Crisis management in borderline personality disorder.

Abstract

Borderline personality disorder (BPD) is a complex and severe mental disorder which manifests in a pervasive pattern of instability in interpersonal relationships and self-image and marked impulsivity (American Psychiatric Association, 2000). The condition is thought to occur globally with a median prevalence of 0.7% (Coid et al., 2006). While many people with BPD are able to negotiate life successfully, there are others who suffer considerably and place a heavy burden on those around them. For example, studies of clinical populations have shown that patients with BPD typically experience significantly greater impairment in their work, social relationships and leisure compared to patients suffering from major depression (Skodol et al., 2002). People with BPD may engage in a variety of destructive and impulsive behaviours including self-harm and are consequently at increased risk of committing suicide (McGirr et al., 2007). In addition, individuals with BPD are more likely to experience adverse life events and their ability to cope with such events might be impaired by poor problem-solving skills (Salkovskis et al., 1990). Despite widespread acknowledgement of these issues, relatively little research has examined the management of acute crises in this population. Although crises are largely subjective in nature, factors commonly associated with the onset of a crisis include: a clear precipitating event causing acute anxiety and emotional suffering; an acute reduction in motivation and problem-solving ability; and an increase in help-seeking behaviour (Sansone, 2004). The nature of crises in individuals with BPD are frequently related to suicidal or homicidal threats, gestures or actions and, consequently, the issue of hospital admission often warrants consideration. However, there remains a widespread belief among clinicians that the problems of such patients are exacerbated by hospital admission and, consequently, there is often resistance to such admissions. BPD patients can certainly pose considerable problems for inpatient staff in terms of splitting and behavioural regression, disruptive behaviour can be intensified or perpetuated by the hospital setting. It has also been reported that the risk of suicide often increases during the initial phase of inpatient hospitalization, although how much of this can be attributed to the process of admission is unclear (Barbe et al., 2005). Against this, there is evidence that patients with comorbid mental state and personality disorders do not fare well with assertive community treatment (Tyrer & Simmonds, 2003) and under such circumstances, admission may be the safer route. Hospital admission may also serve an important function in terms of communicating to the patient that their distress has been taken seriously. In addition, an admission may provide the patient with some distance from a distressing situation and in doing so may help to contain impulsive behaviour. Some authors argue that admissions to a general psychiatric ward should be informal and organized around specific goals agreed between the patient and the clinical team 1 arranged with the clear agreement of nursing staff and should be brief, time limited and goal determined (Bateman & Tyrer, 2004). Ultimately, the use of hospital admission for the acute management of BPD requires systematic research, as data may helpfully inform the debate on the use of hospital beds in the acute management of the condition.