
and temporary escape
(Bancroft
et al., 1976).
Several
factors limil the
conclusions
that can
be
drawn
frotn
existing
studies.
First, rnost
studies have not
reported whether
reasons
for
parasuicide
depend on
gender
or diagnosis,
although it
is
known that both
are important
factors in determining
risk for
suicidal
behavior. Second,
it is extremely difficult
to compare
suicidal
and nonsuicidal
parasuicide
across studies
becatrse of the
tremendous
variation
in methodology,
particularly in how suicide
attempts
are
operationalized.
Many investigators, for
example, fail
to
provide
adequate
definitions of the
parasuicidal
behaviors stud-
ied, and
many do not adequately
assess
(or
report)
the suicide
intent
of
palasuicide. Many studies
do not measure
reasons
comprehensively.
The
current study
is intended to correct these
shortcomings to
better understand
reaserns
for both suicide attempts
and nonsuicidal
self--injury.
All
participants met criteria tbr borderline
personality
disorder
(BPD),
were
wonen, and were assessed with
the same
comprehensive
interview,
thereby
preventing primary
diagnosis,
gender, and methodology
from confounding the
results. We lim-
ited
the sample to
women and BPD because
both suicidal and
nonsuicidal
parasuicide are most common
among women and
within
BPD.
Method
Participants
Participants
rvere 75
women accepted into a randomized
clinical trial lbr
parasuicide. Panicipants were
required to nleet the following
inclusion
criteria:
(a)
diagnosis of
BPD;
(b)
female
gender;
(c)
presence
of
parasui-
I
Unfortunately,
in
tlrese
studies,
it is not
clear if unambiguous suicide
attempts
are compared
with ambivalent suicide
attempts or
with
tlul,v
nonsuicidal
parasuicide.
Reasons
for
Suicide
Attempts and
Nonsuicidal
Self-Injury
in
Women
With
Borderline
Personality
Disorder
Milton
Z. Brown,
Katherine
Anne Comtois,
and
Marsha
M. Linehan
University
of Washington
Self-reported
reasons
for
suicide
attempts and nonsuicidal
self-injury were examined
using
the Parasui-
cicle
History
Interview
within a
sample
of
chronically suicidal
women meeting
criteria for borderline
personality disorder
(N
:
75).
Overall, reasons
given for suicide attempts
differed
from reasons for
nonsuicidal self-injury.
Nonsuicidal acts
were more often
reported as intended
to express
anger, punish
oneself,
generate normal
feelings,
and
distract
oneself,
whereas suicide attempts
were nrore often
reporled
as intended
to
make others better off.
Almost
all
participants repofied that both
types of
parasuicide were
intended
to relieve negative emotions.
It is likely that suicidal
and
nonsuicidal
parasuicide have multiple
intents
and
functions.
198
cide
within
the
past 8 weeks
alrd
at least one
additional
act
in
the
past
5
years:
(ci)
age between
18 and
45
years;
and
(e)
absence of
psychotic
disorders
(except
psychotic
depression,
brief
psychotic disorder, or
substance-induced
psychotic disorder),
bipolar disorder,
or mental
retardation.
Mean age
was 30.0
years
('tD
=
7.3).
A majority
were Caucasian
(847o),
had a
high schooi
education
(907c),
and earned
less than
$10,000
per year
(72olo;
rnostly
frorn disability
or
welfare
paynrents). Eighty-two
percent
met
criteria
for cuffent
major
depressive
disorder or
d.vsthymia, 76Vo
met
criteria
for at least
one cuffent
anxiety
disorder' and
279a
met
criteria fbr
a cuffent
substance
use
disorder.
As se ssment
I nstruments
All
assessments
were
given by
trained assessors
before
assignnlent to
treatment
condition.
BPD diagnosis
was
nade with the
Personality Disor-
ders
Examination
(PDE;
Loranger,
1995) and
cont]rmed on
the
Structured
Clinical
Interview
for DSM-N
(SCID-II;
First, Spitzer,
Gibbon, &
Wil-
liams, 1997).
The SCID
was used
to assess
Axis
I dia-snoses
(SCID;
First'
Spitzer, Gibbon,
& Williams,
1995). Reliability
in
our
research
clinic is
checked
by having
a second
independent
rater
view 10Va of
the videotapes
of completed
interviews.
The raters
agreed
pelfectly on
the
presence
of
BPD diagnosis
using
the
PDE
and the SCID-II
Interater reliability was
acceptable
for
Axis I disorders
(xs
:
.79 to .97).
