Autobiographical memory and parasuicide in

borderline personality disorder

Mike Startup*
School of Psychology, University of Wales, Bangor, UK
Heidi Heard
Institute of Medical and Social Care Research, University of Wales, Bangor, UK
Michaela Swales
School of Psychology, University of Wales, Bangor, UK
Bethan Jones
Psychology Department, Bath Mental Health NHS Trust, UK
J. Mark G. Williams
Institute of Medical and Social Care Research, University of Wales, Bangor, UK
Robert S. P. Jones
School of Psychology, University of Wales, Bangor, UK
Background. Several studies have found that parasuicidal patients are poor at
recalling specific autobiographical memories when tested with the word-cueing
paradigm and two studies have reported some evidence that over-general recall is a
risk factor for repetition of parasuicide. The aim of the present study was to test
whether this association could be replicated with a sample of patients suffering from
borderline personality disorder (BPD).
Method. Twenty-three patients with BPD completed a version of the Autobio-
graphical Memory Test (AMT) and self-report measures of depression, anxiety and
trait anger. In a structured interview, they also reported the number of times they
had engaged in parasuicidal acts during the previous 4 months.
* Requests for reprints should be addressed to Dr Mike Startup, School of Psychology, University of Wales, Bangor,
Gwynedd LL57 2DG, UK (e-mail: m.j.startup@bangor.ac.uk).
113 British Journal of Clinical Psychology (2001), 40, 113120 Printed in Great Britain
# 2001 The British Psychological Society
Results. The number of general memories produced on the AMT made a significant
contribution to the prediction of the frequency of parasuicidal acts in a multiple
regression analysis but the partial correlation in the final equation was negative.
That is, those who showed greatest over-general recall reported fewest parasuicidal
acts. Anxiety and depression, but not trait anger, also made significant independent
contributions to the prediction of parasuicide.
Conclusion. Over-general autobiographical recall may help to protect borderline
individuals from parasuicidal acts by helping them to avoid distressing memories.
The term parasuicide refers to any non-fatal, intentional, self-injurious behaviour
which results in tissue damage, illness, or risk of death (Kreitman, 1977).
Autobiographical memory holds promise for increasing our understanding of this
problematic behaviour. Several studies have found that patients who are admitted to
hospital following deliberate self-poisoning are poorer than matched control groups at
recalling specific autobiographical memories when tested with the word-cueing
paradigm (Evans, Williams, OLoughlin, & Howells, 1992; Williams & Broadbent,
1986; Williams & Dritschel, 1988; Williams et al., 1996); instead of responding with
memories of events that had occurred on particular days and in particular places, as the
task demanded, they often respond with inappropriately general memories. Theoretical
accounts have been developed to explain how over-general autobiographical recall affects
parasuicidal behaviour.
It has been found that the ability to recall specific memories, among both parasuicide
patients (Evans et al., 1992; Sidley, Whitaker, Calam, & Wells, 1997) and depressed
students (Goddard, Dritschel, & Burton, 1996), correlates positively with the
effectiveness of the solutions suggested for solving hypothetical social problems. Since
research has also shown that parasuicide patients tend to have many important problems
(Paykel, Prusoff, & Myers, 1975), Evans et al. (1992) suggested the difficulties these
patients have in recalling specific events might increase their risk of parasuicide by
making it difficult for them to generate effective solutions to problems and thereby
increasing their hopelessness. However, both Evans et al. (1992) and Sidley et al. (1997)
found that hopelessness did not correlate significantly, within their parasuicide groups,
with either recall specificity or the effectiveness of solutions.
Despite this, the suggestion that over-general recall increases the risk of parasuicide
has received some support from a study by Kuyken and Brewin (1995) in which a small
but significant positive correlation (r = .23) was found between the number of over-
general memories recalled in response to positive cues and the number of suicides
attempted by a sample of depressed women. The suggestion has also received some
support from a study by Sidley, Calam, Wells, Hughes, and Whitaker (1999) of
predictors of parasuicide repetition among a sample of patients admitted to hospital as a
result of a deliberate drug overdoses. These patients were followed up at 1, 6 and 12
months and, at each follow-up, the sample was divided into repeaters, if deliberately
inflicted self-harm had resulted in medical treatment in a hospital setting, and non-
repeaters. It was found that the repeaters scored lower than the non-repeaters at one
month on two of five measures derived from the Autobiographical Memory Test (AMT):
latency and number of specific memories in response to positive cue words. However,
there were no significant differences between the groups on any of the AMT variables at
114 Mike Startup et al.
6 or 12 months and none of the AMT variables entered the stepwise logistic regression
analyses used to predict parasuicide repetition at any of the follow-ups.
