Crisis-focused psychosocial interventions for borderline personality disorder: systematic review and narrative synthesis

Abstract

Background Mental health crisis presentations are common in those who have a diagnosis of borderline personality disorder (BPD), and psychosocial interventions should be provided. However, there is limited evidence outlining what a crisis-focused psychosocial intervention for this population should include. Aims To conduct a systematic review and narrative synthesis of crisis-focused psychosocial interventions for people diagnosed with BPD. Method Three databases (MEDLINE, Embase, PsycInfo) were searched for eligible studies. Studies were included if they were quantitative studies comparing a crisis-focused intervention with any control group and they included adults (18+ years of age) who were diagnosed with BPD (or with equivalent experiences). A narrative synthesis was undertaken to analyse results. Results A total of 3711 papers were initially identified, 95 full texts were screened and 5 studies were included in the review. Two of five studies reported on the same trial, so four individual trials were included. Overall moderate risk of bias across studies was identified. The review tentatively demonstrated that crisis-focused psychosocial interventions are feasible and acceptable to people with BPD and that they have potential impacts on outcomes such as self-harm and number of days spent in hospital. There is limited consensus on what outcome measures should be used to assess the impact of interventions. Conclusions There is presently insufficient data to recommend any specific psychosocial crisis intervention for people with BPD. Given the relationship between BPD and the high frequency of crises experienced by this group, further large-scale trials examining crisis-focused psychosocial interventions are required. Statement on language We acknowledge that the term personality disorder can be controversial and stigmatising. As the term borderline personality disorder has been retained in DSM-5 and is used in the research evidence base we have decided to use this term throughout this review. However, we recognise that this term may not be acceptable to all.

Crisis and acute mental health care for people who have been given a diagnosis of a ‘personality disorder’: a systematic review

“…The literature for acute care is smaller than for community care for people with this diagnosis, which is also under researched [ 67 ]. The review included studies that were found in the previous more focused reviews [ 10 , 12 ], but also included a wider range of literature.…”

“…A Cochrane review performed in 2022 of crisis interventions designed for people with a ‘personality disorder’ diagnosis found only two studies: a RCT of a brief admission intervention [ 9 ] and a pilot RCT of crisis planning [ 10 , 11 ], both reporting no effect of the study intervention compared to treatment as usual. A systematic review conducted in May 2022 searched for randomised and observational studies of crisis-focused psychosocial interventions for ‘borderline personality disorder’ that can be delivered within acute care and found five studies [ 12 ]. In four of these studies the intervention was a form of psychological therapy and in one study the intervention was joint crisis planning.…”

A proposed clinical pathway for the patients with Borderline Personality Disorder presenting to Emergency Departments

“…14 Unnecessary admissions may cause harm through psychological trauma and disconnection from ongoing psychotherapeutic approaches. 3 Repeated, frequent presentations to hospital can lead to negative outcomes including increased suicidality, through interference with out-patient treatment, workplace absences, reduction of self-agency, reinforcement of institutionalised dependency, and potentially, behavioural reinforcement of suicidality. 11,14 Hospital presentations may be correlated with BPD severity, or may be indicative of the relative insufficiency of existing services to coordinate care in meeting the complex needs of these patients.…”

“…Patients with borderline personality disorder (BPD) who present repeatedly to Emergency Departments (EDs) with self-injury, intense affective lability and interpersonal dysfunction often receive unstructured, reactive, high-intensity and protracted inpatient care, aimed at providing immediate distress containment, despite the lack of evidence for its effectiveness. 1 , 2 , 3 Interpersonal dysfunction associated with BPD increases negative attitudes among clinicians. 4 Attitudes towards patients with BPD can be negative when compared to patients with other psychiatric diagnoses, partially related to a lack of education and training.…”

Effective management of patients with borderline personality disorder in a busy acute inpatient ward using dialectical behaviour therapy principles

“…9 There is presently insufficient data to recommend any specific psychosocial crisis intervention for people with BPD. 10…”