Parasuicide
was also
assessed
at
pretreatn.)ent using
the Pa'asuicide
History
Interview
(PHI;
Linehan,
Heard,
Brown, &
Wagner' 2001), a
comprehensive
47-item semistructured
interview
measuring
the topogra-
phy, intent,
medical severity,
social
context,
precipitating
and concunent
events,
and outcomes
for single
parasuicide episodes.
The
PHI was
com-
pleted for the
index
(i.e.,
most
recent)
episode
and for every
episode in the
past
year.
On the
basis of
all
information
obtained,
the interviewer
classi-
fied the
behavior
into one
of
three
categories:
(a)
unarnbiguous suicide
attempt,
(b)
ambivalent
suicide
attempt, or
(c)
nonsuicidal
parasuicide.
A
suicide
attempt,
whether
classified
as unambiguous
or
ambivalent, was
deflnecl
as intentional
behavior
with intent
to die or expectation
of death
(certain
or
ambivalent).
Nonsuicidal
self-injury
was defined
as intentional
self-injury
with no
(or
very minimal)
suicide
intent or expectation of
death.
We examined
interrater
agreemeni
by
having a second
independent rater
code
207a
of
the
PHIs
from
videotape. The
raters agreed
on the classifi-
cation of
suicide
attempts
versus nonsuicidal
palasuicide fbr
all but one
episode
(x
:
.85).
Thc reasons
for
parasuicide are
also assessed
during
the PHI.
Specifi-
cally.
participants are asked
to
review a
29-itent list of
potential
reasons
and
to indicate
irll that
were
reasons
for their
parasuicide. The
reason
list
was
generated ftom
unstructured
interviews
with a separate
sample of 51
psychiatric
inpatients
adnritted
for
parasuicide.
Patients
were asked to
describe.
in an
open-ended
fashion,
all
the reasons
for their
parasuicide.
These
interviews
were repeated
until
no new
reasons
were
given.
On the
basis
of their
content,
responses
were collapsed
into 29 distinct
reasons, 22
of
which
were further
clustered
by expert
consensus
(between
Milton Z.
Brown
and Marsha
M. Linehan;
to fbrm
four rationally
clerived scales:
Emotion
Relief
(6
reasons),
Interpersonal
Influence
(8
reasons). Avoid-
ance/Escape
(5
reasons),
and
Feeling
Generation
(3
reasons;
see
Appen-
dix).
The
remaining 7
reasons
were each considered
unique
and thus were
not clustered.
To assess
the
reliability of our
classification of
the 29
reasons. two
independent
expert
raters classified
the
29 items into
one
of
the
fbur scales.
The two
raters
agreed
with our
consensus classification on
lo0o/o
of the
Emotion
Rclief
items, 8070
of the
Interpcrsonal Influence
items,
89olr, of
the Avoidance/Escape
items,
and
667o
of
the Feeling
Generation
items.
The alpha
coefficient
was .65 for Enrtition
Relief, 77 for
Interpersonal
Influence,
.36
for
Avoidance/Escape.
and
.70 for
Feelin-e
Generation.
Because
of
the lorv
alpha, the
Avoidance/Escape
itelns were
analyzed
individually.
Two types
of scale
scores
were used
in these analyses.
Proportion scale
scores
wele computed
as the
proportions of
reasons
endorsed per
scale.
199
Binary
scale scores
indicated whether
at least one
reason
was
endorsed
in
each scale.
Results
The
median number of
parasuicide
episodes
in the
past
year
was 6
(interquartile
range
IIQRI
=
3-1 1). The
nedian time since
the
index
(i.e.,
most
recent)
parasuicide
was
24
days
(IQR
=
14-45).
Forty-six
(6I7c)
of
the index episodes
were nonsuicidal.
Of
the
29
suicide
attempts,
most
(667o)
were classitied as nonam-
biguous
suicide attenpts.
Thirty-nine
participants
(527o)
engaged
in both
suicide attempts
and nonsuicidal
acts in
the
past year,
whereas 32Vo engaged
in only
nonsuicidal acts
and 16Vo
only
attempted suicide.
More
suicide
attenpters
(index
episode) met
criteria
for a current
anxiety disorder
(91Vo)
than did
those with
nonsuicidal
self-injury
(67Ea),
fQ,
N
:
75)
=
4."11,
p
:
.03.