The aim of the present study was to test whether autobiographical recall is associated
with repetition of parasuicide in patients suffering from borderline personality disorder
(BPD). As much as 75% of those who meet criteria for this disorder report at least one
incident of parasuicide (Gardner & Cowdry, 1985) and many report multiple incidents
(Soloff, Lis, Kelly, Cornelius, & Ulrich, 1994). Thus such a sample provides an
opportunity to study relationships between predictors of parasuicide and the frequency
of parasuicidal acts. Since parasuicide is associated with depression and trait anger
(MacLeod et al., 1992) and, among people with personality disorders, self-mutilation is
associated with affective disorders, somatic anxiety and chronic anger (Fyer, Frances,
Sullivan, Hurt, & Clarkin, 1988; Simeon et al., 1992; Soloff et al., 1994), measures of
these emotions are also included as predictors so that the independent contribution of
autobiographical recall may be assessed. Patients with BPD have already been shown to
retrieve significantly more general memories than a matched normal control group in a
previous report based on the present sample (Jones et al., 1999).
Method
Participants
The sample comprised 18 females and 5 males who met criteria for a diagnosis of BPD, as assessed by the
Structured Clinical Interview for DSM-IVPersonality Disorders (SCID-II: First, Spitzer, Gibbon, &
Williams, 1994). The age range of the participants was 1847 years, with a mean of 31.1 (SD = 7.7)
years. They had a mean of 16.6 (SD = 1.7) years of full-time education. Details of methods of
recruitment and exclusion criteria for this sample can be found in Jones et al. (1999).
Measures
Autobiographical Memory Test (AMT). Participants were required to recall specific events from their own
lives in response to a list of 18 cue words. Two sets of cue words were used, each containing six words
with positive valency (e.g. hopeful, pleased), six with negative valency (e.g. guilty, failure) and six neutral
words (e.g. pottery, ladder), but only one of these two sets was used with each participant. The cue words
were presented verbally with positive, negative and neutral words alternating. A 30-second time limit
was set for each word. Details of the cue words, and the procedure are given in Jones et al. (1999). A
specific memory was considered to be a recollection of an event that had occurred on a particular day.
Memories of events that had happened repeatedly or over extended periods of time were considered to be
general memories. A sample of 10% of first responses were transcribed and then independently
categorized by two raters who were blind to group membership. Inter-rater agreement of 100% was
obtained. The number of general first responses to all cue words was used as the measure.
To obtain frequency measures of parasuicidal acts, the relevant section of the Parasuicidal History
Interview (PHI: Linehan, Armstrong, Suarez, Allmon, & Heard, 1991; Linehan, Heard, Wagner, &
Brown, 1997) was administered. Parasuicide is defined in the PHI as any acute behaviour intended to
cause self-injury either with or without intent to die. For the purposes of this study, participants were
asked to report, at interview, the number of parasuicidal acts they had engaged in during the previous 4
months. The PHI is capable of assessing various other features of parasuicidal behaviour but only the
frequency of such behaviour was assessed in the present study in order to limit the burden of assessment
on participants. Since the distribution of this measure was found to be positively skewed, a
transformation to the natural logarithm was applied. Following this transformation, the distribution of
the measure did not depart significantly from a normal distribution nor were any outlier or extreme
values identified by the SPSS Examine procedure.
115 Memory and parasuicide in BPD
Trait anger, anxiety and depression were assessed by the StateTrait Anger Expression Inventory
(STAXI: Spielberger, 1991), the Beck Anxiety Inventory (BAI; Beck & Steer, 1993a), and the Revised
Beck Depression Inventory (BDI: Beck & Steer, 1993b) respectively.
Results
Table 1 shows the means and SDs of the measures. The median number of parasuicidal
acts (raw frequencies) was 6 and the range was 0113.
