Acute
high risk
New
emerging
risk
Chronic
low risk
High- lethality method of self-harm Low- lethality method of self-harm Chronic pattern ofself-harm behaviour self-harm behaviourNew pattern of
Adapted from Spectrum (personality disorder service for Victoria: www.spectrumbpd.com.au)
Figure 8.1 is a guide to estimating the probable level of risk in a person with BPD who self-harms, by
considering the pattern and lethal potential of self-harm. However, risk may change suddenly or be difficult to predict based solely on the signs and symptoms available to the clinician. Frequent review, a trusting therapeutic relationship and helping the person to build a strong support network are necessary to help keep the person safe. A person who has lived with habitual or persistent low-lethality self-harm over time may be at relatively low immediate risk of suicide (green zone, lower left quadrant in Figure 8.1). However, if that person begins to use potentially lethal methods of self-harm, this may indicate high risk for suicide sustained over the long term (amber zone, upper left quadrant in Figure 8.1). In this circumstance, BPD treatment provided within the community (e.g. a structured psychological therapy) may be more appropriate than admission to a psychiatric acute care facility, given that the person is likely to be at continued high risk over the long-term and may benefit most from building a satisfying way of life and relationships.
If a person assessed as being at long-term low risk begins to show symptoms that are new for them, this may indicate increased risk (amber zone, lower right quadrant in Figure 8.1). An appropriate response would involve closer observation, thorough review to identify and manage co-occurring mental illness, and continued active treatment for BPD, such as a structured psychological therapy. Suicide tends to occur when a person is no longer receiving treatment and has given up on receiving help.266 However, accidental deaths due to self-harm sometimes occur even when a person does not intend to die.266
In a person assessed as being at constant high risk for suicide over a long period (amber zone upper left in Figure 8.1), the appearance of new symptoms, behaviour or emergent co-occurring mental illness may indicate an increase in immediate risk of suicide (red zone, upper right in Figure 8.1). This situation may require a change in the management plan to ensure the person’s immediate safety, while continuing BPD treatment and managing co-occurring mental illness to manage long-term risk. Short-term admission to a psychiatric acute care facility may be appropriate to manage acute risk (see Section 6.3).
8.5.3 Crisis management
For a person with BPD, an adverse experience (whether severe or seemingly trivial) may trigger sudden overwhelming emotional distress and psychosocial dysfunction that lasts for days to weeks. While the risk of self-harm is likely to increase during this time, crises do not always represent psychiatric emergencies and may not involve suicidal behaviour.
Any health professional working with people who have BPD may sometimes be contacted by a person with BPD, or their carer, to report that the person has made a suicide attempt, has threatened suicide, has deliberately injured themselves, or feels desperate and cannot cope. An appropriate response (Table 8.5) might help the person’s recovery and prevent further harm.
Health professionals should take the person’s distress seriously and should respond compassionately, never interpreting the person’s behaviour as merely an attempt to gain attention. Health professionals should stay calm and show a supportive, non-judgemental attitude, and avoid expressing shock or anger, even if the person has self-harmed or behaved recklessly. It is appropriate to show empathy and concern for the person’s situation, without over-reacting (see Table 8.5).
During the crisis, any health professional who is not the person’s main clinician should focus on the ‘here and now’. Issues that require more in-depth discussion (e.g. past experiences or relationship problems) can be dealt with more effectively in longer-term treatment by the person’s main clinician or another provider who is treating their BPD (e.g. psychiatrist). If more than one staff member will be dealing with the person (e.g. nurses and doctors in an emergency department), the roles of all staff should be clearly explained to the person.
A risk assessment should be conducted at the time of crisis (see Section 8.5.1). Psychiatric assessment should be conducted during the crisis, if possible. Co-occurring mental illnesses such as depression or psychosis, and substance use or withdrawal should be ruled out.
Although some patients may need brief inpatient care, a crisis should not automatically trigger admission to a psychiatric acute care facility. A crisis episode need not always require a review of pharmacotherapy or prompt initiation of new medicines.
If the health professional dealing with the situation is not the person’s main clinician, they should find out who normally treats the person for their BPD and contact them to discuss an immediate response and the person’s crisis management plan and BPD management plan. The person’s family, partner and carers or other social supports should also be contacted.
GeneRal PRInCIPles foR TReaTMenT anD CaRe of PeoPle WITH BPD Clinical Practice Guideline for the Management of Borderline Personality Disorder 130
If a person with BPD expresses suicidal thoughts during a crisis, it cannot be assumed that they are at immediate high risk, because some people with BPD live with persistent thoughts of suicide. Health professionals should avoid taking control to prevent possible suicidal behaviour. Instead, ask the person to tell you if they want help, and to tell you as clearly as possible what they think will help. Assume that the person can use public emergency services in an emergency. On many occasions it may be helpful for the health professional to understand that the person is expressing an internal state, and to respond empathically, rather than initiating a more active intervention such as calling the police or arranging admission to an acute psychiatric inpatient facility. If risk assessment suggests that the person is at high immediate risk of suicide or potentially lethal self-harm, a more active response may be appropriate (Table 8.6). Even while responding to an immediate threat of suicide, health professionals can engage the person in future treatment. The health professional dealing with the situation should ascertain whether the person is already involved in psychological treatment and, if so, whether they have been taught skills that could be useful in managing their current distress and suicidal thoughts.
In most cases, even when a person with BPD is suicidal, it will be possible to reach an agreement with the person about their care. The fact that the person has disclosed intent suggests a degree of motivation to seek help.
After the crisis, a follow-up appointment should be made and the person should be referred to other appropriate services as necessary. All services should set up a process for ensuring that anyone who is seen during a crisis attends their follow-up appointment, whether the follow-up consultation is arranged within that service or in a specialised referral service.
Health professionals who deal with a person with BPD during a crisis are liable to experience strong emotions including concern, anxiety, frustration and anger. It is helpful to acknowledge such feelings as a normal response and to seek support or supervision from colleagues.
Table 8.5 Principles of response to a BPD crisis