However, the
presence
of a
current depressive
disorder or sub-
stance
abuse-dependence
disorder
did not significantly
diff'er be-
tween
individuals with suicidal
versus nonsuicidal
index episodes.
The
suicidal
methods
were
drug overdose
('l9Vo),
ctttting
(7Vo),
hanging
(37c),
asphyxiation
(3Va),
and other
(7Vc)."Ihe
nonsuicidal
rnethods
were cutting
(7lVo'),
burning
(4%),
stabbing
(4Vo),
drtg
overdose
(47a),
head banging
(4Va),
and other
(137c).
As expected,
medical
risk of the
nonsuicidal
^cts
(M
=
5.30, SD
=
3.21)
was
lower
than for the suicide
attempts
(M
:
11.76, SD
:
5.03),
t(73):6.80,P<.001.
The
major analysis of
the study compared
reasons for suicide
attempts
versus nonsuicidal
parasuicide
on the
index episode for
all
participants. For all analyses,
results are
reported for two-tailed
tests
using an alpha
level of .05.
The index episode
was
analyzed
in the
overall analysis to
minimize
problems remembering one's
parasuicide. There was
no significant difference
between suicidal
and
nonsuicidal index episodes
on number
of reasons endorsed
(Mdns:8.0
and
10.0, respectively).
Three individual
reasons
(not
in scales)
were
endorsed
by fewer than
70Va of
participants
and
thus
were
omitted
from further analyses.
The
item
"to
die" was
omitted
because
it was redundant with
the suicide
attempt versus
nonsuicidal
grouping variable.
Logistic
regression
was conducted on
the three binary scale
scores
and
the
eight individual
items
(see
Table
1). An omnibus
test
indicated an overall difl'erence
in the
reasons
given
for suicide
attempts
versus nonsuicidal self-injury,
,t'(t
t, N
=
75)
=
40.90,
p
<
.001. Classification
as suicidal
or nollsuicidal
was colrect in
'797c
of
the cases. A series of
individual chi-square
tests showed
that
five of the
predictors
significantly
differed
between suicidal
and
nonsuicidal episodes.
Feeling
generation,
ftt,
W
:
75)
:
3.jt,
p
=
.004:
anger expression,
x211.
N: 75)
:
10.79,
p
=
.001; 5glf'-punishmenr,
f(1,
N: 7-5)
:
4.51,p
:.03;
and
clistraction,
f(1,
ll
:'75)
:
5.62,
p
=
.02,
were
more often
endorsed
for nonsuicidal
episodes.
Index
suicide
attempts were
rnore
often intendecl
"to make others better
off,"
t'(l,
N:
75)
--
7.95,
p
=
.005. Comparison
oi'the
three
proportion
scale
scores
indicated that feeling
generation
dift'ered
between nonsui-
cidal
(M
:
.42, SD
:
.43) and suicidal
episodes
(M
:
.14,
.SD
:
.30), t(73;
:
3.12,
p
:
.003,
but that nonsuicidal and
suicidal
episodes did
not significantly
differ on
emotion relief
(Ms
=
.57 and .53, SDs
=
.29 and
.31, respectively) or
interper-
sonal
influence
reasons
(Ms
=
.23 and
.18, SDs
=
.26
and
.26,
respectively).
SHORT
REPOI{TS
SHORT
REPORTS
200
Table
I
Percen.toge
oJ Participants
Endorsing
Rettsons
for
Stricide
Attempts
Versus
Nonsu
ic itlal
P arasuicide
Method
of
analYsis
Index
episodes
between-
persons
though
within-person
tests
increase
statistical
power.
Fortunately,
the
elapsecl
time since
parasuicide
did not
significantly
differ
for
suicidal
and nonsuicidal
episodes.
Discussion
Reasons
for
suicide
attempts
versus
those
for
intentional
but
nonsuicidal
self-injury
appear
to be different
in
important ways
and
quite
similar
in other
ways among
individuals
with BPD'
Suicide
attempts
were more
often
attributed
to
an effort
to make
others
better off.
In
contrast,
nonsuicidal
parasuicide
was more
often
intended
to express
anger,
punish oneself,
regain
normal
feelings,
and distract
oneself.
The
overall
pattern of
reasons cor-
rectly
classified
almost
807a
of
the cases,
a
finding
which' if
replicated,
has
important
implications
for treating
parasuicidal
individuals,
as are
discussed
below.
These
findings
confirm
and
extend
those
of
previous studies.
