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National Collaborating Centre for Mental Health (UK). Borderline Personality Disorder: Treatment and Management. Leicester (UK): British Psychological Society; 2009. (NICE Clinical Guidelines, No. 78.)

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Borderline Personality Disorder: Treatment and Management.

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7MANAGEMENT OF CRISES

7.1. INTRODUCTION

People with borderline personality disorder can often present in a crisis; indeed this is characteristic of many people with the disorder. They present with a range of symptoms and behaviours, including behavioural disturbance, self-harm, impulsive aggression, and short-lived psychotic symptoms, as well as with intense anxiety, depression and anger. As a result they can be regular users of psychiatric and acute hospital emergency services.

Frequent crisis presentation may induce complacency in assessors who fail to estimate the risk accurately; the context of a person’s regular contact with services in a crisis inoculates them against assessing each presentation in its own right. The challenge is to assess risk and to manage the crisis without acting in ways that are experienced by the patient as invalidating or minimising their problems while, at the same time, fostering autonomy. In particular, assessors need to avoid interventions that might cause harm, including undermining a person’s autonomy; this needs to be balanced against the need to intervene. For example, too rapid an admission to hospital may prevent the person from developing skills to manage emotional crises for themselves, and yet refusal to admit the person may endanger them. Assessors need to take into account that the emotional reactivity of patients with borderline personality disorder may mask underlying comorbidities such as depression, while it may also be part of situationally triggered emotional dysregulation that may resolve with limited intervention.

Medication is commonly started when a patient presents in crisis although there is no evidence for the use of any specific drug or combination of drugs in crisis management. In making judgements on the value of psychotropic drugs in the treatment of borderline personality disorder it is important to be aware that there is much prescribing in crisis settings where the imperative to intervene is very strong, which can lead to further prescribing. This has the potential for a dangerous collusion between the patient and the prescriber that should not be fostered if its only gain is short-term satisfaction that is more than offset by long-term adverse effects from continuing prescribed medication. Therefore, when medication is used, it should always be considered in the context of a longer-term treatment plan involving psychological and/or social intervention. Of particular importance is the issue of the patient’s capacity to consent to treatment during times of crisis.

7.2. CURRENT PRACTICE

People with borderline personality disorder may present to a range of emergency services, including ambulance services and emergency departments if self-harm or suicide attempts are part of the presentation, or to the police if public disturbance is part of the picture. Families or carers may be involved in such situations and mental health professionals may approach them in helping to manage crises, while ensuring that they are not over-burdened with responsibility. Crisis teams within mental health services may be called, which enables patients to be offered immediate support while assessment of risk and review of treatment takes place. Offering support and regular contact to the patient is probably the commonest intervention offered in a crisis. On the basis of the crisis evaluation, decisions need to be made to admit or not to admit the person to hospital, offer immediate daily contact including home treatment, arrange outpatient care, continue with scheduled treatment, or start more formal treatment.

7.3. REVIEWING THE EVIDENCE BASE

When searching for RCTs of treatments in people with borderline personality disorder (see Chapter 5 and other evidence review chapters for details of the search for RCTs), none was found in which people had been specifically recruited during a crisis period. Since crises can both pass and recur quickly in people with borderline personality disorder, this is not surprising. Also, the nature of crises in this client group means that there are considerable issues of consent in recruiting people to trials.

This chapter is therefore based on the expert opinion of the GDG (see Chapter 3).

7.4. GENERAL MANAGEMENT OF CRISES

The overall aim during the management of a crisis is to help the person to return to a more stable level of mental functioning as quickly as possible without inducing any harmful effects that might prolong the problems. The person’s autonomy should be maintained as far as possible, their safety and that of others assured, and their emotions, impulses and behaviours reduced to a manageable level. Supportive and empathic comments are necessary in the first instance and these may be particularly beneficial if the initial contact in the crisis is by telephone. Medication use should be limited, following the general guidance below, and should be only for short-term use. Specific goals of treatment should be set.

Vignette of a service user accessing services during a crisis

Being faced with someone with borderline personality disorder in crisis can unfortunately be perceived as quite a daunting prospect for some people. In my experience, though, it needn’t be. Responses don’t need to be that profound or from people with a lot of experience of working with this disorder, they just need to be human. Despite this, I have often found that responses to me during such crises were variable and at times unhelpful. However, I have been fortunate enough to have had some very good responses over the period of my disorder that illustrate this point.

I was experiencing a period of extremely low mood. My psychiatrist who had seen me through most of my journey had recently retired, I had been raped about 6 months previously, and after a destructive relationship had also been through a pregnancy and termination. After previously making so much progress, I was deteriorating rapidly in mood. I had cut-off from my psychologist and was withdrawing from work with my CPN. Although most of the time I was too low to care, at other times I was desperate for connectedness and needed to know that someone was aware of how desperate I was feeling.

