Voluntary visual imagery and non-suicidal self-injury in patients with emotionally unstable personality disorder

Background Emotionally Unstable Personality Disorder (EUPD) is characterised by emotional dysregulation, unstable self-identity, interpersonal difficulties, dissociation, and a high prevalence of non-suicidal self-injury (NSSI). Mental imagery plays a role in emotion processing and autobiographical memory. Yet little is known about the relation between voluntary visual imagery and self-harm in EUPD. The study aimed to examine the imagery characteristics, including visual imagery vividness and synaesthetic-like experiences, and their association with NSSI in EUPD. Method Forty adults aged 18-45 years meeting ICD-10 Diagnostic Criteria for Research (ICD-10 DCR) for EUPD were recruited through purposive sampling. Visual imagery was assessed using the Vividness of Visual Imagery Questionnaire-2 (VVIQ-2). NSSI and its functions were assessed using the Inventory of Statements About Self-Injury (ISAS). Synaesthesia-like experiences were screened using a seven-item questionnaire developed for the study. Group comparisons were performed using independent-samples t-tests, and correlations were assessed using Pearson's correlation coefficient. Results Twenty-nine patients (72.5%) with EUPD had NSSI. Participants with NSSI had significantly higher mean VVIQ-2 scores than those without NSSI (118.48 +/- 24.81 vs. 93.36 +/- 35.66; p = 0.016; Cohen's d = 0.89). VVIQ-2 scores correlated positively with intrapersonal ISAS functions (r = 0.38, p = 0.015) but not interpersonal functions (r = 0.19, p = 0.22). Three participants (7.5%) demonstrated imagery scores compatible with probable hyperphantasia. Four participants reported synaesthesia-like experiences. Conclusions Greater visual imagery was associated with non-suicidal self-harm in patients with EUPD. Imagery vividness was predominantly associated with intrapersonal functions of non-suicidal self-harm, particularly affect regulation, rather than interpersonal motivations. These findings suggest that visual imagery may represent a previously under-recognized cognitive factor contributing to emotional dysregulation and self-injurious behaviour in EUPD. Assessment of imagery characteristics may have clinical relevance when designing psychotherapeutic interventions for EUPD.