Dr. S. Finch MD,CM, FRCPC, ABAM-Diplomate

1. Dr. S. Finch MD,CM, FRCPC, ABAM-Diplomate Crisis, What Crisis? A Systematic Approach to Crisis Management of Borderline Personality Disorder in the Emergency Department

2. Introduction • BPD is common disorder, especially in clinical populations • Prevalence 1-2% general population, up to 10-20% outpatients, 25% agitated emergency patients • BPD often present in crisis, suicidal and often in ED • Challenging to work with

3. Introduction 2 • Diagnosis engenders strong reactions • Over diagnosed and under diagnosed • Black and white approach to treatment • Patient’s concerns may be dismissed, suicide risk minimized and negative outcomes blamed on patient

4. Systematic Approach to BPD crisis • Most literature based on intensive outpatient treatments • Crisis management strategies usually end with transfer to ED • Today’s discussion, 3 parts: • Diagnosis and recognition of BPD • Crisis presentations • Strategies to treat BPD in crisis

5. BPD Diagnosis and Recognition

6. Definition of PD • DSM-IV-TR defines a PD as: “enduring subjective experiences and behaviour that deviate from cultural standards, are rigidly pervasive, have an onset in adolescence or early adulthood, are stable through time and lead to unhappiness and impairment.”

7. BPD • Borderline between psychosis and neurosis • characterized by extremely unstable affect, behaviour, mood, self-image and object relations • ICD-10: emotionally unstable PD • “as-if” personality

8. BPD: DSM-IV-TR criteria • Abandonment • Stormy relationships • Identity disturbance • Impulsivity • Chronic suicidality • Mood reactivity • Emptiness • Anger/rage • Paranoia/dissociation

9. BPD: Associated Features • Negative counter transference reaction • Manipulation • Self-sabotage • Help-seeking, help-rejecting pattern • Transitional objects, “teddy bear” sign

10. BPD is not... • Just a negative reaction to a patient • A cross-sectional diagnosis • A hopeless case

11. Co-morbidities • more commonly have childhood histories of physical and sexual abuse, neglect, and early parental loss and separation • Frequently co-morbid with other PDs • Axis 1: mood disorders, PTSD, SUDs, eating disorders, ADHD, panic disorder, dissociative disorders

12. BPD Etiology • Unknown • Multifactorial • heterogeneous • Genetic/neuroanatomy • Amygdala/limbic system • Serotonin 5HTT transporter gene • Heritability inconsistent • Dimensional, genetic phenotypes • Livesley – four factor model • Developmental • Kernberg – object relations • Mahler – object constancy • Bowlby – insecure attachments • Bipolar variant • Recent review (Paris,Gunderson) did not support • Complex PTSD • Herman

13. Crisis Presentations

14. What is a Crisis? • “an unstable period” • “a crucial stage or turning point” • A sudden worsening

15. Typical Crisis Presentation • “frantic effort to avoid abandonment” manifests itself in an exaggerated, often maladaptive response • Attempt to solicit caring response • Present in crisis due to extreme response, instability, affect dysregulation, lack of social supports, trauma history • Self harm, suicidality, aggression/anger, intoxication, risky impulsivity, psychosis/dissociation

16. What triggers a Crisis? • Loss • Abandonment • Rejection • Financial stress • Impulsive behaviour • Self-loathing • Conflict in relationships • Intoxication • Being alone • Trauma • New • Re-enactment • Triggers

17. Counter transference reactions Splitting Projective Identification Good Object Bad Object

18. How do we respond to a crisis? Idealized, good object Devalued, bad object Dismisser Doesn’t listen or empathize Dismisses patient concerns Reacts angrily Challenging, confrontational Gives “cookbook”, unhelpful suggestions • Rescuer • Wants to help pt • Takes over • Over advocates • Poor boundaries • Reinforced by pt. statements such as: “you are the only one who has ever understood”

19. Dangers and Pitfalls Rescuer Dismisser Escalate pt. Anger Increased suicide risk Pt. Threats, complaints Reject pt. • Feeds into splitting • Divides team • Decreased pt. Responsibility • Boundary violations • Isolated with pt. • Burned out • Abandon pt.

