The Interpersonal Theory of Suicide and Borderline Personality Disorder
Updated: Jul 11, 2019
I have much stronger emotional reactions than almost everyone else.
It makes me really angry when people insult me in even a minor way.
I find myself asking people I feel close to how they truly feel about me.
Sometimes the people I feel close to become irritated with me for seeking reassurance as to whether they truly care about me.
I never know where my emotions will go from moment to moment.
(Rogers & Joiner, 2016)
It is very lonely to experience your emotions as uncontrollable, unpredictable, and unmanageable. Sometimes, I wonder if the people around me are also shipwrecked as they order their coffee, as they board the bus. Tangled up in my daily pendulum from joy to despair to rage, I am always on the edge of abandonment. I can hear my friends complaining about me when I’m gone, I imagine my partner preparing to break the news that she no longer loves me. I feel my classmates rolling their eyes as I raise my hand to speak, my professors reading my papers and sinking with disappointment. I am too much. I am a hurricane no one wants to be in the centre of. I am an unidentified bag at an airport, I am a cigarette dropped in dry foliage.
When I was younger I would pull people into the storm with me. Now, I am quiet in the hurricane.
In his book Why People Die by Suicide, Thomas Joiner explained the diverse risk factors for death by suicide with the interrelation of thwarted belongingness, perceived burdensomeness, and the acquired capability for suicide (reduced fearlessness of death and heightened pain tolerance). Individuals who are isolated and perceive themselves to be a burden experience suicide ideation, but may not be capable of suicide. When individuals who have experience with pain, violence, or fear are alienated and feel their loved ones would benefit more from their death than their life, they are at highest risk for death by suicide.
In my post BPD and Suicide: The Myth of Suicide Gestures, I cited the death by suicide rate of 10% and the attempt rate of 60-75% in those touched by BPD. Emotion dysregulation, a core feature of BPD, has been found to predict suicide attempts. Teenagers with emotion dysregulation are more likely to die by suicide as adults, and adults who die by suicide are more likely to have experienced emotion dysregulation both at the time of their deaths and when they were teenagers. How does emotion dysregulation confer elevated risk for individuals with BPD?
Megan Rogers and Thomas Joiner, the latter of whom authored the original Interpersonal Theory of suicide, found evidence for emotion dysregulation contributing to both perceived burndensomeness and thwarted belongingness, and that after accounting for feelings of thwarted belongingness, emotion dysregulation still uniquely influenced suicidal ideation. Often experiencing debilitating fear of abandonment, individuals with BPD are at higher risk for both emotion dysregulation and heightened sensitivity to loneliness and perceived burdensomeness.
Emotion Dysregulation and Perceived Burdensomeness
Rogers and Joiner described the process by which dysregulated emotion contributed to perceived burdensomeness, which in turn contributed to the desire for suicide. When perceived burdensomeness was accounted for, the relationship between emotion dysregulation and desire for suicide was not significant, which means emotion dysregulation indirectly contributed to the desire for suicide via the elevation of perceived burdensomeness.
For example, an individual whose emotions are intense and labile might have frequent expressions of anger, interpersonal conflict, and engage in self-injurious behaviour to help regulate their intense emotions. The route by which these phenomena will increase the individual’s suicidal ideation is by the individual feeling like a burden on their family and friends. Thus, if an individual experiences intense and labile emotion but does not perceive themselves to be a burden, they might be protected from the desire for suicide.
Emotion Dysregulation and Thwarted Belongingness
A different model emerged to explain the relationship between emotion dysregulation, thwarted belongingness, and suicidal ideation. Emotion dysregulation was significantly related to feelings of thwarted belongingness (isolation, alienation, lack of meaningful relationships), but both phenomena contributed independently to the desire for suicide. The relationship between emotion dysregulation and suicidal desire could not be explained by the exacerbation of thwarted belongingness.
The relationship between emotion dysregulation, interpersonal functioning, and suicide is complex. Borderline Personality Disorder research received $567 million less than Bipolar Disorder over 25 years (Zimmerman & Gazarian, 2014) despite similar prevalence, mortality, and disability rates. In order to understand suicide, we must also understand its relationship with a disorder that is characterized by the majority of its sufferers having seriously attempted suicide in their lifetime. Borderline Personality Disorder is characterized by frequent, intense episodes of negative affect, loneliness, and separation anxiety – all known risk factors for suicide. The disorder, then, is an invaluable model for understanding the interplay of emotional and social contributors to suicide ideation and attempts.
Rogers, M. L., & Joiner Jr, T. E. (2016). Borderline personality disorder diagnostic criteria as risk factors for suicidal behavior through the lens of the interpersonal theory of suicide. Archives of Suicide Research, 20(4), 591-604.
Link to article: https://doi.org/10.1080/13811118.2016.1158681
Zimmerman, M., & Gazarian, D. (2014). Is research on borderline personality disorder underfunded by the National Institute of Health?. Psychiatry research, 220(3), 941-944.