Inpatient Admission

Clinicians who treat patients with Borderline Personality Disorder (BPD) are likely to encounter the question of whether to admit to hospital at some point or another. Patients with BPD have a relatively high rate of multiple service usage, including that of hospital inpatient units and emergency departments. Many patients may consider hospital visitation as a means of containing intolerable affect states, and thus may approach the hospital on a relatively frequent basis. Others may hope to avoid admission, but may end up at hospital due to severe suicidality or other symptoms of a comorbid Axis I disorder (See section on Comorbidities on the Associated Features page).

There is virtually no empirical consensus regarding the use of hospitalization in the treatment of patients with BPD. Although many patients with BPD end up being hospitalized at some point in time, at least for a brief admission, no clinical trials have tested the effectiveness of inpatient treatment for reducing suicidal behaviour or treating other symptoms of the disorder (Paris, 2004). However, findings from a large-scale study in the Netherlands that examined 3 levels of care (outpatient, day treatment, inpatient) for patients with cluster B (primarily borderline) Personality Disorders (PD) found similarly positive outcomes for all three levels (Bartak et al., 2011). Even after accounting for the strong influence of baseline patient characteristics, there seemed to be a slight advantage for inpatient treatment.

According to the American Psychiatric Association Practice Guideline for the Treatment of Patients with BPD (Oldham et al., 2001), indications for extended inpatient hospitalization include: persistent and severe suicidality, self-destructiveness, or nonadherence to outpatient treatment or partial hospitalization; comorbid refractory axis I disorder (e.g., eating disorder, mood disorder) that presents a potential threat to life; comorbid substance abuse or dependence that is severe and unresponsive to outpatient treatment or partial hospitalization (See page on Substance Abuse); continued risk of assaultive behaviour toward others despite brief hospitalization; symptoms of sufficient severity to interfere with functioning, work, or family life (See section on Functional Impairment on the Associated Features page) that are unresponsive to outpatient treatment, partial hospitalization, and brief hospitalization.

The APA practice guidelines recommend brief hospitalization when a patient presents imminent danger to others, has lost control of suicidal impulses or made a serious suicide attempt, is experiencing transient psychotic episodes associated with loss of impulse control or impaired judgement, or has symptoms of sufficient severity to interfere with functioning, work or family life that are unresponsive to outpatient treatment or partial hospitalization. In practice, however, many patients with borderline personality disorder meet these criteria but are never hospitalized (Pascual et al., 2007).

Among the most common reasons why borderline patients are admitted to hospital are serious suicide attempts and episodes of psychosis (Hull, Yeomans, Clarkin, & Li, 1996). Hospitalization in such cases can provide an opportunity for review of a patient’s treatment plan and to control symptoms of psychosis with neuroleptic medication. In general, however, recommendations in the literature suggest that hospitalizations should be brief (Linehan, 1993; Paris, 2004) and that suicidal behaviour is best managed in structured outpatient psychotherapy (McMain, 2007; Oldham, 2006; Paris, 2008). Ultimately, clinical judgement must guide decisions about whether to hospitalize a patient and a range of factors, including the patient’s risk for suicide, need to be evaluated.