Assessment and Management of Borderline Personality Disorder in the General Hospital Setting

Psychiatric TimesVol 41, Issue 2

In this CME article, examine the etiology of poor medical outcomes in borderline personality disorder and learn more about the assessment and management of patients with reported borderline personality disorder who have been admitted medically.

borderline personality disorder



Premiere Date: February 20, 2024

Expiration Date: August 20, 2025

This activity offers CE credits for:

1. Physicians (CME)

2. Other

All other clinicians either will receive a CME Attendance Certificate or may choose any of the types of CE credit being offered.


To discuss the etiology of poor medical outcomes in borderline personality disorder and to provide a framework for psychiatrists when consulted for the assessment and management of patients with reported borderline personality disorder who have been admitted medically.


1. Appreciate the role that consultation-liaison psychiatrists play in enhancing not only the psychiatric outcomes of medical hospitalized patients with borderline personality disorder but also the medical outcomes.

2. Understand from the consultation-liaison perspective how to assess patients with reported borderline disorder and the behavioral, psychotherapeutic, and psychopharmacologic strategies that can be employed in managing these patients.


This accredited continuing education (CE) activity is intended for psychiatrists, psychologists, primary care physicians, physician assistants, nurse practitioners, and other health care professionals who seek to improve their care for patients with mental health disorders.


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This activity is funded entirely by Physicians’ Education Resource, LLC. No commercial support was received.


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“Ms R.,” a 26-year-old female patient with an unclear psychiatric history, type 2 diabetes mellitus, and frequent urinary tract infections, was hospitalized for flank pain and fever found to be pyelonephritis. Ms R. frequently refused blood draws or antibiotics, requested transfer to a “better hospital,” and verbally abused staff, claiming “nobody cares about my pain.” Ms R. repeatedly demanded to speak with a psychiatrist without divulging a reason, ultimately prompting a psychiatry consult for nonadherence.

Borderline personality disorder (BPD) is a cluster B personality disorder characterized by a high degree of impulsivity and marked instability in self-image, emotions, and interpersonal relationships.1 BPD was initially named as such because psychoanalysts in the 1930s considered patients with this condition to represent the “middle ground” between the then-called neurotic patients, who were “more in touch with reality” and had unconscious conflicts manifesting in depression and anxiety, and psychotic patients, who were “less in touch with reality” and had unconscious conflicts manifesting in delusions and hallucinations.2 Because of their tendency to brief psychotic regressions, these patients were thus on the “borderline” between psychosis and neurosis. At the time, more phenomenological diagnoses of personality disorders had not been developed.

BPD affects 0.7% to 2.7% of adults.1 The condition can be notoriously difficult to treat, even in comparison with other personality disorders,3 requiring a combination of psychotherapeutic, behavioral, and pharmacologic strategies. However, despite assumptions that patients with BPD are untreatable, the majority of patients who receive comprehensive treatment do achieve remission.1

Patients with BPD have worse general medical health and are overrepresented in the general hospital setting,4 where their health care is managed by clinicians who have significantly less experience caring for such patients compared with psychiatrists. Patients with BPD are also more likely to behave in ways that frustrate and challenge health care teams (including treatment refusal and nonadherence), leading to worse health outcomes. Psychiatry consults for patients with BPD are often vaguely or inaccurately worded, reflecting the inherent distress in caring for patients with severe personality pathology.

The purpose of this CME article is to help consultation-liaison (C-L) psychiatrists assess and treat patients with BPD in the general hospital setting, applying psychiatric principles to management of patients as well as effective liaison with primary teams.

Physical Health Outcomes in BPD

Patients with BPD have increased overall rates of health care utilization, including visits to primary care offices, use of diagnostic imaging services, and medical hospitalizations. Patients with active or unremitted BPD are almost twice as likely as patients with remitted BPD to be medically hospitalized.5,6 This is likely due, at least in part, to their worse physical health.

