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For the purposes of this section a “crisis” can be usefully defined as a brief acute, non-illness impairment of functioning characterised by behavioural disorganisation and increased emotional dysregulation with escalating dysphoria. The specific clinical features of a crisis will vary according to the precipitating situation and the personality structure of the individual.

While a crisis is not a clinical disorder, one can contribute to the other. An emergency is more than a crisis and requires a different type of response. Crises may be triggered by stress related to a range of internal or external factors. Frequently interpersonal or social system factors are important contributors. The duration of crisis episodes can vary significantly, but it would be untypical for an acute crisis episode to last beyond 72 hours. However, crises may occur in a connected series.

Many evolving crises will not require specific input from mental health services, especially if the patient has prepared a crisis self-management plan. A distinction can usefully be drawn between a crisis self-management plan and a clinical crisis care plan. A crisis self-management plan is developed by the patient, often with the support of a clinician, and essentially provides a description of a crisis and its early indicators, options and resources which have proved useful in previous crises, things which have previously proved unhelpful when in crisis and which should be avoided, and an outline plan of action for the next evolving crisis. This can be especially useful as problem solving and cognitive flexibility is typically impaired with escalating emotional arousal. In contrast, a clinical crisis care plan is developed by the treating team with the collaboration of the patient to provide a plan outlining how the team aims to respond to the patient’s next crisis.

When intervention by services is indicated, the aim is to enable the patient to return to their usual level of functioning as soon as possible. Clinicians should avoid trying to achieve too much during crisis episodes and keep goals and interventions as simple as possible. Only once the acute crisis has resolved should longer term goals be addressed. In terms of the ‘phase-based approach’ to the treatment of people with personality disorder, crisis management represents Phase 1 (stabilisation) work, with the initial emphasis on safety and containment, although work to promote self regulation is likely to follow shortly after.

Risk assessment is important in crisis episodes, especially of risk of suicide, although other risks should also be considered. During risk assessment, it is important to draw the distinction between chronic (longstanding) and acute (newly increased) risk. Many people with personality disorder have chronic thoughts that life is not worth living or frank suicidal thoughts. Two principal factors which can contribute to an acute increase in risk of suicide are increased intent and increased impulsivity.