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Ashley Smith: BPD in our Community

Ashley Smith: BPD in our Community. Ronald Fraser, MD, CSPQ, FRCPC Assistant Professor Department of Psychiatry McGill University Dalhousie University. Disclosure. Disclosure. Ashley Smith. History. Ashley Smith born January 29, 1989 in NB, adopted at age 5 days

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Ashley Smith: BPD in our Community

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  1. Ashley Smith:BPD in our Community Ronald Fraser, MD, CSPQ, FRCPC Assistant Professor Department of Psychiatry McGill University Dalhousie University

  2. Disclosure

  3. Disclosure

  4. Ashley Smith

  5. History • Ashley Smith born January 29, 1989 in NB, adopted at age 5 days • Reportedly uneventful childhood • Age 13-14: distinct behavioral change • By age 15: 14 appearances before juvenile court for petty crimes • Multiple suspensions from school

  6. History • Initial assessment in March 2002 – no evidence of mental illness • Second assessment in March 2003: • ADHD • Learning Disability • Borderline Personality Disorder with Narcissistic traits

  7. History • 2003-2006 – remanded numerous times to NB Youth Center • Initial charge at age 14 for throwing crab apples • Assaulting guards, pranks like setting off sprinklers and fire alarms – 50 additional charges • > 800 incidents and minimum of 150 attempts to self-harm • Self-strangulation and self-mutilation

  8. History • February 23, 2005 – enters system for the final time at age 17 • January 2006, she turned 18 • October 2006 – transferred to adult correctional system

  9. History • October 5, 2006 – SJRCC – mostly in segregation due to out of control behavior • Tasered twice, pepper sprayed once • October 26, 2006 – transferred to federal system and Nova Institute • Over the next 11 months she was transferred 17 times amongst 8 federal institutions

  10. Ashley Smith at Age 19

  11. History • October 16, 2007 –she requested transfer to a psychiatric facility • October 18, 2007 – placed on suicide watch • October 19, 2007 – died in custody • 2011 Inquest • 2012 Inquest • Homicide but no liability

  12. What is Borderline Personality Disorder?

  13. Symptoms of BPD • Erratic mood swings; intense anger • Living without an “emotional skin” • Chaotic relationships; interpersonal problems • Self-mutilation & suicide • Substances, gambling, reckless driving, sex • Distortions in thinking; transient paranoia

  14. Etiology • Bio-psycho-social vulnerability factors • Biological • Psychosocial • Diagnosed in adolescence, early adulthood • 75% in treatment for BPD are women

  15. Prognosis • The bad news: • Can be among the most difficult disorders to treat because common sense approaches can backfire • The good news: • Individuals with BPD get better when treated with evidence-base therapies and interventions • True in clinical contexts and in the community

  16. Community prevalence • 10-13% prevalence of personality disorders • 2% BPD (American Psychiatric Association, 2000) • In Quebec, estimation of 84,000 citizens

  17. In mental health services • 10-15% in emergency • 40% in inpatient services • Increased drugs & alcohol abuse • Self-mutilation • 24,437 seen in Ontario emergencies (Stats Canada, 2009) • Suicides involving a diagnosis of BPD • 25% of adult suicides • 33% of youth suicides

  18. Psychosocial services • Youth protection services • 50% of mothers with BPD traits (Perepletchikova et al., 2010) • 360 mothers in Centre jeunesse de Montreal only • Many adolescents followed by protective services

  19. Judicial system • 2.2 million youths arrested in 2003 • 60% in court procedure have mental illness • the majority, personality disorders • 70-85% of crimes involve a personality disorder diagnosis • Familicide in Quebec 1986-2000 (Léveillé et al., 2007) • 37.5% BPD traits • 18.8% had BPD

  20. 84,000 Québecois with BPD Tel jeune interveners Women’s Shelter workers Siblings Other family Child Psychiatrists YPS workers Parents Judges Lawyers Children Teachers Conjoint Judges Conjoint Patient Police Conjoint Mental Health Professionals Emergency Staff Friends Co- workers General Practitioners Union reps SOS suicide interveners Community workers and millions affected

  21. Why is BPD so costly?

  22. BPD costs economy millions The personal costs of BPD have a domino effect

  23. BPD costs economy millions

  24. BPD costs economy millions

  25. BPD costs economy millions

  26. BPD costs economy millions “The social costs and disruptions caused by PDs is disproportionate to the amount of attention this disorder gets in public consciousness, in government research and clinical funding, in medical and graduate school, and in psychiatric residency training” Frances, Paris, & Reugg, 2006

  27. Case vignette

  28. Case vignette: Chantal 1999 (26 years old) • Begins heavy resource use • Numerous ER visits • Multiple hospitalizations • Numerous psychotherapies • Poly medications

  29. Case vignette: 1995 - 2005 1995 - 2005 Medications Risperidal, Zyprexa, Seroquel, Largactil, Haldol, Nozinan Remeron, Effexor, Parnate, Nardil, Prozac, Paxil, Celexa, Wellbutrin, Serzone, Nortriptyline, Imipramine Lithium, Epival, Tegretol, Topamax, Neurontin, Lamictal Ritalin, Ativan, Rivotril, Valium

  30. Case vignette: Chantal 1995 - 2005 • Treatments • ECT • Weekly individual psychotherapy • Twice weekly group psychotherapy • Extremely close psychiatric follow-up

  31. Case vignette: Chantal 2005-2008 • Entered specialized BPD program • Weekly individual and group therapy • Psychiatric follow-up each 2-4 weeks • 3 medications • Clozapine, Mipramine, Seroquel

  32. Case vignette: Chantal Cost 2002 – 2005 $272,000 2006 – 2008 $0

  33. Case vignette: Chantal Cost 2002 – 2005 $17,000 2006 – 2008 $0

  34. Case vignette: Chantal Since discharge in August 2008 • No psychotherapy • Psychiatric follow-up each 4-8 weeks

  35. Allan Memorial Institute

  36. MUHC patients with BPD Before and after specialized program

  37. What is the solution?

  38. What is needed? • Knowledge • Skills • Teaching and Training • Research Or, a website that provides a doorway to all of the above

  39. Who can benefit? • Health providers and clinicians • Students • 30% of continuing medical education via Internet (2008) • Effective • Cost efficient • Evidence-based medical decision making • Formal E-learning virtually nil in BPD • Language issue

  40. Who can benefit? Police, legal practitioners Youth Protection Services interveners Community workers Schools Unions Government agencies and others

  41. How can it benefit? • Change perceptions of BPD • Training to deliver superior services • Help all those that interface with BPD • Help streamline service delivery systems • Increase knowledge at all levels • Save money

  42. Return on investment • A web site is cost-effective • Implication for the plan d’action • National & international potential • Quebec as innovative leader

  43. Why are we the best • Clinical expertise • experience • outcomes • excellence • Teaching excellence • McGill: a leader in RUIS standards of care • McGill’s international reputation • McGill has done this before

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