In comparison with their remitted counterparts, nonremitted patients with BPD are significantly more likely to have a history of chronic “syndromelike” conditions such as chronic fatigue or fibromyalgia.5,6 They are also more likely to have a history of other chronic medical conditions such as obesity, osteoarthritis, diabetes mellitus, hypertension, back pain, and urinary incontinence.5 Furthermore, these patients are more likely to have lifestyle factors that contribute to systemic medical illness, such as a sedentary lifestyle, cigarette smoking, and drug and alcohol use.

The poor physical health of patients with BPD manifests in decreased life expectancy, up to 20 years less than those without personality pathology.7 This health disparity is driven primarily by poor physical health and associated harmful health behaviors.

Why do patients with BPD have worse physical health and medical outcomes? There are 3 possible explanatory models, which will also inform the C-L psychiatrist’s approach to assessment and management of patients with BPD. These include the reciprocal model, the biological predisposition model, and the countertransference model (Figure).

FIGURE. Models Explaining Why Patients With BPD Have Worse Medical Outcome

Figure. Models Explaining Why Patients With BPD Have Worse Medical Outcome

In the reciprocal model, the medical burden carried by patients with BPD makes it harder for them to recover from their BPD. In turn, their now-exacerbated psychiatric illness causes them to exhibit poor self-care, worsening these patients’ medical condition. A similar model has been proposed to explain the relationship between peripheral artery disease and major depressive disorder.8 The reciprocal model highlights the need for C-L psychiatry to appreciate both the psychiatric and the systemic medical needs of the patient while highlighting those interrelationships for other health care staff in order to better coordinate care.

In the biological predisposition model, patients with BPD have some underlying biological/genetic condition that leads to both an increased likelihood of poor physical health and an increased likelihood of developing BPD. In support of this model is the finding that the heritability of BPD is moderate to high.9 This model accentuates the importance of obtaining a developmental and longitudinal history to better appreciate the likely shared etiologies of both psychiatric and systemic medical comorbidities.

Finally, and most relevant for the present discussion, is the countertransference model. In this context, countertransference refers to the emotional reaction of the clinician to the patient. Patients with BPD evoke strong negative countertransference in psychiatrists and other psychiatric clinicians,10 and this effect is likely even stronger in nonpsychiatric health care staff, given their limited training in caring for patients with BPD. The strong negative emotional response patients with BPD can evoke in their general medical teams can thus result in worse medical care, leading to the poor general medical outcomes and resultant increased health care utilization seen in this population.

The countertransference model necessitates the familiarity of the C-L psychiatrist with defenses such as splitting and projective identification, as well as the importance of explaining these concepts to primary medical and nursing teams to reduce the negative sequelae of countertransference.

Countertransference in Medically Hospitalized Patients With BPD

Patients with BPD may evoke a variety of feelings in their caretakers; classically these feelings will be negative, but they may also be positive. For example, a medical staff member might feel a stronger need to care for the patient and consequently become overinvolved if that patient is “being good” with that staff member. However, patients with BPD are more likely to behave in a way that leads to frustration and anger for their health care team members. This is because patients with BPD are less able to cope with emotionally challenging situations like medical hospitalization.

In response to the acutely stressful scenario of systemic medical illness, patients with BPD may exhibit a variety of maladaptive defense mechanisms including acting out, dissociating, passive aggression, manipulation, splitting, and projective identification. These defense mechanisms then provoke negative emotions in those who interact with patients exhibiting these behaviors. We will next focus on the latter 2 defense mechanisms, splitting and projective identification, which have been found to distinguish BPD from other personality disorders.11

Splitting is a defense mechanism wherein the patient becomes unable to hold 2 opposing thoughts simultaneously and sees individuals and situations as either “all good” or “all bad.”11 Splitting points toward a common theme in BPD: These patients live at the extremes (eg, seeing each day as either absolutely amazing or terrible). Splitting can be especially problematic in the general medical setting for multiple reasons.

First, general medical staff are less likely to be familiar with common behaviors in patients with BPD compared with psychiatrists and are consequently less practiced in being aware of and responding to behaviors like splitting.

