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Crisis, What Crisis? A Systematic Approach to Crisis Management of Borderline Personality Disorder in the Emergency Department
Dr. S. Finch MD,CM, FRCPC, ABAM-Diplomate
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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
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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
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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
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BPD Diagnosis and Recognition
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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.”
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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
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BPD: DSM-IV-TR criteria
Abandonment
Stormy relationships
Identity disturbance
Impulsivity
Chronic suicidality
Mood reactivity
Emptiness
Anger/rage
Paranoia/dissociation
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BPD: Associated Features
Negative counter transference reaction
ManipulationSelf-sabotageHelp-seeking, help-rejecting patternTransitional objects, “teddy bear”
sign
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BPD is not...
Just a negative reaction to a patientA cross-sectional diagnosisA hopeless case
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Co-morbidities
more commonly have childhood histories of physical and sexual abuse, neglect, and early parental loss and separation
Frequently co-morbid with other PDsAxis 1: mood disorders, PTSD, SUDs,
eating disorders, ADHD, panic disorder, dissociative disorders
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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
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Crisis Presentations
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What is a Crisis?
“an unstable period”
“a crucial stage or turning point”
A sudden worsening
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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
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What triggers a Crisis?
Loss Abandonment Rejection Financial stress Impulsive
behaviour Self-loathing
Conflict in relationships
Intoxication Being alone Trauma
New Re-enactment Triggers
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Counter transference reactions
SPLITTING PROJECTIVE IDENTIFICATION
BadObject
GoodObject
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How do we respond to a crisis?
IDEALIZED, GOOD OBJECT
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”
DEVALUED, BAD OBJECT
Dismisser Doesn’t listen or
empathize Dismisses patient
concerns Reacts angrily Challenging,
confrontational Gives “cookbook”,
unhelpful suggestions
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Dangers and Pitfalls
RESCUER
Feeds into splitting Divides team Decreased pt.
Responsibility Boundary violations Isolated with pt. Burned out Abandon pt.
DISMISSER
Escalate pt. Anger Increased suicide risk Pt. Threats,
complaints Reject pt.
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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
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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
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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
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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.”
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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
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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
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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.”
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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%)
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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
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Approach to Crisis management in ED
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Approach 1: WAIT!
Triage BPD patients last as long as safely contained in ED
Some pts leave before seenSome pts settle, use own resources
to manage crisis+ reinforcement of positive
behaviour, - reinforcement extreme behaviours
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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
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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
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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
Interpretation
Confrontation
Clarification Encouragement to
Elaborate
Empathic Validation
Advice and Praise
Affirmation
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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
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Approach 6: Simple CBT techniques
▪ Reinforce successful adaptive strategies▪ Distraction▪ + self talk▪ Thought stopping▪ Substitution▪ Grounding▪ Journalling/artwork▪ Emotion log/ emotion sheets
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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
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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
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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
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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
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Transitional Objects
Helpful to give the patient something▪ Follow-up appointment▪ Crisis line number▪ Prescription/meds▪ Voice mail▪ Treatment plan▪ Written note
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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