20. Counter transference • Interactions can lead to re-enactments of negative, traumatic relationships • Interactions can make pt. worse and increase suicide risk • Important to be real, caring, set limits, enforce boundaries – therapeutic for the patient

21. Suicide Risk and Assessment • 8-10% of patients with BPD complete suicide • Patients with BPD represent 9-33% of all suicides • History of suicidal behaviour in 60-78% of patients with BPD • Chronic suicidality with 4 or more visits to psych ED, most often diagnosed with BPD, 12% of all psych ED visits • Common co-morbidities increase suicide risk • BPD pts. have multiple suicide risk factors

22. Suicide risk 2 • McGirr et al., 2007 • BPD suicide associated with higher levels Axis 1 co-morbidity, novelty seeking, hostility, co-morbid PD, lower levels harm avoidance • Fewer psych hospitalizations and suicide attempts but increased SUD, cluster B co-morbidity • Pompili et al., 2005 • Higher rates of suicide in short term vs. Long term follow-up, suggests highest suicide risk in initial phases of illness • Links suggests higher risk of suicide in young pts. (adolescence to 3rd decade) • Paris suggests higher risk of suicide in late 30s, no active treatment, failed treatment

23. Suicide risk 3 • Zaheer, Links, Liu Psychiatric clinics NA, 2008 • RCT, 180 patients, BPD + recurrent suicidal behaviour • Prospective trial to assess risk factors of high lethality vs. Low lethality attempters • High lethality attempters: older, more children, PTSD, other PD esp. ASPD, specific phobia, anorexia, lower GAF, more childhood abuse, more exp to meds, more hospitalizations, more expectation of fatal outcome • Independent variables: exp fatal outcome, schizotypal dim, PTSD, lower GAF, specific phobia, # psych admissions last 4 months • “suffering chronic illness course with significant psychosocial impairment. These patients may be demonstrating an escalating series of suicide attempts with more and more suicide intention.”

24. Suicide Risk 4 • Acute on chronic risk • Acute stressors and acute risk factors increase acute risk • Many BPD pts. meet criteria for Form 1/3 chronically • Current Axis 1 co-morbidity, substance use, stressors, lack of protective factors and supports • 3 signs that immediately precede pt. Suicide: a precipitating event, intense affective state, changes in behaviour patterns • Hendin et al., 2001

25. To Admit or Not to Admit? • Dawson – never admit a patient with BPD • influential • Paris, Linehan – recommend against admission • Positively reinforcing socially • Reinforces suicidal and self-destructive behaviours • Regression • Sometimes patients admitted due to lack of connection with resources • APA Guidelines 2001 • Indications for brief hospitalization: • Imminent danger to others • Serious suicide attempt, loss of control suicidal impulses • Psychotic episodes with poor judgement/ poor impulse control • Severe unresponsive symptoms interfering with functioning

26. Admission? 2 • Patient quote from Williams, 1998 • “Do not hospitalize a person with BPD for more than 48 hours. My self-destructive episodes – one leading right into another – came out only after my first and subsequent hospital admissions, after I learned the system was usually obligated to respond....When you as a service provider do not give the expected response to these threats, you’ll be accused of not caring. What you are really doing is being cruel to be kind. When my doctor wouldn’t hospitalize me, I accused him of not caring if I lived or died. He replied, referring to my cycle of repeated hospitalizations, “That’s not life.” And he was 100% right.”