Furthermore, the hierarchical nature of the hospital setting and health care teams creates an environment that can amplify the harmful effects of splitting. For example, a patient with BPD may see the nurses on the team as being “all bad” and the physicians on the team as being “all good.” The nurses may then become frustrated with this dynamic. However, due to fear of hierarchy-related reprisal, the nurses may feel that they cannot openly communicate this frustration to the physicians; instead, they may sublimate their frustration in a way that hinders patient care.

Projective identification is another hallmark defense mechanism in patients with BPD.11 Here, the patient attributes an unwanted aspect of themselves to another individual. For example, if the patient sees themselves as “bad,” they may ascribe this belief to a medical staff member. This projection can be so strong that the staff member acts out the projection unconsciously and begins treating the patient as if they are “bad.” Mere awareness of this defense mechanism may be enough to defuse it and prevent its negative consequences, and more specific approaches on how to respond to projective identification will be discussed later.

Assessment of BPD in the General Medical Setting

Upon initial interview, Ms R. began listing a litany of complaints against the “incompetent” staff and noted that the C-L psychiatrist was the only person who listened to her. With great effort, the interview was steered toward obtaining a psychiatric history, which revealed multiple prior psychiatric diagnoses, including bipolar disorder and schizophrenia, but no clear history of manic or psychotic episodes. Further history and chart review showed a childhood history of trauma, prior self-harm, and multiple psychiatric hospitalizations with no consistent outpatient psychiatric care, as well as numerous psychotropic medication trials without clear benefit.

In DSM-5-TR, BPD is diagnosed when the patient exhibits a “pervasive pattern of instability” in interpersonal relationships, self-image, and affect, along with marked impulsivity.12

This is indicated by the presence of 5 of the following 9 symptoms: (1) a pattern of unstable and intense interpersonal relationships with alternation between idealization and devaluation, (2) identity disturbance, (3) impulsivity in at least 2 areas that are self-damaging, (4) affective instability, (5) inappropriate and intense anger or difficulty controlling anger, (6) chronic feelings of emptiness, (7) recurrent suicidal behavior, (8) transient stress-related paranoid ideation or severe dissociative symptoms, and (9) frantic efforts to avoid abandonment. BPD begins by early adulthood, presents in multiple contexts, and causes functional impairment (Table12).

TABLE. Diagnostic Criteria for BPD

Table. Diagnostic Criteria for BPD12

Differential diagnoses include bipolar disorder (patients with BPD are often misdiagnosed as having bipolar disorder13), major depressive disorder, delirium, posttraumatic stress disorder, and attention-deficit/hyperactivity disorder. Recall that psychiatric comorbidity is common in these patients. Ideally, C-L psychiatrists are able to establish the diagnosis by obtaining a thorough history directly from the patient rather than relying solely on chart review, as many patients who carry the BPD label in the electronic medical record (EMR) may not actually have this disorder. Future efforts should be aimed at establishing the accuracy of the BPD diagnosis in EMRs, including the option to edit problem lists retroactively after a definitive diagnosis is rendered.

Previous research has identified that psychiatric diagnoses made by nonpsychiatric physicians are in accordance with the final C-L psychiatrist diagnoses only approximately 50% of the time. Nonpsychiatric physicians are especially inaccurate in diagnosing personality disorders.14

When assessing the patient, careful attention should be paid to the time course of the patient’s symptoms. BPD is necessarily a pervasive and persistent condition, and it is essential that C-L psychiatrists do not overdiagnose patients without BPD who are temporarily acting in a way that is not consistent with their usual personality structure. In other words, not every patient acting out—especially in the medical setting—necessarily has BPD. Here, chart review may have some utility in giving the psychiatric consultant some information on how the patient responded on previous admissions, which may provide a more longitudinal representation of the patient.

The overall form that the patient gives to their life history can provide valuable information for making the diagnosis. For example, a patient struggling to give a coherent narrative history of their life may be manifesting their identity instability.4 Furthermore, if available, collateral data from friends and family of the patient may be helpful in making a diagnosis of BPD: A romantic partner can be queried about a pattern of instability in their relationship, and the patient’s parents could be asked about a history of self-harm.

