● Being malnourished and not thinking clearly. ● Battling with disordered thoughts. ● Feeling that their suffering is a burden to their friends and family. ● Feeling like there is no other way out, trapped by their thoughts and rigid or chaotic daily routines. (Berman & Ekern, 2015) Distorted self-image may cause those with eating disorders to strive for an unrealistic, unattainable level of perfection so they never feel they are good enough in their own eyes (Selby & Coniglio, in press). Their perceived failure to reach their unhealthy goals may lead them to feel hopeless and worthless and consider suicide for escape. People with eating disorders often also have co-occurring mental health disorders and are Borderline personality disorder Borderline personality disorder (BPD) is a personality disorder that is gaining increased recognition in medical and mental health settings but remains less well-known than other psychiatric disorders. This is particularly problematic as BPD is a disorder known to have a high degree of suicide risk, with approximately 6-10% of those with the diagnosis dying by suicide (Temes, Frankenburg, Fitzmaurice, & Zanarini, 2019). Personality disorders involve substantial problems with underlying behavioral, emotional, and belief patterns, fractured or problematic interpersonal relationships, antagonistic or overdependent behavior, and problematic views of individual identity and the behaviors and intentions of others (APA, 2013). Of all the personality disorders, BPD appears to have a uniquely strong association with suicidal behavior. Symptoms of BPD include a combinate of five of the following: ● Intense fear of abandonment that may involve going to extreme efforts to avoid either real or imagined separation or rejection. ● A pattern of unstable intense relationships that involve idealizing someone one moment and then feeling completely negative about the individual at another moment. Non-suicidal self-injury (NSSI) Related to BPD is non-suicidal self-injury (NSSI), which is often a symptom of BPD, but in recent years has been identified as commonly occurring in youth and young adults outside the context of BPD (Selby, Kranzler, Fehling, & Panza, 2015). As was noted in Table 1, NSSI is defined as “self- injury that is inflicted without suicidal intent” (Glenn et al., 2020). NSSI has often been a challenging behavior in the field of suicidology due to its frequent presence among suicidal individuals and its tendency to be mistaken for suicidal behavior among individuals who are not suicidal. Broadly, NSSI refers to behavioral methods that result in bodily injury, tissue damage, or pain, such as cutting, burning, stabbing, hitting oneself, wall punching, extreme pinching, or excessive scratching or rubbing. In moderate to extreme instances these behaviors can be mistaken for suicidal behavior, but individuals engaging in the behavior will often deny suicidal ideation. Of note, excessive hair pulling or picking/scratching compulsively at skin or scabs can be mistaken for NSSI, but in most cases these behaviors are better classified as either trichotillomania or excoriation, respectively. The “non-suicidal” prefix can mislead therapists into thinking that NSSI is not relevant to suicide, though it is in fact one of the strongest predictors of future suicidal behavior and the odds of a suicide attempt increase many-fold among those who actively self-injure (Kiekens et al., 2018). While not experiencing suicidal intent, over a third of individuals reported they had engaged in NSSI while actually experiencing suicidal thoughts (Cerutti, Zuffiano, & Spensieri, 2018). Research over the last two decades has revealed that NSSI is a particularly prevalent behavior, especially in adolescents and young adults, and although the behavior decreases in prevalence with age, a subset of young adults continues the behavior into
socially isolated in an attempt to hide their disorder from family and friends. They may have conflicts with loved ones because they refuse to eat and refuse to seek treatment. They often display a lack of fear of death and have committed self-injurious acts including previous suicide behavior (Selby & Coniglio, in press). Among those with eating disorders, the most at-risk of suicide are older, lowest in weight, those with a history of substance, physical, and sexual abuse, and a history of suicide attempts (Goldstein & Gvion, 2019). The clinicians must work with the patient and family to develop a plan to identify and monitor risk and health factors. The plan should include an emergency plan to intervene if warning signs of immediate danger are observed. ● Rapid changes in self-identity and self-image that include shifting goals and values, such as frequent changes in beliefs, religious orientations, identity, etc. ● Periods of stress-related paranoia or dissociation from reality that lasts for a few minutes to a few hours. ● Impulsive and risky behaviors, such as substance use, gambling, spending sprees, reckless driving, unsafe sex, binge eating, and other impulsive behaviors. ● Suicidal behavior, including threats and/or non-suicidal self- injury (NSSI). ● Mood lability characterized as wide swings in emotions that can last from a few hours to a few days. ● Chronic feelings of emptiness. ● Inappropriate, intense anger that is out of proportion to a real or perceived offense. Although BPD has typically been thought of as an adult disorder, growing evidence indicates that BPD can begin to emerge in adolescence (Lazarus et al., 2019), so clinicians should be aware of the symptoms of this disorder and its strong association to suicidal behavior. Finally, BPD is most often treated with Dialectical Behavior Therapy (DBT), which will be discussed in detail in the subsequent section treating suicidal behavior. adulthood (Wester, Trepal, & King, 2018). Fortunately, substantial research has also improved our understanding of the functions of NSSI behavior. Clinicians should be aware of the following associated features of NSSI: ● Methods used for NSSI can change over time, potentially becoming more severe. ● Method switching was particularly common in people who cut themselves; more than 60% changed methods over time, most frequently to overdose/self-poisoning. ● Longitudinal research has identified NSSI as one of the most important risk factors for suicide attempts. ● Self-cutting is the most common method of NSSI and a behavior that is often regarded as being of limited seriousness by clinical services. However, there is evidence that self-cutting that results in hospital treatment is actually associated with greater risk of eventual suicide than overdose in both adults and adolescents. ● Even episodes of self-harm with no reported suicidal intent are related to an elevated risk of repeat self-harm and suicide compared with the general population. ● A study of nearly 8,000 individuals presenting with overdose or self-injury to four emergency departments showed the subsequent suicide mortality was equally elevated regardless of whether individuals indicated that they did or did not wish to die at the time of injury. ● More than 80% reported almost daily urges to self-injure. ● More than 60% reported at least once-a-week acts of self- injury. ● 74% of self-injuring adolescents reported having attempted suicide at least once in the past six months; thus, one of the most problematic issues is the risk of missing associated suicidality when using the term “non-suicidal.”
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Book Code: PYCA1423
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