Our
data,
however,
address
an
additional
question:
Do the
ditfer-
ences
in reasons
retlect
differences
in
suicidal
and
nonsuicidal
episodes
per
se
(regardless
of
who
is engaging
in the
behavior), or
do
they
rnore
reflect
differences
in suicidal
and
nonsuicidal
people
(regardless
of
whether
the
specific
parasuicide episode
is suicid-
al)?
Reasons
lbr
suicidal
and
nonsuicidal
parasuicide
were com-
pared
in a within-person
analysis
to
help interpret
the
between-
persons
difl'erences.
The
differences
in reasons
for
anger
expression,
t'eeling
generation,
and
distraction
were
again
found,
suggesting
that nonsuicidal
self-injurious
acts
are
intended
(more
than
suicide
attempts)
to
express
anger'
regain
nonlral
feelings'
and
distract.
Suicide
attempts
were intended
to
make
others
better
off
in
both analyses,
suggesting
that
the
perceived
tunction of
suicidal
acts is to
decrease
the burden
one
creates
for others.
Our
fin<ling
that the self-punishment
reason
significantly
difl'ered be-
tween
suicicle
attempters
and
nonsuicidal
selfinjurers
in the
between-persons
comparison
but
not in the
within-person
colnpar-
ison suggests
that
people
who engage
in
nonsuicidal
acts
intend to
self-punish
with both
suicidal
and
nonsuicidal
parasuicide.
If self-
punishment
were more
the
function
ofnonsuicidal
acts
per
se, then
sglt'-punishment
would
be a
less common
reason
for
suicide at-
tempts
among
people
who have done
both'
This
within-person
result
does
not appear
to
be due
to
problems
remembering
distant
parasuicide
acts.2
Reasons
measured
in this
study
suggest
that
palasuicidal indi-
viduals
attribute
both
suicidal
and
nonsuicidal
self-injury
to ex-
cessive
negative
emotions
(ct'.
Linehan,
1993)'
Almost
all 75
participants
reported
an
inlention
to reduce
or
express
aversive
intemal
states,
and the
mean
number
of
emotion
relief
reasons
reported
rvas 3.3
(i.e.,557o
of
the 6
reasons).
In
contrast.
the mean
number
of
interpersonal
influence
reasons
was I
'6
(207o
of the 8
reasons),
and
the
tnean
nunlber
of
feeling
generation
reasons
was 0.6
(317o
ol
the
2 reasons).
Because
reasolls
given for
para-
suicide
(its
perceived function)
could
reflect
its actual
function,
2
To check
if
problems remembering
distant
parasuicide
episodes may
account
for
the results
of
the
within-person
analysis,
a second
between-
persons
analysis
was conducted,
analyzing
only
the
index
(nrost
recent)
parasuicide
for the .39
participants
who engaged
in
both
suicidal and
nonsuicidal
palasuicide
in the
past
year
(17
suicide
attempts.
22 nonsui-
cidal
episodes).
The sanre
difl'erences
between
suicidal
and
nonsuicidal
episodcs
ernerged
in this between-persons
analysis.
Within-persons
Reason
SA
NS
SA
NS
At
least
one
reirson
from'
Emotion
Relief
Interpersonal
lnfl uence
Feeling
Generation
Single
reason
Self-punishntent
Anger
exPression
Self-validation
To
make
others
better
off
To
get
awaY
or
escape
To
get
a
vacation
Distraction
To
prevent being
hurt
worse
96
bt
54
tlJ
bJ
20
0'7
52
17
35
33
86
45
21**
38*
10
31**
59
17
l0*
21
r;.
51
28*
*
33
**+
og*-
_59
59
54
05
I
Note.
NS
:
nonsuiciclal
(n
:
46): SA
:
suicide
attempt
(n
:
29);
Within-persons
:
within-persons
analysis
in
which
participants
(n
:
39)
did
both
suiciclal
anrl
nonsuicidal
parasuicide
in the
past
year- Within-
person statistics
were
computed
only
for
reasons
showing
significant
iiff"r"n"",
between
suicidal
and
nonsuicidal
pzLrasuicide
on
the between-
persons statistic
(dashes
:
not
conrputed).
*p
<
.05.
*+p
<
.01.
***
p
<
.001.