I made contact with the out-of-hours social work team by telephone. This is a service that deals primarily with emergency child, welfare and older adult issues, but takes over from the adult mental health out-of-hours service after 10pm. Although most of the social workers are Approved Social Workers and have knowledge of the Mental Health Act and the issues associated with it, the majority of them have not had any specific therapeutic training or any specialist personality disorder related training. The point I am making is that none of them was a skilled therapist with experience of people with borderline personality disorder.

I phoned them and got through to one of the duty social workers who helped me to calm myself enough to talk. This was achieved by him remaining calm, reassuring me and not making me feel that I had limited time or needed to rush. A few gentle questions helped, not, what I call, big questions such as ‘How can I help?’ or ‘What’s happened?’, but smaller questions such as ‘I can hear you’re upset, how long have you been feeling like this’, ‘do you know why you’re feeling like this?’ Big questions such as ‘How can I help?’ or ‘What’s wrong?’ always feel to me too overwhelming and too difficult to find a starting point.

It only took a few little questions to get me started and to begin to articulate what I was feeling. I hadn’t spoken to anyone in days – so I really appreciated not feeling rushed, pressurised into speaking or sensing that the other person was getting frustrated with my inarticulateness. Once I began to speak, it became easier to express my distress with the help of some prompts, some empathy and some help with articulation when I was struggling to express myself. I didn’t need much. I just needed a sense of connection to another human being, to feel reassured; I needed to feel that the person cared enough to have some empathy. I didn’t need anything done, nor crisis admission or referral (even though I would need a more assertive intervention in the weeks to come, that wasn’t what I was looking for or needed at that moment). I didn’t even need anyone specialised. I just needed a caring human response, to hear a voice.

We were on the telephone for only about 30 minutes in total, but it was enough to help and to ‘hold’ me through the night. The social worker gave me the option to ring back again in the night if I needed to, and although I didn’t wish to, it helped me to contain my feelings knowing that the option was there. The other useful outcome of this phone contact was the knowledge that there would be some kind of follow-up the next morning. The social worker following my phone call sent a fax to my CPN outlining the details of my contact with a request for my CPN to ring me to check that I was OK and if any further follow-up was needed. Just knowing that a follow-up and human contact were in place for the next day makes such a big difference in helping to contain the intense emotional distress that can occur with this disorder and stopping situations escalating into admission, crises or self-harm. On this occasion and during a number of previous situations I didn’t need much from my CPN once he rang; sometimes I would need an extra visit, but on other occasions the knowledge that the phone call was to take place was enough to settle me for the time being. Knowing that I’d have an opportunity to talk about the feelings I was struggling with was enough to enable me to manage until the next scheduled appointment time.

7.4.1. Clinical practice recommendations

Clinical practice recommendations relating to the management of crises in primary care can be found in the care pathway in Chapter 8.

7.4.1.1.

When a person with borderline personality disorder presents during a crisis, consult the crisis plan and:

  • maintain a calm and non-threatening attitude
  • try to understand the crisis from the person’s point of view
  • explore the person’s reasons for distress
  • use empathic open questioning, including validating statements, to identify the onset and the course of the current problems
  • seek to stimulate reflection about solutions
  • avoid minimising the person’s stated reasons for the crisis
  • refrain from offering solutions before receiving full clarification of the problems
  • explore other options before considering admission to a crisis unit or inpatient admission
  • offer appropriate follow-up within a time frame agreed with the person.

7.5. PHARMACOLOGICAL MANAGEMENT OF CRISES

7.5.1. Drug treatment during crises

It is recognised that drug treatments are often considered part of the emergency management of crises, sometimes including self-harm and violence, however no specific treatments for borderline personality disorder or for particular symptom clusters are recommended.

Moreover, no drug has UK marketing authorisation for the treatment of borderline personality disorder so the continued prescribing of medication in people with borderline personality disorder should be undertaken with caution and normal prescribing practice for patients at risk of self-harm should be taken into account. Prescribing should, wherever possible, be limited to the short-term management of crises using sedatives (or to the treatment of comorbid conditions). Some advice is available on the use of medication off licence – see ‘Use of licensed medicines for unlicensed applications in psychiatric practice’ published by the Royal College of Psychiatrists (http://www.rcpsych.ac.uk/files/pdfversion/cr142.pdf).

There is no evidence that people with borderline personality disorder, or other personality disorders, need higher doses of drugs than other patients. Dosage should be kept within the normal therapeutic range.

Drugs prescribed during a crisis may be continued inadvertently after the symptoms that presented during the crisis have subsided. This may lead to service users taking more than one drug for an extended period of time – there is evidence that people with borderline personality disorder are prescribed inappropriate combinations and an excessive number of psychotropic drugs at any one time (Sansone et al., 2003; Zanarini et al., 2004a). Any patient, whatever their current diagnosis, who describes a treatment history of polypharmacy with limited beneficial response should have their diagnosis reviewed with consideration given to the possibility of borderline personality disorder.

7.5.2. Clinical practice recommendations

7.5.2.1.

