Self-mutilation and Suicidality

Self-Mutilators With Personality Disorders at Increased Risk of Suicide

WESTPORT, CT (Reuters Health) Mar 20 - Individuals with personality disorders who purposely injure themselves differ clinically from other psychiatric patients in ways that increase their risk of suicide, New York City investigators report in the March issue of the American Journal of Psychiatry. For this reason, the investigators add, suicide attempts of these individuals should not be dismissed.

Dr. Barbara Stanley of the New York State Psychiatric Institute and colleagues evaluated 53 suicide attempters with cluster B personality disorders, which included borderline, antisocial, narcissistic or histrionic personalities, 30 of whom had a history of self-mutilation.

Both the self-mutilators and non-mutilators had an average of three previous suicide attempts and had similar rates of current major depression. Approximately 75% of suicide attempts in both groups involved pill overdose, with lethality of attempts judged as relatively serious.

However, the self-mutilators scored significantly higher than the non-mutilators on the Hamilton depression scale, mean of 24.4 versus 19.1, and on the Beck Hopelessness Scale, 12.0 versus 9.0. The frequency and duration of suicidal ideation was greater in those who self-injured. They also scored higher on an aggression scale and demonstrated more severe borderline pathology.

Not all self-mutilators have personality disorders, Dr. Stanley told Reuters Health, adding that it also occurs in the context of depression. "When the depression resolves, the self-injury goes away," she said.

A problem often faced by patients who self-injure is rejection by healthcare providers, according to Dr. Stanley. "These people meet with a lot of condemnation by emergency room doctors," she said. "Physicians should understand that [self-injurious behavior] is what patients [do] to relieve what feels like an intolerable sense of anxiety, sense of tension, sense of badness - and that this is the best they can do."

Dr. Stanley believes that such behavior is still "in the closet," as eating disorders were in the past. The condition "should be addressed directly with the patient," she recommends. These patients "should be referred for help and reassured that this is not a hopeless problem. Dialectical behavior therapy can often help them develop other means of coping than self-injury."

Am J Psychiatry 2001;158:427-432.

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