In order to examine whether over-general autobiographical recall makes an
independent contribution to the prediction of parasuicide, a multiple regression
analysis was conducted with the transformed measure of parasuicide as the dependent
variable. The BDI, BAI, and Tr. Anger were entered simultaneously as predictors in a
first step, giving a R
2
of .56 (F(3,19) = 8.10, p = .001). When the measure of over-
general memories was entered in a second step, the change in R
2
was .10, which was also
significant (F(1,19) = 5.09, p = .04). R
2
for the final equation was .66, which was
highly significant (Adjusted R
2
= .58, F(4,18) = 8.65, p < .001). However, the
partial correlations from the final equation, also shown in Table 1, reveal that the
coefficient for the measure of over-general memories was negative. Thus, the more the
borderline patients produced over-general memories the less they engaged in
parasuicide, other things being equal.
Discussion
The results of the multiple regression analysis suggested, contrary to prediction, that a
tendency to produce over-general memories on the Autobiographical Memory Test is
associated with less rather than more frequent parasuicide. Thus, although over-general
recall is associated with poor social problem solving (Evans et al., 1992; Goddard et al.,
Table 1. Means and SDs of measures and correlations with frequency of parasuicide
Correlations with parasuicide
Measure M SD Zero order Partial
AMT 7.4 4.2 70.32 70.47*
BAI 35.6 12.3 0.55** 0.54*
BDI 35.2 10.7 0.60** 0.64**
Tr. Anger 26.9 5.6 70.18 70.26
Parasuicide 13.3 25.2
*p < .05; **p < .01, two-tailed.
Key. AMT = Total generic memories on the Autobiographical Memory Test; BAI = Beck Anxiety
Inventory; BDI = Beck Depression Inventory; Tr. Anger = Trait Anger subscale from the StateTrait
Anger Expression Inventory.
Note. Means and SDs for parasuicide are for frequencies of episodes but the correlations are based on the
natural logarithm of the frequency. The partial correlations are from the multiple regression analysis when
all measures were entered as predictors.
116 Mike Startup et al.
1995; Sidley et al., 1997) and difficulties in imagining specific futures (Williams et al.,
1996), it appears it is not associated with increased parasuicide in borderline personality
disorder, in the short term at least.
One major limitation of this study is that parasuicide was assessed from retrospective
self-reports. Since both autobiographical retrieval and reporting of parasuicidal acts
depend on memory, the two measures may be confounded. That is, the correlation
between the number of over-general memories and the number of parasuicides may have
been negative because those patients who experienced difficulties in retrieving specific
memories in response to cue words also had difficulties recalling specific parasuicidal
acts. However, Linehan et al. (1991), in their study of cognitive-behavioural treatment
of chronically parasuicidal borderline patients, found good agreement between scores on
the Parasuicidal History Interview (PHI) and therapist notes on the number of
parasuicidal acts, and between PHI scores and physician or nurse ratings of the lethality
of the parasuicidal methods. These results show that borderline individuals memories of
parasuicidal acts can be accurate when they are asked directly about them. Nevertheless,
future research on predictors of parasuicide in BPD would benefit from prospective
designs with continuous monitoring of parasuicide.
If the negative correlation found in this study between the number of over-general
memories and the number of parasuicides should prove to be replicable with improved
methods, a theoretical account for it might be derived from Williams use (Williams,
1996; Williams, Stiles, & Shapiro, 1999) of descriptions theory (Norman & Bobrow,
1979) as a framework to explain over-general recall. This theory suggests that a directed
memory search may be aborted when a mnemonic cue activates categoric intermediate
descriptions that begin to retrieve fragments of a specific episode with high affective
content. In such cases, only the intermediate descriptions are available for recall. The
latter, according to this theory, lead to ruminative self-focus whereas retrieving specific
episodes leads to acute emotional dysregulation if the episodes are associated with
intense negative affect.