Before starting short-term drug treatments for people with borderline personality disorder during a crisis (see recommendation 7.5.2.2):

  • ensure that there is consensus among prescribers and other involved professionals about the drug used and that the primary prescriber is identified
  • establish likely risks of prescribing, including alcohol and illicit drug use
  • take account of the psychological role of prescribing (both for the individual and for the prescriber) and the impact that prescribing decisions may have on the therapeutic relationship and the overall care plan, including long-term treatment strategies
  • ensure that a drug is not used in place of other more appropriate interventions
  • use a single drug
  • avoid polypharmacy whenever possible.
7.5.2.2.

Short-term use of sedative medication may be considered cautiously as part of the overall treatment plan for people with borderline personality disorder in a crisis.14 The duration of treatment should be agreed with them, but should be no longer than 1 week.

7.5.2.3.

When prescribing short-term drug treatment for people with borderline personality disorder in a crisis:

  • choose a drug (such as a sedative antihistamine15) that has a low side-effect profile, low addictive properties, minimum potential for misuse and relative safety in overdose
  • use the minimum effective dose
  • prescribe fewer tablets more frequently if there is a significant risk of overdose
  • agree with the person the target symptoms, monitoring arrangements and anticipated duration of treatment
  • agree with the person a plan for adherence
  • discontinue a drug after a trial period if the target symptoms do not improve
  • consider alternative treatments, including psychological treatments, if target symptoms do not improve or the level of risk does not diminish
  • arrange an appointment to review the overall care plan, including pharmacological and other treatments, after the crisis has subsided.
7.5.2.4.

After a crisis has resolved or subsided, ensure that crisis plans, and if necessary the overall care plan, are updated as soon as possible to reflect current concerns and identify which treatment strategies have proved helpful. This should be done in conjunction with the person with borderline personality disorder and their family or carers if possible, and should include:

  • a review of the crisis and its antecedents, taking into account environmental, personal and relationship factors
  • a review of drug treatment, including benefits, side effects, any safety concerns and role in the overall treatment strategy
  • a plan to stop drug treatment begun during a crisis, usually within 1 week
  • a review of psychological treatments, including their role in the overall treatment strategy and their possible role in precipitating the crisis.
7.5.2.5.

If drug treatment started during a crisis cannot be stopped within 1 week, there should be a regular review of the drug to monitor effectiveness, side effects, misuse and dependency. The frequency of the review should be agreed with the person and recorded in the overall care plan.

7.6. MANAGEMENT OF INSOMNIA

7.6.1. Introduction

Although insomnia can be a problem for people with borderline personality disorder, there is nothing specific to its management in relation to the disorder. Therefore, general advice relevant to anyone with sleep problems can be given, including advice on sleep hygiene, such as avoiding activity or caffeine near to bedtime.

7.6.2. Clinical practice recommendation

7.6.2.1.

Provide people with borderline personality disorder who have sleep problems with general advice about sleep hygiene, including having a bedtime routine, avoiding caffeine, reducing activities likely to defer sleep (such as watching violent or exciting television programmes or films), and employing activities that may encourage sleep.

7.6.3. Short-term management of sleep disturbance

Some people with borderline personality disorder have found the occasional use of sedative antihistamines useful when sleep disturbance has been associated with emotional instability.

There is also a NICE Technology Appraisal on the use of newer hypnotic drugs in managing insomnia (NICE, 2004b). This recommended:

1.1.

When, after due consideration of the use of non-pharmacological measures, hypnotic drug therapy is considered appropriate for the management of severe insomnia interfering with normal daily life, it is recommended that hypnotics should be prescribed for short periods of time only, in strict accordance with their licensed indications.

1.2.

It is recommended that, because of the lack of compelling evidence to distinguish between zaleplon, zolpidem, zopiclone or the shorter acting benzodiazepine hypnotics, the drug with the lowest purchase cost (taking into account daily required dose and product price per dose) should be prescribed.

1.3.

It is recommended that switching from one of these hypnotics to another should only occur if a patient experiences adverse effects considered to be directly related to a specific agent. These are the only circumstances in which the drugs with the higher acquisition costs are recommended.

1.4.

Patients who have not responded to one of these hypnotic drugs should not be prescribed any of the others.

7.6.4. Clinical practice recommendation

7.6.4.1.

For the further short-term management of insomnia follow the recommendations in ‘Guidance on the use of zaleplon, zolpidem and zopiclone for the short-term management of insomnia’ (NICE technology appraisal guidance 77). However, be aware of the potential for misuse of many of the drugs used for insomnia and consider other drugs such as sedative antihistamines.

Footnotes

14

Sedative antihistamines are not licensed for this indication and informed consent should be obtained and documented.

15

Ibid.

Copyright © 2009, The British Psychological Society & The Royal College of Psychiatrists.

All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. Enquiries in this regard should be directed to the British Psychological Society.

Bookshelf ID: NBK55407

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