Moreover, sustained observation of the patient over the span of multiple consultant visits can again help the consultant formulate a more global assessment of the patient’s general psychiatric condition. For example, a patient’s chronic inability to form stable interpersonal relationships may become evident in their frequent clashes with staff throughout 1 (or more) admission(s).

Finally, self-report screening scales such as the McLean Screening Instrument for BPD as well as structured interviews such as the Structured Clinical Interview for DSM-5 Personality Disorder are available to aid in assessment.15 Educating patients on the condition may be helpful in making the diagnosis when the patient finds that they do or do not identify as having specific features of BPD.

BPD is frequently comorbid with other psychiatric conditions, including depressive and bipolar disorders (80% to 96% of patients with BPD have a comorbid depressive or bipolar disorder), anxiety disorders (88%), substance use disorder (64%), or posttraumatic stress disorder (30%).15,16 The presence of comorbidities may make assessing the patient more challenging. For example, diagnosing BPD in a medically hospitalized patient with a substance use disorder is difficult, as these 2 conditions have overlapping symptoms domains, including impulsivity, affective lability, and externalizing behaviors.4 Ultimately, BPD can and should be distinguished from other psychiatric disorders, and making this distinction is essential for guiding treatment planning.

Management of BPD in the General Medical Setting

Behavioral Interventions Aimed at the Health Care Team

Given the corrosive effects of classic behaviors of patients with BPD such as splitting and projective identification on health care staff, one of the most valuable interventions for C-L psychiatrists when consulted for a patient with BPD is to liaison with the primary team and health care staff working with the patient and assess for negative impact.

The first step in this process is to assess the team’s emotions and orientation toward the patient. This can begin with an appreciation of the tone of the consult.17 For example, a manipulative patient may trigger a guilty consult. If the patient with BPD is self-destructive and suicidal, the consultee may approach the C-L psychiatrist in an angry, frustrated manner. The C-L psychiatrist should also speak with other members of the health care team, including nurses, physical therapists/occupational therapists, and bedside sitters, to gauge their perception of the patient.

After becoming aware of the team dynamics in relation to the patient with BPD, C-L psychiatrists should aim their efforts at creating an open dialogue around the patient through, for example, arranging team meetings. This is especially important if team members are starting to become frustrated with the patient or each other. Creating an open dialogue among team members gives them a full view of the patient, which can mitigate the consequences of, for example, splitting.

This kind of intervention is crucial, as worse relationships among medical team members are associated with worse medical outcomes, including increased rates of medical complications, whereas improved trust and mindfulness among medical team members is associated with decreased complication rates.18 When C-L psychiatrists encourage open dialogue and address countertransference, patients may receive better medical care and have improved medical outcomes.

C-L psychiatrists should also deploy interventions aimed specifically at addressing splitting if the patient is exhibiting this defense mechanism. As stated, the problem with splitting arises when the patient pits the “good” staff members against the “bad” staff members, while simultaneously being “good” with the “good” staff members and being “bad” with the “bad” staff members. When this happens, staff become suspicious of each other, and communication suffers—and when communication suffers, the patient suffers.

The most important solution to this problem involves reestablishing open communication among staff so that they develop a well-rounded view of the patient.19 It must also be made clear to the patient that they cannot destroy the caregiving system or be destroyed by it. It may be helpful to remind the staff, especially those who have limited experience caring for patients with BPD, that these defense mechanisms incite frustration in even the most experienced caregivers. Statements like “yeah, everybody gets frustrated by these kinds of patients” may be helpful in allowing the staff to vent their negative emotions away from the patient, so that they can remain as empathetic and compassionate as possible when working with the patient.

