Psychological Interventions for Self-harm Behaviour and Suicide Attempts in Borderline Personality Disorder: A Systematic Review

Abstract

Self-harm behaviour and suicide attempts are considered maladaptive coping mechanisms by individuals with a diagnosis of borderline personality disorder (BPD). Numerous studies have demonstrated that individuals with BPD are at a heightened risk for self-harm behaviour and suicide. Therefore, there is a need for intervention efforts aimed at reducing self-harm and suicide attempts in this population by promoting more functional coping strategies. No systematic review has been conducted to explore the effectiveness of such interventions. A systematic review was performed to identify randomized controlled trials of interventions to reduce self-harm and suicide attempts among individuals with BPD, published between 2012 and 2022. PsycARTICLES, PubMed, Web of Science, Science Direct, and Taylor & Francis databases were examined in the review. A total of 6,760 studies were initially screened, only 13 were selected for review based on the inclusion and exclusion criteria. The results indicated that the standard dialectical behaviour therapy protocol, with the addition of psychological intervention components such as skills training, exposure and acceptance, statistically significantly increased recovery. Statistically significant results have been obtained from various psychotherapeutic intervention groups such as schema therapy, cognitive behavioural therapy and emotion regulation therapy However, it was noted that existing protocols might be inadequate in preventing relapse and addressing potential negative outcomes such as premature termination of therapy.

Keywords

• Borderline personality disorder
• self-harm
• suicide
• psychological intervention

Borderline Bireylerde Kendine Zarar Verme Davranışı ve İntihar Girişimine Yönelik Psikolojik Müdahaleler: Sistematik Derleme

Öz

Kendine zarar verme davranışı ve intihar girişimi, borderline kişilik bozukluğu tanılı bireylerin başvurduğu uyumsuz baş etme yöntemleri olarak kabul edilmektedir. Birçok araştırmada bu kişilerde kendine zarar verme davranışı ve intihar riskinin yüksek olduğu ortaya konmuştur. Dolayısıyla bu popülasyonda daha işlevsel baş etme yöntemlerinin kazandırılması, kendine zarar verme davranışının ve intihar girişiminin azaltılması yönünde müdahale çalışmalarına ihtiyaç duyulmaktadır. Bu müdahale çalışmalarının etkileri üzerine herhangi bir siste-matik derlemeye rastlanılmamıştır. Borderline kişilik bozukluğu tanılı bireylerde kendine zarar verme ve intihar girişimini azaltmaya yönelik yapılan 2012-2022 yılları arasında yayınlanmış randomize kontrollü çalışmaları belirlemek için sistematik bir derleme yapılmıştır. Derlemede PsycARTICLES, Pubmed, Web of Science, Science Direct ve Taylor & Francis veri tabanları taranmıştır. Dahil etme ve dışlama kriterlerine göre başlangıçta 6760 çalışma taranmış ve sadece 13 çalışma derleme için seçilmiştir. Derleme sonucunda, standart Diyalektik Davra-nışçı Terapi protokolüne maruz bırakma, beceri eğitimi, kabul gibi psikolojik müdahale bileşenlerinin eklenme-sinin iyileşmeyi istatistiksel olarak anlamlı derecede arttırdığı tespit edilmiştir. Şema Terapi, Bilişsel Davranışçı Terapi, Duygu Düzenleme Terapisi gibi çeşitli psikoterapotik müdahale gruplarından istatistiksel olarak anlamlı sonuçlarelde edildiği tespit edilmiştir. Ancak mevcut protokollerin, nüks önlemede ve terapiyi bırakma gibi olası olumsuz sonuçlarla başa çıkmada yetersiz kalabileceği belirtilmiştir.

