The Myth of Suicide Gestures
If you are living with BPD or love someone who is, you have dealt intimately with the concept of suicide. You might be familiar with the often cited 10% completion rate of suicides in individuals diagnosed with BPD, or you might be one of the 60-75% of people with BPD who have attempted suicide. Why, then, are patients with BPD dismissed as attention-seeking when we disclose suicidal ideation or make a suicide attempt?
The Myth of Suicide Gestures
The term “suicide gesture” began to appear in the literature in the late 1960s to describe patients presenting at emergency rooms for suicide attempts and other self-injurious behaviour. Quickly, the term was applied to the “communicative” nature of suicide and self-injury in BPD patients. The research on suicide and BPD in the 20th century was dominated by the idea that suicide attempts in BPD differed from “real” suicide attempts in lethality, motviation, and intent to die. Rather than being a serious attempt at death, self-injury by people with BPD was seen as motivated by interpersonal manipulation. A major contributor to this image was the conflation of non-suicidal self-injury and suicide attempts.
Differentiating Suicidal and Non-Suicidal Self-Injury
The study of “deliberate self-harm” emerged in the 1990s as a suicide-related behaviour. It wasn’t until the early 2000s that “non-suicidal self-injury” was differentiated from suicide attempts and ideation. Presently, it is understood that non-suicidal self-injury serves a regulatory function in the emotional experience of people with BPD, and can be viewed as a survival rather than a suicidal behaviour. Unpairing NSSI from suicide attempts clarified the study of suicide and BPD.
Lethality and Motivations for Suicide
What do we know about the interaction between lethality (the likelihood of a suicide attempt resulting in death) and motivations for suicide? Interpersonal motivations for suicide, such as influencing or eliciting attention from others, is the least common motivation for attempting suicide. It is also inversely related to suicidal intent, or the degree to which a person wants to die during a suicide attempt. Importantly, suicide attempters with BPD do not tend to differ from non-BPD attempters in their endorsement of interpersonal influence motivations for suicide, nor do they differ on ratings of intent to die or lethality of attempt. There is a substantial need for further research on suicide motivations, intent, and lethality in BPD to deconstruct the myth of the suicide gesture.
Why Does it Matter?
The first two times I presented in an emergency room for suicidal ideation, I was sent home with no follow up. The second time I clearly stated to the emergency nurse my plan for suicide, when I intended to attempt suicide, and how I did not feel safe leaving the hospital. I spoke plainly and clearly, as someone who is trained in suicide risk assessment, to ensure she would provide me with adequate protection from my suicidal behaviour. I was sent home with my partner, who had to watch me over the next couple of days to ensure I was safe. I believe it is sheer luck that I did not attempt suicide that night or the nights that followed.
Today the term “suicide gesture” is present in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) as the fifth criterion for the diagnosis of BPD: “Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior”. In comparison, a similar criterion is present in Major Depressive Disorder (MDD): “Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide”. In BPD, non-suicidal self-injury and suicide attempts are lumped into the same category, despite their very different motivations and presentations, as well as the existence of non-suicidal self-injury in MDD. In addition, MDD’s “suicide ideation” is termed “gestures or threats” in the BPD symptom – transforming an expression of intense pain and despair into attention-seeking behaviour. Finally, the MDD symptom plainly describes “a suicide attempt or a specific plan for attempting suicide” whereas the BPD symptom calls the same phenomenon a “gesture”.
There is a long history of dismissing suicidal expressions of BPD sufferers due to the belief that these expressions are made to elicit care or attention. It is paramount that any expression of suicidal thought, however frequent it may be, is taken seriously. It is crucial that we are believed when we say we want to die.