Similarly, promoting staff self-care—for example, by reminding staff to take breaks and spend time with other patients—will help prevent staff burnout.4 Firm, nonpunitive limit setting, to be discussed shortly, is also crucial for addressing splitting. So, when engaging with health care teams caring for patients with BPD in acute medical settings, C-L psychiatrists should assess the team’s orientation toward the patient, promote open communication among staff, and educate team members on BPD behaviors and their consequences, keeping in mind that these interventions are ultimately in service of the patient.

Behavioral Interventions Aimed at the Patient

In addition to behavioral interventions aimed at the team, C-L psychiatrists should directly work with patients to minimize any harmful consequences of typical BPD defense mechanisms. Setting limits is one of the most fruitful ways in which C-L psychiatrists can improve the course of a hospital stay for a patient with BPD. Limits are guidelines enacted by clinicians to counter or prevent antisocial, passive-aggressive, or self- destructive activity.20

Limits should be firm but not overly rigid. They should be just firm enough to prevent the unwanted behavior without being overly restrictive on the patient. Repetition is also key to setting limits, and the patient should be gently reminded of the limit if they try to breach it.

In setting limits, it is important to appeal to the patient’s sense of entitlement rather than impinging on this sense. Statements like “you deserve the best medical care we can give you, which is why we want to taper your lorazepam” may demonstrate to the patient that your goals are aligned with theirs and encourage cooperation. Lastly, one should avoid being drawn into arguments or negotiations regarding limits, which are not likely to improve any aspect of patient care.

Projective identification is a hallmark BPD defense mechanism wherein the patient externalizes an unwanted feeling onto another person, who may consequently unconsciously accept the unwanted feeling as their own.17 For example, a patient with BPD may hold hateful feelings toward themselves and thus believe that their physician hates them as well. The negative consequences of this defense mechanism arise if that physician unconsciously begins to act hatefully toward the patient.

To prevent this, C-L psychiatrists should ensure that health care team members remain cognizant of their own feelings toward the patient. Feelings toward the patient should be accepted without judgment and should be used as data about the patient. Through this process, negative feelings toward the patient are used to enhance patient care rather than harm it.


Brief psychotherapy may have some utility in managing BPD in the general medical setting. In general, psychotherapy is likely effective in treating BPD. A systematic review and meta-analysis with 2256 patients in 33 trials found that both dialectical behavioral therapy (DBT) and psychodynamic approaches are more effective than control treatments, although effects were small and the durability of the effect at follow-up was questionable.21 However, randomized controlled trials support the efficacy of DBT, and other modalities such as mentalization-based therapy are also likely to be effective. DBT may also have utility in preventing harmful polypharmacy.22

The question remains regarding how to translate these findings into the general medical setting. Full intervention using DBT or other evidence-based therapies is not possible during a few consultation visits. However, merely providing the patient with DBT worksheets may relieve some of their distress during the hospitalization.

Training in DBT or other evidence-based modalities may make all interactions with patients with BPD more productive and therapeutic. Brief tactical therapy can be employed when seeing patients with BPD who are receiving acute medical care. The rationale for this is that the patient’s illness might unlock a state where they have the capacity for change. Moreover, the process of recovering from a general medical illness may serve as a template for the patient making recoveries in other aspects of their life.

Brief tactical therapy consists of 2 maneuvers, roughly corresponding to the frame and the content in traditional psychotherapy: Containment involves controlling affect, distorted cognition, and destructive behavior, while intervention involves correcting the patient’s maladaptive life trajectory by helping them modify the narratives around their life. Of utmost importance prior to initiating any therapy when a patient with BPD is medically hospitalized is to ensure that the patient is willing and able to engage in therapy. Their medical condition must be taken into consideration when making these decisions.

Good psychiatric management (GPM) is another empirically validated tool that should readily be deployed by psychiatrists for all patients with BPD who are medically hospitalized. GPM’s core principles include “an active, not reactive, interpersonal approach; selective validation and support; education on diagnosis and polypharmacy risks; collaborative goal setting; and problem-solving adaptive response to interpersonal stressors.”4

GPM has been shown to be as effective as DBT in treating BPD23 while requiring less training and being more time efficient, making it ideal for use on general medical floors by C-L psychiatrists. For example, a C-L psychiatrist taking the nonreactive stance stipulated by GPM will avoid the common pitfall of overprescribing psychotropic medication for patients with BPD who are transiently acting out.