Anahtar Kelimeler

• Borderline kişilik bozukluğu
• intihar
• kendine zarar verme davranışı
• psikolojik müdahale

References

1. Aksoy A, Ögel K (2003) Kendine zarar verme davranışı. Anadolu Psikiyatri Derg, 4:226-236.
2. APA (2013) The Diagnostic and Statistical Manual of Mental Disorders Fifth edition: DSM-5. Washington, DC, American Psychiatric Association.
3. APA (2021) The Diagnostic and Statistical Manual of Mental Disorders Fifth edition text revision DSM- 5 TR. Washington, DC, American Psychiatric Association.
4. Andreoli A, Burnand Y, Cochennec MF, Ohlendorf P, Frambati L, Gaudry-Maire D et al. (2015) Disappointed love and suicide: a randomized controlled trial of "Abandonment Psychotherapy" among borderline patients. J Pers Disord, 30:271-287.
5. Andrewes HE, Hulbert C, Cotton SM, Betts J, Chanen AM (2019) Relationships between the frequency and severity of non-suicidal self-injury and suicide attempts in youth with borderline personality disorder. Early Interv Psychiatry, 13:194–201.
6. Beck AT, Steer RA, Brown G (1996)Manual for the Beck Depression Inventory–II. San Antonio, TX, Psychological Corporation.
7. Black DW, Blum N, Pfohl B, Hale N (2004) Suicidal behavior in borderline personality disorder: prevalence, risk factors, prediction, and prevention. J Pers Disord, 18:226-239.
8. Carey TA, Stiles WB (2016) Some problems with randomized controlled trials and some viable alternatives. Clin Psychol Psychother, 23:87-95.