'iior
the three
ieason
scales,
the
reported
values
are
the
percentage of
palticipants
endorsing
at
least
one
reason
fron
each
scale'
These
results.
however,
raise
an adclitional
question: Do diff'er-
ences
found
reflect
differences
in suicidal
and
nonsuicida'l
acts
per
se
(e.g.,
regardless
of
who
engages
in
the behavior)'
or do
tlrey
more
reflect
differences
in
suicidal
and
nonsuicidal
people
(e'g''
regardless
if specific
acts
are
intended
to
kill oneself)?
For exam-
ple, certain
personality
or
biological
factors
more
common
in those
*hn.ngug.
in
nonsuiciclal
parasuicide
could
conceivably
explain
why
such
people
parasuicide
to
express
anger
or sglf'-punish,
and
the
same
individuals
could
have similar
reasons
for
attenlpting
suicide.
To
rule
out
these
possible
confounds,
scale
scores
and
individual
reasons
that
significantly
differed
in
the
between-
persons
analysis
were
next
compared
within
individuals
with both
suicidal
and
nonsuicidal
episodes.
lf
differences
in
reasons
were
truly
due
to differences
in
the
function
of suicide
attempts
and
nonsuicidal
parasuicicle,
then
the
reasons
would
also
differ
within
a
single
individual.
In
contrast'
if differences
in
reasons
are due
primarily
to characteristics
of
the
parasuicidal
person,
then we
would
expect
similar
reasons
for the
two
types
of
behavior in
within-pcrson
comParisotls.
Thus,
the
most
lecent
suicide
attempt
was compared
with the
most
recent
nonsuiciclal
parasuicide
lbr
the
39
participants with
both
suicidal
and
nonsuicidal
parasuicide
in the
past
year
(one
of
each
pair was
an
index
episode).
McNemar
tests
replicated
the
differences
in
feeling
generation.
anger
expression,
distraction,
and
"to make
others
better
off'found
in
the betu'een-persons
analyses
Endorsement
of
the
self-purlishment
reason,
horvever,
did
not
cliffer
between
the
two
types
of
parasuicide
in
this
analysis even
SHORT
REPORTS
201
emotion
relief may
be
an
important
function
of
parasuicide. This
study
also
suggests
lhat
motives
lbr
parasuicide
are
complex, thus
contraclicting
conventional
clinical
wisdom
that
parasuicidal
indi-
viduals
are either
trying
to
die
(or
relieve
emotional
pain.)
or
manipulate
others,
but
not
both. Suicide
atlempts
and nonsuicidal
self-injury
apparently
involve
similar
and
multiple
motives'
The
mechanistns
of
emotion
relief
and
expression'
feeling
gen-
eration,
and self-punishment
need
to be better
understood
if they
are
to be
heated
more
effectively.
Because
nonsuicidal
acts are
attributed
to self-punishrnent
and
anger
expression'
nonsuicidal
parasuicide may be
prompted
by
anger
at oneself.
Half of the
participants in two other
studies
cited
anger
at self
as a
prilnary
reason
for
their self-mutilation,
citing
anger
at others much
less
often
(Bennum
&
Phil,
i983;
Roy,
1978).
This
account of self-
punishment
fits
with
Linehan's
(1993)
theory that
parasuicidal
individuals
learn
from
their
environments
to
punish, disregard' or
otherwise
invalidate
themselves
in extreme
ways.
This account
also
fits
with
psychodynamic
fon.trulations
of
parasuicide as anger
turned
inward
(for
a
review'
see Guralnik
& Simeon'
2001).
These
findings
suggest
several
treatment
approaches
for chronic
parasuicicle. Becattse
negative
emotions,
interpersonal
influence,
and
"to
get
away or
escape"
were
common
reasons
for
parasuicide
regardless
of suicide
intent,
clinicians
should
ask
about these
reasons
as
a way
to determine
precise treatment
targets.
These data
also suggest
that it
may
often
be a
mistake
to assume
that
the first
reason
reported
is the
only
reason because
it appears
that
parasui-
cidal
patients
have multiple
reasons
for
their actions.
Thus,
clini-
cians should
inquire
about
multiple
reasons
for
parasuicide.
This
stutly
also
highlights
the
importance
of
distinguishing
between
suicidal
and
nonsuicidal
parasuicide.
Because some rea-
sons depend
on
suicide
intent,
clinicians
should
ask
patients
about
their
intention
and
expeclation
of
death.
Clinicians
working
on
nonsuiciclal
self:injury
may
hypothesize
that anger
expression,
self-punishment,
feeling
generation,
and
distraction
are
key
pro-
cesses
that explain
the
behavior'
These
patients can
be
taught
alternative
ways to
regulate
or tolerate
anger or
the experiences
associated
*1,1t 5slf--punishment
(e-g.,
sell'-invalidation,
self-
hatred,
and
shame).
