How to manage a borderline personality disorder (BPD) crisis?

Managing a Borderline Personality Disorder Crisis

In a BPD crisis, prioritize immediate safety assessment, minimize restraints, provide crisis-specific psychotherapy (particularly DBT skills), and avoid benzodiazepines—reserving low-potency antipsychotics like quetiapine only for severe acute agitation that poses imminent danger. 1

Immediate Crisis Assessment and Safety

First-line approach: Assess for imminent risk of self-harm or suicide, then deploy brief intensive psychotherapy rather than defaulting to medication or hospitalization. 2

• Conduct medical screening to rule out co-occurring medical disorders that may present as psychiatric symptoms, as BPD patients have high rates of baseline medical comorbidity 3
• Evaluate specifically for suicidal ideation, self-harm behaviors, severe dissociative symptoms, and risk of harm to others 1
• Screen for domestic violence and interpersonal stressors, as social isolation and relationship conflicts are common crisis triggers 3

Crisis Intervention Strategy

Use the least restrictive setting possible and actively discourage physical restraints, as these can escalate rather than de-escalate BPD crises. 3

For Non-Agitated Patients:

• Deploy short but intensive psychotherapy, specifically DBT-based crisis intervention skills including distress tolerance, emotion regulation, and interpersonal effectiveness 2
• Implement or review the patient's crisis response plan, which should identify warning signs, self-management skills, and social supports—this approach shows statistically significant reduction in suicide attempts 4
• Provide immediate access to crisis resources: local crisis call center, National Suicide Prevention Lifeline, Crisis Text Line 3

For Agitated Patients:

• Use symptom-specific pharmacotherapy only when necessary for severe acute agitation 2
• Prescribe low-potency antipsychotics (quetiapine) or off-label sedative antihistamines (promethazine) for short-term crisis management 1
• Avoid benzodiazepines (diazepam, lorazepam) as they may increase disinhibition in BPD patients 5, 1

Disposition and Follow-Up

Mental health and substance use care must remain available even when patients don't meet medical admission criteria but do meet criteria for psychiatric care. 3

• Formulate aftercare services based on existing community resources and partnerships 3
• Arrange for ongoing DBT or psychodynamic therapy, as these are the only treatments with moderate to large effect sizes (standardized mean difference -0.60 to -0.65) for core BPD symptoms 6, 1
• Consider telehealth options for follow-up to maintain continuity while respecting the patient's need for accessibility 3

Critical Pitfalls to Avoid

Do not prescribe medications targeting core BPD symptoms, as there is no evidence that any psychoactive medication consistently improves the fundamental features of BPD. 1

• Antipsychotics like paliperidone should be reserved only for patients who pose risk of injury to self or others due to severe impulsivity, are at risk of losing access to services due to behavioral dyscontrol, or have failed adequate psychotherapy 5
• Medication should never substitute for appropriate psychotherapeutic services, which remain the cornerstone of BPD treatment 5
• Recognize that crisis is a multidimensional subjective experience—interventions should remain person-centered rather than diagnosis-driven 7

Evidence Limitations

Current RCT evidence for specific crisis interventions in BPD is extremely limited, with only two small studies showing no clear benefit over treatment as usual. 8

• Joint crisis plans showed no difference in self-harm episodes, inpatient nights, or quality of life compared to usual care 8
• Brief admission by self-referral similarly showed no clear difference in deaths, self-harm, or days of inpatient care 8
• This lack of robust evidence underscores the importance of focusing on established psychotherapeutic approaches (DBT) rather than novel crisis-specific interventions 6, 9, 8