Is intentional self-harm more commonly associated with bipolar disorder or borderline personality disorder (BPD)?

From the Guidelines

Intentional self-harm is more commonly associated with bipolar disorder than borderline personality disorder, with a lifetime prevalence of 29.2% in bipolar disorder compared to 5.6% in major depressive disorder and 4.9% in non-bipolar controls 1. When considering intentional self-harm in the context of bipolar disorder and borderline personality disorder, it's essential to understand the differences in manifestation and treatment approaches.

• In bipolar disorder, self-harm typically occurs during severe depressive or mixed episodes, often as a suicide attempt rather than non-suicidal self-injury.
• Treatment for bipolar disorder usually involves mood stabilizers like lithium (600-1200mg daily), valproate (750-1500mg daily), or lamotrigine (100-200mg daily), along with atypical antipsychotics such as quetiapine (300-600mg daily) or olanzapine (5-20mg daily) 1. In contrast, self-harm in borderline personality disorder is often non-suicidal, serving as an emotional regulation strategy or response to feelings of emptiness.
• BPD treatment focuses on dialectical behavior therapy (DBT) for 6-12 months, sometimes with adjunctive medications like low-dose antipsychotics or mood stabilizers to target specific symptoms 1. For both conditions, crisis planning is essential, including identifying triggers, creating safety plans with emergency contacts, and removing access to means of self-harm.
• Proper diagnosis is crucial as treatment approaches differ significantly, with medication being primary for bipolar disorder while psychotherapy (particularly DBT) is the foundation for BPD treatment 1. It's also important to note that epidemiological, clinical, and psychosocial risk factors can contribute to the development or worsening of suicidal behaviors, and some risk factors are shared by all mood disorders, while others are more specific 1.
• The rate of suicide in mood disorders is often evaluated in studies that compare frequencies in relation to different psychiatric conditions in different countries with various health systems, and national registries which quantify the number of suicides in people with mood disorders at national level may provide a more accurate suicide estimation 1.

From the Research

Intentional Self-Harm in Bipolar Disorder and Borderline Personality Disorder

• Intentional self-harm is a significant concern in both bipolar disorder and borderline personality disorder, with studies indicating a higher prevalence of self-harm in individuals with bipolar disorder, particularly those with an evening chronotype 2.
• A study published in JAMA Psychiatry found that self-harm rates were lower in patients with bipolar disorder prescribed lithium compared to those prescribed valproate, olanzapine, or quetiapine 3.
• Borderline personality disorder often overlaps with bipolar disorder, and differentiating between the two conditions can be challenging 4.
• Research suggests that mood stabilizers, such as lithium and valproic acid, are effective in reducing self-harm and suicidal behavior in individuals with bipolar disorder 3, 5.
• Atypical antipsychotics, like quetiapine and olanzapine, may also be used in combination with mood stabilizers to manage symptoms of bipolar disorder, but their use should be carefully considered due to the risk of adverse effects 5.

Comparison of Self-Harm Rates

• A study published in the Journal of Affective Disorders found that individuals with bipolar disorder who self-harmed had a higher risk of repetition compared to those without bipolar disorder 6.
• The same study found that previous self-harm, unemployment, contact with psychiatric services, and sleep disturbance were more common in individuals with bipolar disorder who self-harmed 6.
• Another study found that self-harm rates were higher in individuals with bipolar disorder who had an evening chronotype, with 37% of participants in this group reporting self-harm 2.

Treatment Strategies

• Lithium is considered a gold standard treatment for bipolar disorder, particularly for individuals with typical features of the condition 5.
• Valproic acid may be more effective for atypical forms of bipolar disorder, such as mixed-prevalence and rapid-cycling 5.
• Atypical antipsychotics, like quetiapine, may be used as adjunctive strategies in maintenance treatment, but their use should be carefully considered due to the risk of adverse effects 5.