Approximately 69% to 80% of individuals with BPD will self-mutilate or attempt suicide while in this disinhibited state of mind,2 and 10% percent of these will ultimately commit suicide.5 Assisting the patient in resolving the immediate problem is the key component in crisis management. Consider the following recommendations when confronted by a BPD patient in crisis:7

  • Behavioral interventions
  • Establish therapeutic boundaries that provide structure, containment, and direction for the patient. Unclear boundaries may decrease the patient’s sense of safety and trust, which may increase stress and anxiety levels.
  • Ask direct questions about suicide. Inquire about previous suicide attempts and assess the current level of risk to self or others.
  • Inquire about effective management strategies used in the past.
  • Assist in alleviating anxiety by encouraging the use of coping skills and focusing on the current problems.
  • Explore reasonable changes that will enable the patient to deal with the current problems.
  • Develop a formal behavioral treatment plan and schedule a follow-up appointment at an agreed-upon time.
  • Medication management

Use of medications for a short term may be warranted during a crisis period. Health-care professionals must ensure that medications are not used in place of more appropriate behavioral treatment options.

Establish the risk of using any type of medications—consider current use of alcohol or any other substance. Tricyclic antidepressants and selective serotonin reuptake inhibitors may reduce impulsiveness, depression, and anxiety symptoms; however, the benefits of using these medications must be weighed against the high risk of potential overdose.

  • Avoid polypharmacy—use one medication to target symptoms.
  • Choose a medication with a low side-effect profile and low potential for addiction.
  • Use the minimum effective dose.
  • Establish a plan for medication adherence.
  • Discontinue medication if symptoms do not improve.

Consider referring for mental-health services when it is apparent that the anxiety and level of distress have not subsided, when risk of harm to self or others has increased, or when the patient requests services from a mental-health professional.

Primary-care clinicians must be very skilled to successfully manage the care of patients with BPD, particularly during crisis situations. Following the crisis, assess the impact of personal, social, and environmental factors as antecedents. Evaluate the overall treatment strategy, including medication management and safety concerns. Finally, develop a treatment plan in concert with the patient and his or her significant others. Long-term treatment options should include psychotherapy, which is best managed in the psychiatric setting.

Dr. Rowser is an assistant professor and director of the graduate nursing program at the University of Southern Indiana, College of Nursing & Health Professions, in Evansville.

References

1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, D.C.: American Psychiatric Association; 1994.

2. Gabbard GO, Ball VL. Treating borderline personality disorder. Psychotherapy options have increased and appear equally effective. Harv Ment Health Lett. 2010;26:1-3.

3. Coid J, Yang M, Tyrer P, et al. Prevalence and correlates of personality disorder in Great Britain. Br J Psychiatry. 2006;188:423-431.

4. Koekkoek B, van der Snoek R, Oosterwijk K, van Meijel B. Preventive psychiatric admission for patients with borderline personality disorder: a pilot study. Perspect Psychiatr Care. 2010;46:127-134.

5. Fertuck EA, Makhija N, Stanley B. The nature of suicidality in borderline personality disorder. Primary Psychiatry. 2007;14:40-47. 

6. Miller M. Borderline personality disorder: origins and symptoms. Harv Ment Health Lett. 2006;22:1-3.

7. Agency for Healthcare Research and Quality. Borderline personality disorder: treatment and management. 

All electronic documents accessed March 15, 2011