Very weak evidence exists to support the use of psychotropic medications in BPD; behavioral interventions and psychotherapeutic approaches should be first line.24 There is some evidence for symptom-based treatment, which may be especially relevant in the general medical setting, where the patient may be in an acute crisis necessitating more urgent symptomatic management.25 Pharmacotherapy should be considered if the patient is so agitated that they are unable to receive medical care.

Regarding symptom-based treatment, there is some evidence for the use of antipsychotics for paranoia, which should be used at lower doses compared with when treating psychotic disorders such as schizophrenia. Antidepressants have demonstrated utility for anxiety and anger but are unlikely to be useful in the short time that most patients are medically hospitalized. Meanwhile, mood stabilizers such as carbamazepine have the best evidence for impulsivity, anger, anxiety, and depressed mood. Although psychotropic medications should primarily used to improve the patient’s symptoms, the mere act of prescribing medication may help build alliance and relieve distress in the patient.26

Pharmacotherapy, however, may confer an increased risk of iatrogenesis when compared with behavioral or psychotherapeutic interventions and should be initiated cautiously, given the limited benefits of medications in BPD.26 Polypharmacy and drug interactions should be considered when treating patients with BPD who are receiving acute medical care, especially since these patients may be receiving additional medications that they do not normally take.19 For example, macrolide antibiotics inhibit enzymes belonging to the cytochrome P450 system that are also responsible for metabolizing atypical antipsychotics, which can precipitate antipsychotic toxicity.27

Considering the elevated rates of polypharmacy in the BPD population, C-L psychiatrists should be vigilant for signs of delirium in these patients, especially when antipsychotics or benzodiazepines are being administered. All patients receiving antipsychotics acutely should be monitored via EKG for QTc prolongation.

Finally, evidence-based deprescription methods should be employed cautiously in patients who are in acute medical crisis, which can easily be exacerbated by psychiatric decompensation. However, if possible, C-L psychiatrists should at least consider deprescription in an effort to reduce iatrogenesis.28

Concluding Thoughts

The C-L psychiatrist agreed to see Ms R. for a predetermined time interval daily during her hospitalization. The C-L psychiatrist also encouraged nursing staff to be present during medical team rounds to reduce splitting and provided behavioral strategies to the medical team and nursing staff as part of their consult notes.

Initially, Ms R. reacted with anger, claiming abandonment when the C-L psychiatrist would not present on demand. However, she was frequently reminded that the C-L psychiatrist would return, but only at the specified time. The psychiatrist also took the nonreactive stance prescribed by GPM, avoiding caving to the patient’s demands when paged by nursing. Ultimately, the patient began working within the limits that were set and was discharged with plans for outpatient psychiatric follow-up.

We have argued that the poor general medical outcomes experienced by patients with BPD may be at least in part attributable to these patients receiving worse medical care as a result of the corrosive behaviors, such as splitting, they are capable of exhibiting. In light of this, when a C-L psychiatrist is consulted for a patient with BPD, it is essential that they employ behavioral interventions aimed at both the patient and the treatment team to mitigate these behaviors so that the patient can receive the best possible acute general medical treatment.

Psychotherapeutic approaches can also be employed, while psychopharmacologic treatment should be used for symptomatic management only if nonpharmacologic interventions remain ineffective. Meanwhile, proper management begins with proper assessment; this is especially relevant for the present discussion, as patients with BPD are often misdiagnosed.

Finally, many of the management strategies outlined in this article, such as the discussion of brief tactical therapy, are based on theory rather than observation. More data on the management of patients with BPD in the general medical setting are essential to address the disparities these patients face in terms of their physical health outcomes.

Mr Nemeh is a student at the University of Texas Southwestern Medical School in Dallas, Texas. Dr Khandai is an assistant professor in the Department of Psychiatry at the University of Texas Southwestern.


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