9. Chugani CD (2015) Dialectical behavior therapy in college counseling centers: current literature and implications for practice. J College Stud Psychother, 29:120–131.
10. Chen Y, Fu W, Ji S, Zhang W, Sun L, Yang T et al. (2023) Relationship between borderline personality features, emotion regulation, and non-suicidal self-injury in depressed adolescents: a cross-sectional study. BMC Psychiatry, 23:293.
11. Çelebi E (2017) Diyalektik Davranış Terapisi. In Psikoterapi Yöntemleri: Kuramlar ve Uygulama (Eds E Köroğlu, H. Türkçapar (Ed.). Ankara, HYB.
12. First MB, Spitzer RL, Gibbon M, Williams JB (1995) Structured Clinical Interview for DSM-IV Axis I Disorders-Patient Edition (SCID-I/P, Version 2.0). New York, Biometrics Research, New York State Psychiatric Institute.
13. Fung HW, Wong MYC, Lam SKK, Wong ENM, Chien WT, Hung SL et al. (2023) Borderline personality disorder features and their relationship with trauma and dissociation in a sample of community health service users. Borderline Personal Disord Emot Dysregul, 10:22.
14. Grant JB, Batterham PJ, McCallum SM, Werner-Seidler A, Calear AL (2023) Specific anxiety and depression symptoms are risk factors for the onset of suicidal ideation and suicide attempts in youth. J AffectDisord, 327:299-305.
15. Gratz KL, Bardeen JR, Levy R, Dixon-Gordon KL, Tull MT (2015) Mechanisms of change in an emotion regulation group therapy for deliberate self-harm among women with borderline personality disorder. Behav Res Ther, 65:29-35.
16. Gratz K, Roemer L (2004) Multidimensional assessment of emotion regulation and dysregulation: development, factor structure, and initial validation of the difficulties in emotion regulation scale. J Psychopathol Behav Assess, 26:41–54.
17. Gratz KL,Tull MT (2010) Emotion regulation as a mechanism of change in acceptance-and mindfulness-based treatments. In Assessing Mindfulness and Acceptance: Illuminating the Theory and Practice of Change (Eds. RA Baer):107-133. Oakland, CA, New Harbinger.
18. Gratz KL, Tull MT, Levy R (2013) Randomized controlled trial and uncontrolled 9-month follow-up of an adjunctive emotion regulation group therapy for deliberate self-harm among women with borderline personality disorder. Psychol Med, 44:2099-2112.
19. Gunderson JG, Stout RL, McGlashan TH, Shea MT, Morey LC, Grilo CM et al. (2011) Ten-year course of borderline personality disorder: psychopathology and function from the collaborative longitudinal personality disorders study. Arch Gen Psychiatry, 68:827-837.
20. Harned MS, Gallop RJ, Valenstein-Mah HR (2018) What changes when? The course of improvement during a stage-based treatment for suicidal and self-injuring women with borderline personality disorder and ptsd. Psychother Res, 28:761-775.
21. Harned MS, Korslund KE, Linehan MM (2014) A pilot randomized controlled trial of dialectical behavior therapy with and without the dialectical behavior therapy prolonged exposure protocol for suicidal and self-injuring women with borderline personality disorder and PTSD. Behav Res Ther,55:7-17.
22. Inigo AP, Marina DM (2021) Association between non-suicidal self-injury and suicidal behavior in borderline personality disorder: a retrospective study. Actas Esp Psiquiatr, 49:199-204.
23. Klonsky ED, Glenn CR (2013) The relationship between nonsuisidal self-injury and attempt suicide: converging evidence from four samples. J Abnorm Psychol, 122:231-237.
24. Krantz LH, McMain S, Kuo JR (2018) The unique contribution of acceptance without judgment in predicting nonsuicidal self-injury after 20-weeks of dialectical behaviour therapy group skills training. Behav Res Ther, 104:44-50.
25. Krüger A, Kleindienst N, Priebe K, Dyer AS, Steil R, Schmahl Cet al. (2014) Non-suicidal self-injury during an exposure-based treatment in patients with posttraumatic stress disorder and borderline features. Behav Res Ther, 61:136-141.
26. Küçük A, Çetinkaya S (2019) İntihar amaçlı olmayan kendine zarar verme davranışı ve intihar ilişkisi; tanı, borderline kişilik bozukluğu ve mizaç ve karakter özelliklerinin rolü. Cukurova Medical Journal, 44:360-368.
27. Lin TJ, Ko HC, Wu JY, Oei TP, LaneHY, Chen CH (2019) The effectiveness of dialectical behavior therapy skills training group vs. cognitive therapy group on reducing depression and suicide attempts for borderline personality disorder in Taiwan. Arch Suicide Res, 23:82-99.
28. Linehan MM, Korslund KE, Harned MS, Gallop RJ, Lungu A, Neacsiu AD et al. (2015) Dialectical behavior therapy for high suicide risk in individuals with borderline personality disorder: a randomized clinical trial and component analysis. JAMA Psychiatry, 72:475-482.