27. Admission? 3 What Actually Happens • Pascual et al., 2007 • 11,578 consecutive visits to psych ED • BPD diagnosed for 9% (1032 visits), 540 individuals • 11% hospitalized – suicide risk, danger to others, symptom severity, difficulty with self-care, non-compliance to treatment • Pts. with BPD had greater clinical severity, percent hospitalized lower (11 vs 17%)

28. Admission? 4 • General Principles: • Try to discharge • Admit as briefly as possible • Overnight in ER or holding beds • Keep voluntary • Carefully assessed diagnosis essential • Care plans • Good discharge planning

29. Approach to Crisis management in ED

30. Approach 1: WAIT! • Triage BPD patients last as long as safely contained in ED • Some pts leave before seen • Some pts settle, use own resources to manage crisis • + reinforcement of positive behaviour, - reinforcement extreme behaviours

31. Approach 2, outpatient strategies • Linehan, 1993 • Listen to emotional content of sucidality/crisis and validate feelings • Identify circumstances leading to feelings • Dialogue with pt to develop alternative solutions • Livesley, 2005 • Safety and managing crises • Containment • Control and regulation • Interventions to reduce self-harming behaviours • Controlling and regulating dysphoria • Reframing triggering situations

32. Approach 3 • Listen and empathize • Validate pt • Help pt id emotions • Develop rapport • Rogers-empathy, non-judgemental, unconditional + regard • Get at underlying trigger and emotion • Often pt unaware • Helps defuse • Therapeutic • Avoid, proactive • Suicide assessment • Expression of distress • May shift • Reassess regularly • Acute vs. Chronic • Don’t dwell on it • May reflect escape, control

33. Approach 4: Containment • Relief from emotional pain comes from connection to someone who understands • Align with pt’s distress and offer support and understanding • Weakened by failure to acknowledge distress, lengthy attempts to clarify feelings, interpretations • Strategies • Praised for seeking help • Help pt id strengths • Survival skills • Put situation into perspective

34. Approach 5: Plan • Mobilize supports-family, friends, professionals • Stepwise way to approach crisis • Follow-up arrangement • Caring statements, photographs • Can always come back to ED • Joint Crisis Plans: pt and are team prepare ahead of time

35. Approach 6: Simple CBT techniques • Reinforce successful adaptive strategies • Distraction • + self talk • Thought stopping • Substitution • Grounding • Journalling/artwork • Emotion log/ emotion sheets

36. Medications 1 • Benzodiazepines • Antidepressants • Mood stabilizers • Antipsychotics • AVOID except acutely • Dependency • SSRIs>MAOIs • Low mood, anxiety, impulsivity, anger • Anger management • Safety risks – OD, preg • Helps all symptoms • Low dose, prn, ongoing • Side effects • Typical vs. atypical

37. Medications 2: General Principles • Meds are tools to help with symptom control • Meds symptom based vs. generally helpful • First do no harm • OD potential • Pregnancy risk • Med dependency/diversion • withdrawal • Prescriptions for small amounts

38. Medications 3: what happens in practice • Pascual et al, 2008 • 11,578 consecutive visits to psych ED over 4 years • 1032 (9%) visits diagnosed BPD, 540 individuals • Prescribe benzos • Male sex, anxiety, good self care, few med or drug problems, housing instability • Prescribe antipsychotics • Male sex, danger to others, psychosis • Prescribe antidepressants • Depression, little premorbid dysfunction

39. Medications 4: Atypical Antipsychotics in ED • Damsa et al, 2007 • 25 pts, severe agitation + BPD • Received 10mg im olanzapine • Reduced agitation, good tolerance within 2hrs • 16% required second dose • Pascual et al, 2004 • 12 BPD pts • Received ziprasidone 20mg im then oral ziprasidone 40-160mg/day, monitored up to 2 weeks • Overall significant improvement, well tolerated

40. Transitional Objects • Helpful to give the patient something • Follow-up appointment • Crisis line number • Prescription/meds • Voice mail • Treatment plan • Written note

41. Contracting for Safety • Beware • No medico-legal value • Does not replace assessment, treatment plan, documentation • Helpful when ongoing therapeutic relationship • Sometimes helpful as part of suicide assessment • Do not base clinical decisions on contract