Patients
rvho
parasuicide to
feel nonnal f'eel-
ings
may benetit
from
reducing
numbing
or dissociation,
perhaps
by
treating
posttraumatic
stress
disortler.
Patients
who
parasuicide
to
tlistract themselves
can
be
taught
altemative
ways to cope
with
problems causing
them
distress.
Because
suicide
attempts
involve
the
intent
to make
others
better
off' suicidal
patients may need to
moclify erroneous
beliefs
that
they burden
others'
or tbey may need
help
to see that
suicide
could
have even
more
adverse
efl'ects on
significant
others.
On
the
other
hand, such
patients rray
need
to
moclify
their belief
that
viewing
oneself
as a burden
requires
suicide
as
thg onl)
solution
Suicidal
patienls
may
need
help
to
develop
relationships
that
are
more
effective
and
less burdensome
to others.
Unfortunately,
this
study
is limited by
problenis inherent
with
self-reports
of intent.
People
may
not know
or
remember their
intents,
or
their
intentions
may
not
always
correspond
to the actual
variables
contr-olling
their
behavior'
Although
concurrent sub-
stance
use could
rnake
retrospective
reporting
invalid,
it
does
not
appear
to
account
for the
results.s The
results
of
this study
may not
apply
to
parasuicide among
individuals
without
BPD
or to men.
However,
this study
represents
a useful exploration
of the
lunction
of
suicidal
and nonsuicidal
parasuicide
in
a population in
which it
is
very common.
Given
the limited sample size,
it will be
useful to
rep'licate
these
results.
3
Substance
use
was reported
for 25Vo of
parasuioide episodes. Neither
the three
binary scale scores
nor
the eight individual items
differed between
those
episodes
with and
without substance
use, and statistically controlling
for substance
use
(any
vs. none) did
not
change
the results.
References
Bancro{t,
J., Skrimshire,
A., & Simkin,
S.
(1976).
The reasons
people
give
for taking overdoses.
British
Joumal of
Ps.tchiany, 128,538-548.
Bennum,
I.,
&
Phil, M.
(1983).
Depression and
hostility in self-mutilation.
Suicide
and
Life Threatening
Behavior, 13(2),'71-84.
Boergers,
J., Spirito,
A., &
Donaldson, D.
(1998).
Reasons for adolescent
suicide
attempts: Associations
with
psychological
functioning. .IoLrnal
oJ'the
American Academy
of Child
and Adolescent Psychiatry,
i7,
1287
-1293.
First,
M. B.,
Spitzer, R. L.,
Gibbon, M., &
Williams, J. B.
W.
(1995).
Stntctured
Clinical
Inteniew
for
DSM-IV Axis
I
Disorders:
Patient
edition
(SCID-l/P).
Nerv York:
Neiv York State Psychiatric
Institute,
Biometrics
Research Departmellt.
First,
M. B., Spitzer,
R. L., Gibbon,
M., &
Williams,
J.
B. W.
(1997).
Structured
Clinical Interview
for
DSM-IV
Personality
Disorders
(SCID-II).
Washington, DC: American
Psychiatric
Press.
Gunnell,
D., &
Frankel, S.
(1994).
Prevention of suicide:
Aspirations
and
evidence.
B ri ti s
h M e dical J ournal,
3 0 8. 1227
-
1233.
Guralnik,
O.,
& Simeon,
D.
(2001).
Psychodynamic theory and treatment
of
impulsive self-injurious
behaviors.
In D.
Sinreon
&
E. Hollander
(Eds.),
Self-injurious
behaviors:
Assessment and
treatment
(pp.
175-
197).
Washington, DC: Americatr
Ps.vchiatric Press.
Holden,
R. R., Ken, P. S.,
Mendonca, J. D.,
& Velamoor,
V.
R.
(1998).
Are
some
rnotives rnore
linked to suicide
proneness
than others? Journal
oJ'
Clitical
Psychologr,
54, 569
-51
6.
Jones,
I.. Congiu,
L.. Stevenson, J..
Strauss, N., &
Frei, D.Z.
(1979).
A
biological
approach to two
tbrms of
human
self-injury.
Journal
of
Nen'otts
and Mental
Disease, 167\2),74-78.
Linehan,
M.
(1986).
Su:icidal
people:
Orre
population
or
two? In J. J.
