Where do self-harming behaviors come from in BPD?

Self-harming behavior, particularly self-mutilation, is perhaps the most horrifying of borderline symptoms to bystanders and treating professionals.

Perhaps what is most vexing and perplexing is the lack of concern that people with BPD often show toward this behavior, becoming indignant at the prospect that anyone would want to put an end to it, since in its own way it seems to bring such comfort along with the pain.

Self-injury is a compulsion. An irresistible urge accompanies a buildup of tension, which is relieved by giving in to the urge. The release is cathartic, poetically expressed by AJ Mahari (webmaster of this site) in her article Self- Harm Defeated as "the way my body cried." For many, these behaviors are a substitute for the natural release that normally accompanies crying and helps to regulate mood. For others, the intensity of the catharsis is akin to orgasm. While it feels as though nothing else could possibly relieve the tension, it would eventually dissipate with enough time, more time than most people with BPD are able to wait.

Rather than address the question "Where does it come from?" it makes more sense to address "What does it mean?" and "What sustains it?"

The meanings of borderline self-injury are complex and vary from person to person and from time to time. While they are addressed in detail in Chapter 10 of Lost in the Mirror, I will try to summarize them here.

For many people with BPD, self-injury modulates the balance between feeling too intensely and unfeeling. When emotional distress is blaring, physical pain can be distracting enough to overcome it for a time. Physical pain can also trigger physiologic processes, such as the release of endorphins, the brain's built in pain relieving substances, which provide comfort for emotional distress as well. When emotional numbness has been too long present, physical pain can renew contact with the feeling world.

Self-injury is often a way of punishing the self. Since people with BPD have periods of feeling worthless and are often wracked with guilt over perceived transgressions both in the present and the past, self-mutilation can function as a penance for these offenses. If you are borderline, feelings of worthlessness and guilt may arise out of your tendency to see yourself or others in black-and-white. This tendency to split the world into good and evil can also lead to a division between the body and the self, so that the body or a body part becomes the repository of evil and can be sacrificed with a self-mutilating act, in effect purifying the self. The scapegoat in the old testament was sent into the wilderness bearing the sins of the community. The role of sacrifice in ancient religions is partly based on an exaggerated splitting into good and evil.

Self-injury may sometimes reenact earlier injury at the hands of others. Freud first described the compulsion to repeat traumatic experiences from the past, perhaps as part of an effort to master such events. It may also be a form of "identifying with the aggressor." I have, in fact, known people with Dissociative Identity Disorder in whom one of the alternate personalities was a personification of their abuser.

Finally self-injury is a powerful interpersonal communication. For better or for worse, it inevitably grabs others' attention. It can be a cry for help, signaling distress at times when words fail or seem inadequate. It can be a forceful rebuke. And it can be an instrument of blackmail, holding others hostage to its destructive potential.

Once begun, self-mutilation is sustained by powerful forces. Any behavior that is sufficiently rewarded tends to be repeated. Self-injury is powerfully rewarded by the tension relief that it brings. It may also be rewarded by the responses of others. The most significant reinforcer, though, may be the outpouring of endorphins that accompanies pain and injury. An addiction may, in fact, develop to one's own built-in opiates. This may provide a clue to future treatments of compulsive self-injury, perhaps borrowing from our experience with addictions.

How can the transition be made from self-injury to healthier coping behaviors?

AJ's entry "How and Why I Stopped Self-Harming" is one of the clearest descriptions I have seen of how healing from this behavior can occur. Rather than repeat here what AJ has so articulately put, I will instead elaborate upon it.

Self-injury, like other forms of acting-out, is a substitute for feeling. As long as these behaviors continue, the awareness of feeling is often limited to undifferentiated distress and perhaps anger. The full spectrum of feelings, including nuances of sorrow and sadness, hurt, fear, guilt and shame, love and compassion, and joy may remain obscure. Only when the behavior is interrupted or at least delayed, as AJ discovered, do these underlying emotions begin to emerge. Stopping is therefore a step along the way to understanding and can greatly accelerate the healing process. It is important, if growth is to occur, to have ways of acknowledging and processing feelings as they arise. Journaling, talking with friends, and being in treatment are all ways to facilitate healing.

Self-injury is fundamentally a means to self -soothe. The ideal shift would therefore be from self-injury to direct self-nurturing. This is too great a leap for most people. Instead, a progression from painful self-harm to harmless pain to self-nurturing would be more realistic.

It is possible to release endorphins and relieve distress without destroying tissue. One example would be aerobic exercise. Marathon runners reach a point after "hitting the wall" when they get a second wind and the race may for a time seem effortless. Endorphins are probably also released, however, at various stages of less heroic aerobic workouts. I once met a woman who was working out on the Stairmaster with particular intensity. When I inquired how much longer she would be, she explained that she had a migraine headache and that about thirty minutes on this machine was usually adequate to resolve it. She had very likely learned how to tap into her built-in pain relieving system with exercise to relieve her physical pain.

Acupuncture is another means of stimulating endorphin release, which may be a key to its efficacy. It is interesting that penetrating the skin is crucial both to this treatment modality and to the relief that many people with BPD get from self-injury. I wonder if acupuncture might be helpful in relieving emotional distress for some people with BPD. Perhaps even the use of one of the electrical devices designed to stimulate acupuncture points would be a safer substitute for more risky behaviors.

Rather than seeking an alternative route to reward, eliminating reward can be an effective means of terminating unwanted behaviors. In addictions treatment, drugs are sometimes used to block the effects of drugs that are being abused. Naltrexone, an opiate blocking agent, has been used to treat opiate addiction. More recently it has been found useful in reducing alcohol craving as well. Naltrexone can also interfere with the effects of the endogenous opiates or endorphins. Theoretically, this might also block the reinforcement of self-mutilation. There are studies underway examining this approach. Several years ago, I treated a patient with naltrexone who had a particularly dangerous and stubborn form of self-mutilation. The results were dramatic. She stopped all self-injury for an entire year while taking the drug. When she stopped taking naltrexone, however, because of its high cost, her symptoms returned and did not stop again when the drug was resumed.

Beyond tension relief through pain is self-nurturing. How might this occur? For some people physical forms of comfort may be soothing. An example would be the use of a comfort object that has symbolic significance and could be held or stroked. Most satisfying in the end, however, would be self-affirming thoughts. An excellent example would be AJ's appreciation that the choice that she made to stop hurting herself was healthy and good and that in doing so she had taken control of her life back from her abusers. Self-nurturing can also occur when one reaches out to others with effective communication rather than remaining isolated. Developing sound personal boundaries and standing up for oneself with others will enhance personal security, power, and comfort.

Finally, permitting feelings is probably the ultimate means of self-nurturing. For so many people with BPD, feelings and their expression have long been forbidden. One of the worst forms of abuse is being denied the opportunity to cry. Letting the tears flow, once you have given yourself full permission to cry, can be exhilarating and freeing. Then you may no longer need the pain that makes your body cry.

© Dr. Moskovitz

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