Background:

Borderline personality disorder (BPD) is frequently encountered in emergency departments. Acute emotional crises, suicidal behaviors, and severe interpersonal distress often precipitate care. Despite the high clinical burden and elevated suicide risk associated with this disorder, guidance for emergency decision-making remains fragmented and sometimes contradictory.

Objective:

This scoping review aimed to identify key elements informing emergency psychiatric assessment, disposition decisions, and acute management strategies for adults diagnosed with BPD. Methods: Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidelines, four electronic databases were searched for studies published between January 1st, 2000, and December 31st, 2025, examining evaluation, orientation, or management of adults with BPD in emergency settings. Eligible studies were screened independently, and data were charted and synthesized thematically.

Results:

Twelve studies met inclusion criteria. Three interrelated domains emerged: structured suicide risk assessment contextualized within chronic vulnerability; preference for brief, goal-directed crisis hospitalization over prolonged inpatient admission; and cautious, symptom-targeted pharmacological use limited primarily to short-term management of acute agitation. Evidence consistently highlighted a paradox in which individuals with BPD often present with severe distress but are admitted less frequently than other psychiatric populations. Emerging clinical pathways emphasize voluntary short stays, rapid follow-up, and linkage to outpatient services to reduce recurrent emergency presentations and iatrogenic harm. Overall, pharmacotherapy plays an adjunctive rather than a central role in emergency care.

Conclusions:

Emergency encounters with individuals living with BPD represent critical inflection points in trajectories often marked by recurrent crises and suicide risk. Current evidence supports structured, formulation-based assessment, time-limited crisis stabilization, and integration with outpatient services, while underscoring significant gaps in high-quality research. Strengthening system-level pathways may enhance safety, continuity, and therapeutic engagement in this high-risk population.

1 Introduction

Borderline personality disorder (BPD) is characterized by pervasive instability in affect regulation, interpersonal relationships, and self-image, accompanied by marked impulsivity and recurrent self-destructive behaviors, including suicidal acts (1). A core feature of the disorder is profound sensitivity to real or perceived abandonment, which often precipitates intense emotional dysregulation and maladaptive coping strategies. Individuals with BPD also frequently experience chronic feelings of emptiness, intense anxiety, and unstable self-perception, which may further contribute to crisis presentations and recurrent emergency service utilization. With an estimated lifetime prevalence of 1%-2% in the general population, BPD is a major public health concern (2). Its high rates of psychiatric comorbidity (including mood, anxiety, substance use, and post-traumatic stress disorders as well as the frequency of self-injurious and suicidal behaviors, contribute to substantial functional impairment and recurrent utilization of emergency services (3–7).

Accordingly, personality disorders account for a significant proportion of psychiatric emergency consultations. Prevalence rates in psychiatric emergency departments have been reported as high as 26%, with BPD alone representing approximately 9% of visits (8, 9). The burden extends beyond psychiatric facilities: in general hospitals, BPD is identified in nearly 2% of all admissions, underscoring its cross-sector impact on healthcare systems (10).

Emergency department (ED) presentations frequently result in either psychiatric hospitalization or referral to outpatient services. However, a striking paradox has emerged in the literature: although individuals with BPD presenting to emergency services often exhibit greater clinical severity compared to other psychiatric populations, they are less likely to be admitted to inpatient units (11–13). Multiple factors may contribute to this discrepancy. Emotional dysregulation and interpersonal volatility may complicate engagement during acute assessment. Structural stigma and therapeutic pessimism toward personality disorders may also influence clinical decision-making. Furthermore, clinical guidelines often emphasize outpatient psychotherapeutic management as the preferred intervention, but access to evidence-based ambulatory treatments is inconsistent or insufficient in many settings (10, 14).

This issue is particularly concerning, considering suicide risk data. An Australian study found that approximately one quarter of individuals with BPD who died by suicide had presented to an emergency department within the six weeks preceding their death (15). Clinicians are therefore confronted with a complex and high-stakes dilemma: whether to proceed with hospitalization (an intervention associated in some reports with potential symptom aggravation and limited protective effect against suicide risk) or to discharge patients toward outpatient services whose availability and continuity of care may be uncertain (16–18). The ethical and clinical tensions are substantial, involving both the imperative to ensure patient safety and the responsibility to direct individuals toward interventions with demonstrated efficacy.

Through a scoping review, we sought to identify key elements to inform clinical decision-making during emergency psychiatric assessments of individuals diagnosed with BPD. Specifically, our objectives were: (1) to delineate factors relevant to hospitalization versus discharge decisions; (2) to clarify recommended care pathways following emergency evaluation; and (3) to synthesize available evidence regarding pharmacological interventions applicable to this population in acute settings.

2 Methods

2.1 Search strategies

This scoping review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) (19). A comprehensive and systematic search strategy was developed to identify empirical and review literature examining the evaluation, orientation, and management of patients diagnosed with BPD in emergency settings.

The electronic databases PubMed, Embase, PsycInfo, and CINAHL were searched to ensure multidisciplinary coverage of psychiatric, medical, psychological, and nursing literature. The search strategy combined controlled vocabulary terms (e.g., MeSH, Emtree) and free-text keywords to maximize sensitivity. Core search concepts included “personality disorder(s),” “borderline AND personality,” and “emergency.” Boolean operators were used to combine terms, and truncation and proximity operators were applied where appropriate to capture variations in terminology. The full search strategy for each database, including the syntax and applied limits, is provided in the Supplemental Materials.

The search covered publications from January 1, 2000, to December 31, 2025. This timeframe was selected to reflect contemporary conceptualizations of BPD, developments in emergency psychiatric practice, and evolving clinical guidelines regarding hospitalization and outpatient management. No restrictions were imposed at the search stage on study design to capture the breadth of available evidence relevant to clinical decision-making in emergency departments. The search strategy was developed collaboratively by MBB and MD, both experienced in psychiatric research methodology.