29. Linehan MM, Wilks CR (2015) The course and evolution of dialectical behavior therapy. Am J Psychother, 69:97-110.
30. Martin R, Young J (2010) Schema Therapy. Handbook of Cognitive-Behavioral Therapies (Ed KS Dobson):317-346. New York, NY, Guilford Press.
31. Martino F, Gammino L, Sanza M, Berardi D, Pacetti M, Sanniti A et al. (2020) Impulsiveness and emotional dysregulation as stable features in borderline personality disorder outpatients over time. J Nerv Ment Dis, 208:715–720.
32. Mattingley S, Youssef GJ, Manning V, Graeme L, Hall K (2022) Distress tolerance across substance use, eating, and borderline personality disorders: a meta-analysis. J Affect Disord, 300:492-504.
33. McLaughlin SP, Barkowski S, Burlingame GM, Strauss B, Rosendahl J (2019) Group psychotherapy for borderline personality disorder: a meta-analysis of randomized-controlled trials. Psychotherapy (Chic), 56:260-273.
34. McMain SF, Fitzpatrick S, Boritz T, Barnhart R, Links P, Streiner DL (2017) Outcome trajectories and prognostic factors for suicide and self-harm behaviors in patients with borderline personality disorder following one year of outpatient psychotherapy. J Pers Disord, 32:497-512.
35. Miller PA, Rathus JH, Linehan M (2007) Dialectical Behavior Therapy with Suicidal Adolescents. New York, NY, Guilford Press.
36. Mohamadizadeh L, Makvandi B, Pasha R, Bakhtiarpour S, Hafezi F (2017) Comparing of the effect of dialectical behavior therapy (dbt) and schema therapy (st) on reducing mood activity and suicidal thoughts in patients with borderline personality disorder. Acta Medica Mediterranea, 33:1025-1031.
37. Murphy A, Bourke J, Flynn D, Kells M, Joyce M (2020) A cost-effectiveness analysis of dialectical behaviour therapy for treating individuals with borderline personality disorder in the community. Ir J Med Sci, 189:415-423.
38. Norrie J, Davidson K, Tata P, Gumley A (2013) Influence of therapist competence and quantity of cognitive behavioural therapy on suicidal behaviour and inpatient hospitalisation in a randomised controlled trial in borderline personality disorder: further analyses of treatment effects in the boscot study. Psychol Psychother, 86:280-293.
39. Osby U, Brandt L, Correia N, Ekbom A, Sparen P (2001) Excess mortality in bipolar and unipolar disorder in Sweden. Arch Gen Psychiatry, 58:844–850.
40. Özdel K (2015) Dünden bugüne bilişsel davranışçı terapiler: teori ve uygulama. Turkiye Klinikleri J Psychiatry-Special Topics, 8:10-20.
41. Öztürk E, Şar V (2016) Formation and functions of alter personalities in dissociative disorder: A theoretical and clinical elaboration. J Psychol Clin Psychiatry, 6:385.
42. Page MJ, Moher D, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD et al. (2021) PRISMA 2020 explanation and elaboration: updated guidance and exemplars for reporting systematic reviews. BMJ, 372:n160.
43. Rizk MM, Choo TH, Galfalvy H, Biggs E, Brodsky BS, Oquendo MA et al. (2019) Variability in suicidal ideation is associated with affective instability in suicide attempters with borderline personality disorder. Psychiatry, 82:173–178.
44. Soloff P, Lis J, Kelly T, Cornelius J, Ulrich R (1994) Self-mutilation and suicidal behavior in borderline personality disorder. J Pers Disord, 8:257–267.
45. Stratton N, Mendoza-Alvarez M, Labrish C, Barnhart R, McMain S (2018) Predictors of dropout from a 20-week dialectical behavior therapy skills group for suicidal behaviors and borderline personality disorder. J Pers Disord, 34:216-230.
46. Temes CM, Frankenburg FR, Fitzmaurice GM, Zanarini MC (2019) Deaths by suicide and other causes among patients with borderline personality disorder and personality-disordered comparison subjects over 24 years of prospective follow-up. J Clin Psychiatry, 80:18m12436.
47. Tunç P, Şahin D (2019) Sınır kişilik bozukluğunda dürtüsellik, kendine zarar verme ve intihar davranışlarının yordayıcıları. Anadolu Psikiyatri Derg, 20:341-349.
48. Türkçapar MH (2018) Bilişsel Davranışçı Terapi Temel İlkeler ve Uygulama. İstanbul: Epsilon Yayınevi.
49. Türkçapar MH, Sargın AE (2012) Bilişsel davranışçı psikoterapiler: tarihçe ve gelişim. Bilişsel Davranışçı Psikoterapi ve Araştırmalar Dergisi, 1:7-14.
50. Walton CJ, Bendit N, Baker AL, Carter GL, Lewin TJ (2020) A randomised trial of dialectical behaviour therapy and the conversational model for the treatment of borderline personality disorder with recent suicidal and/or non-suicidal self-injury: an effectiveness study in an Australian public mental health service. Aust N Z J Psychiatry, 54:1020-1034.
51. Wang L, Liu J, Yang Y, Zou H (2021) Prevalence and risk factors for non-suicidal self-injury among patients with depression or bipolar disorder in China. BMC Psychiatry, 21:389.