How can I effectively manage a patient with BPD who presents with self-harming behavior in a primary care setting?

Effective management of a patient with borderline personality disorder (BPD) presenting with self-harming behavior in primary care involves several key steps. First, recognise the possibility of BPD if the patient has repeatedly self-harmed or shows persistent risk-taking or marked emotional instability, and consider referral to community mental health services for assessment (or to CAMHS if under 18) ¹.

During a crisis presentation, assess the current level of risk to self or others, explore previous episodes and effective management strategies, and support the patient in managing anxiety by enhancing coping skills and focusing on current problems ¹.

Encourage identification of manageable changes to help the patient deal with current problems and offer a follow-up appointment at an agreed time ¹.

If distress or risk is increasing or not subsiding despite attempts to reduce anxiety, or if the patient requests further help, refer to community mental health services ¹.

For self-harm specifically, ensure a psychosocial assessment is carried out, either by referral to specialist mental health services or by a trained primary care professional if referral is not possible ². This assessment should include social, psychological, and motivational factors, suicidal intent, and risk factors ².

Manage the physical consequences of self-harm and consider the toxicity of prescribed medicines and substance use ².

If stopping self-harm is unrealistic short-term, provide harm minimisation strategies such as distraction, coping strategies, wound care, and information on complications and substance impact ².

Develop an individual care plan with goals to improve social/occupational functioning, quality of life, reduce risk-taking, and manage comorbid mental health problems ².

Compile a crisis plan outlining self-management strategies, contact numbers, and steps to take if self-management fails ².

Maintain communication and share care and crisis plans with all involved professionals, including the GP, ensuring the patient is aware of information sharing ².

Drug treatment during crises may be considered short-term but should be used cautiously, with consensus among prescribers, avoiding polypharmacy, and not replacing other interventions ¹.

Throughout, maintain a calm, non-threatening, and empathic approach, validating the patient’s distress and exploring solutions collaboratively without minimising their experience ¹.