Bipolar Disorder and Self-Injury

People with bipolar disorder, depression, and other mood disorders often have episodes when they feel extremely sad, hopeless, anxious, or confused. When these emotions get too intense, the person may struggle with how to cope with overwhelming emotions, and for some people, efforts at coping with distress may take the form of acts of self-injury.

Self-injury, often including cutting, self-mutilation, or self-harm, is an injurious attempt to cope with overpowering negative emotions, such as extreme anger, anxiety, and frustration. It is usually repetitive, not a one-time act. Often, people who deliberately injure themselves are survivors of traumatic events during childhood or early developmental periods in life. Self-injuring behaviors that occur because of difficulty coping with stress are not a symptom of bipolar disorder, but may happen when someone's emotional coping strategies are not well-developed, or when certain other mental health problems co-exist with bipolar disorder.

Self-injurious behavior is most widely recognized as a key feature of a condition called borderline personality disorder. Borderline personality disorder is a disturbance involving longstanding problems in regulating moment- to-moment emotional reactions to stressful events, especially those involving strong emotional reactions with high sensitivity to interactions with other people. Self-injuring behaviors also sometimes happen in people whose behavior becomes disorganized because of a primary psychotic disorder (that is, an inability to literally differentiate reality from fantasy), head traumas, or developmental disabilities.

What are some forms of self-injury?

Cutting the skin with a sharp object is one form of self-injury. Other forms of self-injury may include burning, scratching, hitting or bruising, biting, head-banging, or picking at skin. Sometimes pulling out hair is a form of self- injury.

Some people who engage in self-injury may do so methodically or regularly, almost as if self-injury were a ritual. Other people may use self-injury impulsively -- at the spur of the moment -- as a way to get immediate release for built-up tension. They may use self-injury either as a way to regulate intense emotions or as a distraction technique.

No matter how self-injury is used, it is an unhealthy and dangerous act and can leave deep scars, both physically and emotionally.

Why do people engage in self-injury?

Just as there are healthy ways to relieve stress, such as exercise, there are also unhealthy ways to cope with negative feelings. For some people, self-injury is a coping mechanism.

Along with self-injury, some people with bipolar and other psychiatric disorders may be more apt to abuse drugs or alcohol than people without mood disorders. Some experts believe that risky behaviors are related to the patient trying to self-soothe unpleasant mood states, particularly if they feel overwhelmed by distressing emotions.

Like drugs and alcohol, self-injury tends not to be an effective way to try to relieve emotional discomfort. That's why it's important that people with mood disorders -- especially when traumatic events or abuse have occurred in childhood -- talk with their doctors about effective strategies to help manage emotional distress.

Can self-injury lead to suicide?

Suicide is a major risk for people with bipolar disorder. Between 25% and 50% of those with bipolar disorder attempt suicide, and 15% die by suicide. But people who engage in self-injury to get rid of bad feelings are not necessarily suicidal.

Though self-injury and suicide are different, self-injury should not be brushed aside as a small problem. The very nature of self-injury is physical damage to one's body. It's important for the self-injurer to seek help.

What are warning signs of suicide with bipolar disorder?

Warning signs of suicide may include:

• Talking about suicide
• Always talking or thinking about death
• Making comments about being hopeless, helpless, or worthless
• Saying things like "It would be better if I wasn't here" or "I want out"
• Worsening depression
• A sudden switch from being very sad to being very calm or appearing to be happy
• Having a "death wish," tempting fate by taking risks that could lead to death, like driving through red lights
• Losing interest in things one used to care about
• Putting affairs in order, tying up loose ends, changing a will
• Hoarding pills
• Unusual interest in nationally publicized disasters or suicides

How does someone stop self-injurious behavior if they also have bipolar disorder?

If you or a loved one has both bipolar disorder and, in addition, self-injurious behavior, it's vital that you work with your doctor to jointly manage your illness. By keeping your moods in check, you can avoid overwhelming feelings of sadness or anxiety that may lead to destructive behaviors like self-injury. Self-injury in itself is not a symptom of bipolar disorder, but often may be the sign of another co-occurring disorder, such as borderline personality disorder, that requires its own treatment. Psychotherapies that target self-injurious behavior, such as dialectical behavior therapy (DBT), remain the cornerstone of treatment for this problem. While medicines sometimes can be helpful for trouble controlling angry or aggressive impulses, including impulses to hurt yourself, medication alone is often not as effective as psychotherapy for managing impulses to hurt yourself.

Some ways to keep your bipolar disorder managed include:

• Seeing your doctor regularly for mental health checkups
• Taking your prescribed bipolar medications every day whether or not you have symptoms
• Staying away from alcohol and illicit drugs that may trigger mood swings
• Finding a therapist you trust and working with this professional on your coping skills; some types of behavior therapy can help you learn to deal with emotional distress in healthy ways.
• Following up with your doctor's recommendations on having lab tests
• Joining a support group and strengthening your family and friend support network

Treatment for self-injuring behaviors in borderline personality disorder typically focuses on learning skills to better tolerate distress and refrain from self-harm. Structured psychotherapies such as DBT involve exercises to gain mastery of distress tolerance skills, and using a psychotherapist to provide coaching through the use of those skills when necessary.

If you feel your bipolar symptoms are worsening, contact your doctor immediately. Sometimes a change in medication or dosage is all that's needed to treat breakthrough symptoms of depression or mania/hypomania.

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