A unified theoretical framework for understanding suicidal and self-harming behavior: Synthesis of diverging definitions and perspectives

Borderline Personality Disorder (BPD) has largely been associated with self-harm and chronic suicidality, despite the fact that these behaviours comprise only one diagnostic criterion. Treatments for self-harm are mostly indicated for individuals with BPD. Emerging literature suggests that youth with histories of depression are at risk of both self-harm and completed suicide. For individuals with repeated self-harm, co-occurring suicidal ideation and behavior is not uncommon. In the field of self-harm research, two major positions and corresponding definitional terms have evolved. “Deliberate self-harm” is a broad definition that includes direct suicidal and non-suicidal forms of the behavior. “Non-suicidal self-injury” (NSSI) encompasses only behaviours resulting in direct tissue damage in the absence of suicidal intent. Neither position systematically evaluates indirect self-harm. The discrepancy between definitions and deficiency of either alone produces an inability to compare results in clinical research, and limits the applicability of evidence-based treatments. We propose that these behaviors are best understood as possible dimensions on a broad self-harm spectrum, within a theory derived from the literature on suicide, self-harm, NSSI, and BPD. Methods: Research and theory review. Results: A number of recent empirical studies have concluded that self-harm and suicide should not be considered separately, lending support to a broader definition of self-harm than that encompassed by NSSI alone. Extending the definitional scope of self-harm enables a more thorough understanding of indirect self-harming behaviors, proposed to have the same function as NSSI. These studies as well as Emerging Models from DSM-5 inform the proposed theory. Conclusion: The proposed unified theoretical framework provides a formulation of both NSSI and suicidal behavior as two dimensions on a broad spectrum of self-harming behaviors. The empirical and theoretical basis for the theory is presented alongside the clinical and research ...