Inpatient Psychiatric Management

Key principles of inpatient management of borderline personality disorder (BPD) are consistent with many basic lessons from other levels of care. First, it is important to hospitalize reluctantly, differentiating nonlethal from true suicidal intent and searching for the least restrictive safe option. Decision to hospitalize should ideally involve the patient (clearly presenting risk of destabilization) and outpatient team. When hospitalization is recommended, shorter stays are almost always preferable to longer term, which may easily become regressive. It can be helpful to point out the unconscious desire to be cared for, in the safety provided by the structured holding environment. Taking responsibility for patients' needs in times of crisis may inadvertently undermine their capacity to care for themselves. The goals may include keeping the patient safe, exploring incident antecedents, providing education, evaluating current treatment (approach as well as medication regimen), planning transition to aftercare, and including the patient and family in the various steps. Challenges often present themselves around team splitting, family contact, and increasing anxiety while approaching discharge. Helping patients modulate emotions through this process should aim at generalizing behaviors they can use outside of the hospital.