Mann
&
M. Stanley
(Eds.),
Annnls
o-f thc Netv York
Academy of Scicnce s:
VttL'
487.
The
psychobiologl, of suicide
(pp.
l6-33). New York: Nerv
York
Academy
of Sciences.
Linehan,
N{.
(1993).
Cognitive-behavioral
treantent
for
borderline
per'
sonaliry
disorder.
New York: Guilford
Press.
l,inehan,
M., Heard, H..
Brown, ir4., &
Wagner, A.
(2001).
The Parasui'
cide
History Intervietv.
ir'lanuscript
in
preparation.
Loranger,
A. W.
(
1995). Personality
Disorder Exatnination
(PDE)
manual.
White
Plains, NY: Cornell
Medical
Center.
Parker,
A.
{1981).
The meaning
of attempted suicide
to
young parasui-
cides:
A repertory
grid
stLrdy.
British Jountal o.f
Ps.r'chiatry, 139,306-
312.
Roy,
A.
(1978).
Self-mutilation.
Brirtsh .lr.runnl of
Medical Psychoktgt',
s t.201-203.
Varadaraj,
R.,
Mendonca. J.
D., & Rauchenberg,
P. M.
(l986).
Motives and
intent:
A conrparison of
views
of overdose
patients
and
their ke.v
lelatives/friends.
Canadian
J ou'
nal ol
Psyc
hiatr-t',
-l
l, 621- 624.
(Appendtx
follotYs)
202
Emotion
Relief
To
stop
bad
feelings
To stop
feeling
angry
or
frustrated
or
enraged
To relieve
anxiety
or
terror
To
relieve
t'eelings
of
aloneness,
emptiness
or
isolation
To
stop
feeling
self'-hatred,
shame
To obtain
relief
from
a terrible
state
of mind
Inte
rp e
r sonal
I nJluenc
e
To communicate
to or
let
others
know
how
desperate
you were
To
get helP
To
gain admission
into
a
hospital
or treatment
program
To shock
or impress
others
To
get
other
people to
act differently
or
change
To
get
back
at
or hurt
someone
To
demonstrate
to
others
how
u'rong they
are/were
To
make
others
unde$tand
how desperate
you
are
Feeling
Generalion
To
feel something,
even
if
il was
pain
To
stop
feeling
numb
or
dead
To
l'eel
sexually
arousedAr
Avoidttnce/Escape
To
get
awaY
or
escaPe
To
get
a
vacation from
having
to try so
hard
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SHORT
RI]PORTS
Appendix
List
ol
Reasons
for
Par-asuicide
on the
Parasuicide
History
Interview
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To
get
out
of doing something^2
To distract
yourself from other
problems
To
prevent
being hurt
in a worse
waY
lndividual
Reasons
To
punish
yourself
To
prove
to
yourself
that
things
really
were
bad
and it
was okay to 1'eel as bad
as
you
did
(self-validation)
To make
others bet(er
off
To express
anger or
lrustration
To
give
you
something,
anything
to doA2
To be
with
people
you
loveA2
To dieA3
-liii]J,".
was
not endorsed
by
any
participant.
ntThese
items
were endorsed
by
fewer than
l07c ofparticipants
and thus
u,ere omitted
from analyses.
o3
This
item was omitted
from
analyses because
it
was highly redundant
with
the
parasuicide
grouping variable
(suicide
attemPt
vs. nonsuicidal)'
Received
March 20,
2000
Revision received
August
21, 2001
Accepted
August
21,2001
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    • "Adults diagnosed with BPD report high levels of negative emotion, increased sensitivity to emotional stimuli [72], decreased emotional awareness [51], more disproportionate use of emotion suppression [8], and difficulty not engaging in impulsive action when emotionally aroused [45] relative to healthy controls. Use of maladaptive behaviors commonly seen in those diagnosed with BPD, including suicide attempts, suicide threats, self-inflicted injuries, impulsive behaviors, dissociation , are shown to serve an emotion regulation function [11]. Therefore, emotion dysregulation is a core component of BPD. "
    [Show abstract] [Hide abstract] ABSTRACT: Background Emotion dysregulation is a critical transdiagnostic mental health problem that needs to be further examined in personality disorders (PDs). The current study examined dialectical behavior therapy (DBT) skills use, emotion dysregulation, and dysfunctional coping among adults who endorsed symptoms of cluster B PDs and psychopathy. We hypothesized that skills taught in DBT and emotion dysregulation are useful for adults with PDs other than borderline personality disorder (BPD). Methods Using a self-report questionnaire, we examined these constructs in three groups of community adults: those who reported symptoms consistent with borderline personality disorder (BPD; N = 29), those who reported symptoms consistent with any other cluster B PD (N = 22), and those with no reported cluster B PD symptoms (N = 77) as measured by the Personality Diagnostic Questionnaire-4 + . Results Both PD groups reported higher emotion dysregulation and dysfunctional coping when compared to the no PD group. Only the BPD group had significantly lower DBT skills use. DBT skills use was found to be a significant predictor of cluster B psychopathology but only before accounting for emotion dysregulation. When added to the regression model, emotion dysregulation was found to be a significant predictor of cluster B psychopathology but DBT skills use no longer had a significant effect. Across all groups, DBT skills use deficits and maladaptive coping, but not emotion dysregulation, predicted different facets of psychopathy. Conclusion Emotion dysregulation and use of maladaptive coping are problems in cluster B PDs, outside of BPD, but not in psychopathy. Inability to use DBT skills may be unique to BPD. Because this study relied exclusively on self-report, this data is preliminary and warrants further investigation.