If over-general autobiographical recall is effective in the avoidance of distressing
memories, as this theory suggests, if distressing memories increase emotional
dysregulation, as they do in depression and post-traumatic stress disorder (Reynolds
& Brewin, 1999), and if emotional dysregulation is a major cause of parasuicide, as
research suggests (MacLeod, Williams, & Linehan, 1992), then one would expect over-
general recall to be associated with less, rather than more, parasuicide. According to this
view, over-general recall may have, for some borderline patients at least, an adaptive
function acting to protect the individual from the build-up of the kinds of thoughts,
memories, and feelings that spiral to cause self-harm. This would seem to be consistent
with the common clinical experience that re-exposure of borderline individuals to the
specific details of their traumatic experiences often leads to extreme escalations of
parasuicidal behaviour if those individuals have not previously learned means of
controlling parasuicidal urges (Linehan, 1993). A protective function would also help to
explain why over-general recall is maintained despite its detrimental effects on
important abilities such as social problem solving.
The negative correlation found in this study between the number of over-general
memories and the number of parasuicides appears to be inconsistent with the results of
previous research on autobiographical memory and parasuicide. However, almost all of
117 Memory and parasuicide in BPD
the previous research has focused on patients who had been admitted to hospital
following deliberate self-poisoning (Evans et al., 1992; Sidley et al., 1999; Williams &
Broadbent, 1986; Williams & Dritschel, 1988; Williams et al., 1996). Although
suicidal intent was not assessed in any of these studies, it seems likely that many of the
patients intended to kill themselves. The one exception was the study by Kuyken and
Brewin (1995), which asked directly about suicide attempts (though no details were
given about the method used to assess suicide attempts nor were the results of the
assessment presented). Unfortunately, suicidal intent was not assessed in the present
study either, but parasuicide was defined to include all kinds of deliberate self-harm,
including acts that are evidently not life-threatening. Since parasuicidal behaviour with
and without the intent to die appear to be distinct in terms of lethality, age at onset, sex
ratio and interpersonal meaning (Gardner & Cowdry, 1985), it is likely that the present
study and previous ones focused on different, albeit partially overlapping, behaviours.
Perhaps most crucially, the most common motive for parasuicidal acts that are evidently
not life-threatening appears to be relief from intolerable tension occurring in the context
of overwhelming negative affect (Favazza, 1989; Herpertz, 1995; Leibenluft, Gardner, &
Cowdry, 1987). Thus, it may be that over-general recall is protective only from this
kind of parasuicide. Future research on this topic would be strengthened if the motives
for, and lethality of, the parasuicide were assessed.
That BDI and BAI scores within the BPD group in this study were positively
associated with the amount of parasuicide was not surprising given that parasuicide
among people with personality disorders has been found to be related to affective
disorders (Fyer et al., 1988) and somatic anxiety (Simeon et al., 1992). However, it was
found in this study that anxiety and depression are independently and approximately
equally associated with the amount of parasuicide, which appears not to have been
reported before. Moreover, since linear associations were found between depression and
anxiety, on the one hand, and the transformed measure of frequency of parasuicide, on
the other, this suggests that the real associations between these variables are roughly
logarithmic. Thus increases in anxiety or depression lead to disproportionate increases in
self-harm. This also appears not to have been reported before.
The partial correlation between the measure of trait anger and the frequency of
parasuicide in the present study was small and non-significant. Previous studies have
shown that parasuicide patients are more angry, hostile and irritable than non-suicidal
psychiatric patients and general population control groups both before and after their
parasuicidal behaviour (MacLeod et al., 1992). However, these studies were based on
comparisons of group means and cannot be interpreted in terms of anger causing
parasuicide. The discovery by Simeon et al. (1992) that the amount of self-mutilation
over the lifetime within a group of patients with personality disorders correlated
(r = .43) with ratings of inappropriate chronic anger gives stronger support to the idea
that anger is causally implicated. However, in their study of patients with BPD, Soloff et
al. (1994) found that the patients with a history of self-mutilation expressed less
hostility than the patients with no history of self-mutilation. Thus, the results of studies
to date are inconsistent and further research will be required to elucidate the role of
anger in parasuicide.
In conclusion, the results of this study suggest that over-general autobiographical
recall is negatively associated, and anxiety and depression are positively and
118 Mike Startup et al.
independently associated, with frequency of parasuicide among patients with BPD.
Over-general autobiographical recall may help to protect borderline individuals from
parasuicidal acts by helping them to avoid distressing memories.
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