Introduction: Borderline personality disorder (BPD) is a serious public health problem. It is associated with high levels of mental health service utilization, an important degree of psychosocial impairment and a high rate of suicide (10%). BPD is a common psychiatric disorder and the most frequent personality disorders. Approximately, 15 to 50% of psychiatric inpatients and 11% of psychiatric outpatients meet current criteria for BPD. Recurrent suicidal threats, gestures or behaviour or self-mutilation are common in patients suffering from borderline personality disorder. However, despite their similarities, self-mutilation behaviour differs from suicide attempts by the lack of systematic suicidal intentions. The purpose of our study is to examine the relationships between self-mutilations, suicide and related therapeutic approach.
Methods: We have reviewed the literature published from January 1980 to October 2006, using the following keywords: self-mutilation, suicide, borderline personality (44 articles) with five other additional articles.
Results: Self-mutilation refers to the deliberate, direct destruction or alteration of one's body tissue without conscious suicidal intent. This pattern of behaviour is common in BPD (50 to 80% of cases) and is frequently repetitive (more than 41% of patients make more than 50 self-mutilations). The most common form of self-mutilation behaviour is cutting, but bruising, burning, head banging or biting are not unusual. The functions of self-mutilation are variable: it provides relief from negative mood states, reduces distress, obtains care from other people as well as therapists and expresses emotions in a symbolic fashion. The rate of suicide in clinical samples of BPD is of around 5 to 10%. This rate is about 400 times that of the general population. Authors estimated that 40 to 85% of borderline patients carry out suicide attempts that are usually multiple (average=3). The relationships between self-mutilation and suicide are paradoxical. Some authors identify self-mutilation as a protective factor against suicide. Self-mutilation behaviour can be defined as an attenuated form of suicide ("focal suicide"). In this way, self-mutilation plays the role of an anti-suicide act, allowing patients to emerge from their dissociation and to feel that they are living again. The risk of suicide will not increase so long as self-mutilation produces the expected relief. Nevertheless, most of the authors exhibit self-mutilation as a risk factor of completed suicide.
Discussion: Thus, borderline patients with history of self-mutilation behaviour have about twice the rate of suicide than those without. Repetitive self-mutilations may increase dysphoria, which will only be relieved by suicidal gestures. Self-mutilating suicide attempters may be at greater risk for suicide for several reasons: they experience more feeling of depression and hopelessness, they are more aggressive and display more affective instability, they underestimate the lethality of their suicidal behaviour and finally, they are troubled by suicidal thoughts for longer and more frequent periods of time. Treatment of these patients requires a multidisciplinary approach. Psychoanalytic/psychodynamic therapy and dialectal behaviour therapy (DBT) have been shown to lower rates of attempted suicide among BPD patients. Pharmacotherapy focuses on key symptoms: aggression, irritability and depressed mood (selective serotonin reuptake inhibitors), behavioural dyscontrol and affective dysregulation (mood stabilizers), anxiety, psychoticism and hostility (antipsychotics).
Conclusion: These findings highlight the possibility of self-mutilation as a risk factor of suicide in borderline personality disorder. Nevertheless, to reinforce this assertion, further studies on large sample of borderline patients, with or without self-mutilation, are needed. Moreover, prospective controlled studies on the various treatment models in suicidal BPD patients are necessary.