    Full-text · Article · Dec 2016
    • "For example, although the IPTS suggests that NSSI may increase the risk for suicide by increasing the acquired capability for suicide, there may be other reasons why NSSI is associated with suicide risk and=or attempts. NSSI is associated with elevated levels of shame, self-criticism, and feelings of inferiority (Gilbert et al., 2010), and past research indicates that shame and self-punishment motives are a major contributing factor in an individual's decision to attempt suicide (Brown, Comtois, & Linehan, 2002; Hastings, Northman, & Tangney, 2002; Lester, 1998). Alternatively, the experience of loss of control that accompanies chronic and escalating NSSI may contribute directly to suicide risk, as the individual feels helpless to control the behavior (Buser & Buser, 2013; Groschwitz & Plener, 2012). "
    [Show abstract] [Hide abstract] ABSTRACT: Objectives: This study examined the main and interactive effects of MDD and lifetime nonsuicidal self-injury (NSSI) on current suicide risk and past suicide attempts. We predicted that individuals with a history of NSSI and current MDD would be at greater suicide risk than those with either risk factor alone. An interaction between lifetime MDD and NSSI was hypothesized for past suicide attempts. Methods: 204 substance dependent inpatients completed self-report measures and a diagnostic interview. Results: Patients with both a history of NSSI and current MDD, relative to all other groups, had the greatest suicide risk. No support was found for the lifetime MDD by NSSI interaction. Conclusion: Findings suggest the relevance of both NSSI and MDD in suicide risk.
    Full-text · Article · Mar 2016
    • "We allocated these reasons here rather than to affect regulation because they entailed an active pursuit of numbness rather than a containment of other unpleasant emotions. In this theme we also included acts aimed at terminating a dissociative state in statements such as 'termination of depersonalisation' (Herpertz, 1995) and 'feeling generation' (Brown et al., 2002). Similarly qualitative studies (15/39, 38%) described inducing a dissociative state, for example 'physically lowers my heartbeat, it puts me into a bit of a dissociated state … (Himber, 1994), 'you feel a lot but then you don't feel anything' (Rosenthal et al., 1972). "
    [Show abstract] [Hide abstract] ABSTRACT: Background: Self-harm is a major public health problem yet current healthcare provision is widely regarded as inadequate. One of the barriers to effective healthcare is the lack of a clear understanding of the functions self-harm may serve for the individual. The aim of this review is to identify first-hand accounts of the reasons for self-harm from the individual's perspective. Method: A systematic review of the literature reporting first-hand accounts of the reasons for self-harm other than intent to die. A thematic analysis and 'best fit' framework synthesis was undertaken to classify the responses. Results: The most widely researched non-suicidal reasons for self-harm were dealing with distress and exerting interpersonal influence. However, many first-hand accounts included reasons such as self-validation, and self-harm to achieve a personal sense of mastery, which suggests individuals thought there were positive or adaptive functions of the act not based only on its social effects. Limitations: Associations with different sub-population characteristics or with the method of harm were not available from most studies included in the analysis. Conclusions: Our review identified a number of themes that are relatively neglected in discussions about self-harm, which we summarised as self-harm as a positiveexperience and defining the self. These self-reported "positive" reasons may be important in understanding and responding especially to repeated acts of self-harm.
    Full-text · Article · Nov 2015
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