Self-Harm and Borderline

Personality Disorder
 Suicidal / Self-Harm Attempt
Checklist

 Rapport

 Severity of attempt: planning, note, methods to prevent being found

 Circumstances of overdose: intoxication, impulsivity

 Action after the overdose

 Assessing depression

 Past history of self harm

 Past psychiatric history

 Drug and alcohol history

 Social history
 DSM-5 Criteria for Borderline
Personality Disorder
 A pervasive pattern of instability of interpersonal relationships, self-image, and
affects, and marked impulsivity, beginning by early adulthood and present in a
variety of contexts as indicated by five (or more) of the following:
1. Frantic efforts to avoid real or imagined abandonment

2. A pattern of unstable and intense interpersonal relationships characterized by alternating

between extremes of idealization and devaluation

3. Identity disturbance

4. Impulsivity in at least two areas that are potentially self damaging (e.g. Spending, sex,
substance use, binge eating)

5. Recurrent suicidal behaviour, gestures, or threats, or self-mutilating behaviour

6. Affective instability due to marked reactivity of mood

7. Chronic feelings of emptiness

8. Inappropriate, intense anger or difficulty controlling anger

9. Transient stress related paranoid ideation or severe dissociative symptoms

 Checklist for Borderline Personality
Disorder
 Affective instability

 Self identity issues

 Chronic self harm ideation

 Pattern of unstable relationships

 Damaging Impulsivity (spending, sex, drugs etc.)

 Chronic feelings of emptiness

 Chronic fear of abandonment resulting in frantic efforts to avoid real or

imagined abandonment

 Difficulty controlling anger or inappropriate, intense anger

 Transient stress related psychotic / dissociative symptoms

 Suicidal Ideation

• Sometimes when people get depressed they may find life not worth
living? Have you felt like this ….?

• What thoughts have crossed your mind? (ideation)

• How long have you been thinking about this? (intent/ideation)

• What have you planned? (plans)

• Have you made arrangements for after your death e.g. made a will or
written a note? (intent)

• How close have you come to actually carrying out your plan? (take
patient through) (intent)

• What stopped you/stops you? (protective factors)

• Is there anything to live for at all? Mention friends, family (protective

factors)
 Suicidal Attempt

• Go through detail of attempt

• Alcohol

• Seriousness

• Impulsivity – How long had you been planning this?

• Did you make any arrangements for your death? (e.g. note, will,
finances)

• How do you feel now that you have survived?

• Do you really want to die / have you actually imagined yourself dead?

• Do you currently have any thoughts of suicide?

 Personality Assessment

• Very important aspect often overlooked

• Main one is borderline personality disorder
• Do you often have mood swings / do you find that your moods can shift
from being happy to being sad in a matter of minutes or hours? (mood
instability)
• Are you generally a confident person or do you have difficulty knowing
who… (use name) is? (self identity disturbance)
• Do you feel empty in yourself? (emptiness)
• How often do you think about suicide? Why do you self harm/ how does
it make you feel? (chronic self harm ideation)
• What sort of person are you in relationships? Are you particularly
sensitive to rejection? Are you often worried about being abandoned in
relationships? Does that make you clingy? (sensitive to rejection / fear
of abandonment)
 Personality Assessment

• Are you the sort of person that would let other people know that
he/she is angry or do you bottle it up. Do you have difficulty
controlling your anger? (impulse dyscontrol)
• Would you call yourself an impulsive person? ...a person who does
things on the spur of the moment without thinking of the
consequences? (impulsivity)
• Has that ever gotten you into trouble? Like drugs, sex, reckless
driving, spending and binge eating etc. (impulsivity displayed in at
least two areas that are potentially damaging )
• Transient stress related paranoid ideation and psychotic symptoms
may occur
• Relationship instability, job changes etc. give a clue to the construct
5 or more of the above are required
 Borderline Personality Disorder Principles
of Management

• Assess risk

• Consider in-patient admission if high suicidal or self-harm

risk

• Establish therapeutic alliance

• Management based on establishing professional

boundaries, tolerating transference issues, avoiding
splitting, promote reflection (mindfulness)

• Monitor one’s own counter transference feelings

 Psychological Treatments
(APA Guidelines)

• Psychodynamic Therapy: mindfulness (Tyrer 2004)

• Cognitive – Behavioural Therapy
• Dialectical Behavioural Therapy (Linehan)
• Therapeutic Community
• Cognitive Analytic Therapy
• Behaviour Therapy
• Nidotherapy (Tyrer 2002)
 Drug Treatment (Soloff, 1998)

Cognitive / Perceptual Symptoms: Antipsychotics

Suspiciousness, paranoid ideation, ideas of reference, stress induced
hallucinations, derealisation, depersonalisation

Affective Dysregulation: SSRI’s and MAOI’s

Lability of mood, rejection sensitivity, mood crashes, inappropriate
intense anger, chronic emptiness, dysphoria

Impulsive – Behavioural Dyscontrol: mood stabilisers, SSRI’s

Risky behaviour, low frustration tolerance, impulsive binges (drugs,
alcohol, food, sex, spending), recurrent suicidal threats