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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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Page 1: Dr. S. Finch MD,CM, FRCPC, ABAM-Diplomate.  BPD is common disorder, especially in clinical populations  Prevalence 1-2% general population, up to 10-20%

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

Page 2: Dr. S. Finch MD,CM, FRCPC, ABAM-Diplomate.  BPD is common disorder, especially in clinical populations  Prevalence 1-2% general population, up to 10-20%

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

Page 3: Dr. S. Finch MD,CM, FRCPC, ABAM-Diplomate.  BPD is common disorder, especially in clinical populations  Prevalence 1-2% general population, up to 10-20%

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

Page 4: Dr. S. Finch MD,CM, FRCPC, ABAM-Diplomate.  BPD is common disorder, especially in clinical populations  Prevalence 1-2% general population, up to 10-20%

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

Page 5: Dr. S. Finch MD,CM, FRCPC, ABAM-Diplomate.  BPD is common disorder, especially in clinical populations  Prevalence 1-2% general population, up to 10-20%

BPD Diagnosis and Recognition

Page 6: Dr. S. Finch MD,CM, FRCPC, ABAM-Diplomate.  BPD is common disorder, especially in clinical populations  Prevalence 1-2% general population, up to 10-20%

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.”

Page 7: Dr. S. Finch MD,CM, FRCPC, ABAM-Diplomate.  BPD is common disorder, especially in clinical populations  Prevalence 1-2% general population, up to 10-20%

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

Page 8: Dr. S. Finch MD,CM, FRCPC, ABAM-Diplomate.  BPD is common disorder, especially in clinical populations  Prevalence 1-2% general population, up to 10-20%

BPD: DSM-IV-TR criteria

Abandonment

Stormy relationships

Identity disturbance

Impulsivity

Chronic suicidality

Mood reactivity

Emptiness

Anger/rage

Paranoia/dissociation

Page 9: Dr. S. Finch MD,CM, FRCPC, ABAM-Diplomate.  BPD is common disorder, especially in clinical populations  Prevalence 1-2% general population, up to 10-20%

BPD: Associated Features

Negative counter transference reaction

ManipulationSelf-sabotageHelp-seeking, help-rejecting patternTransitional objects, “teddy bear”

sign

Page 10: Dr. S. Finch MD,CM, FRCPC, ABAM-Diplomate.  BPD is common disorder, especially in clinical populations  Prevalence 1-2% general population, up to 10-20%

BPD is not...

Just a negative reaction to a patientA cross-sectional diagnosisA hopeless case

Page 11: Dr. S. Finch MD,CM, FRCPC, ABAM-Diplomate.  BPD is common disorder, especially in clinical populations  Prevalence 1-2% general population, up to 10-20%

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

Page 12: Dr. S. Finch MD,CM, FRCPC, ABAM-Diplomate.  BPD is common disorder, especially in clinical populations  Prevalence 1-2% general population, up to 10-20%

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

Page 13: Dr. S. Finch MD,CM, FRCPC, ABAM-Diplomate.  BPD is common disorder, especially in clinical populations  Prevalence 1-2% general population, up to 10-20%

Crisis Presentations

Page 14: Dr. S. Finch MD,CM, FRCPC, ABAM-Diplomate.  BPD is common disorder, especially in clinical populations  Prevalence 1-2% general population, up to 10-20%

What is a Crisis?

“an unstable period”

“a crucial stage or turning point”

A sudden worsening

Page 15: Dr. S. Finch MD,CM, FRCPC, ABAM-Diplomate.  BPD is common disorder, especially in clinical populations  Prevalence 1-2% general population, up to 10-20%

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

Page 16: Dr. S. Finch MD,CM, FRCPC, ABAM-Diplomate.  BPD is common disorder, especially in clinical populations  Prevalence 1-2% general population, up to 10-20%

What triggers a Crisis?

Loss Abandonment Rejection Financial stress Impulsive

behaviour Self-loathing

Conflict in relationships

Intoxication Being alone Trauma

New Re-enactment Triggers

Page 17: Dr. S. Finch MD,CM, FRCPC, ABAM-Diplomate.  BPD is common disorder, especially in clinical populations  Prevalence 1-2% general population, up to 10-20%

Counter transference reactions

SPLITTING PROJECTIVE IDENTIFICATION

BadObject

GoodObject

Page 18: Dr. S. Finch MD,CM, FRCPC, ABAM-Diplomate.  BPD is common disorder, especially in clinical populations  Prevalence 1-2% general population, up to 10-20%

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

Page 19: Dr. S. Finch MD,CM, FRCPC, ABAM-Diplomate.  BPD is common disorder, especially in clinical populations  Prevalence 1-2% general population, up to 10-20%

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.

Page 20: Dr. S. Finch MD,CM, FRCPC, ABAM-Diplomate.  BPD is common disorder, especially in clinical populations  Prevalence 1-2% general population, up to 10-20%

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

Page 21: Dr. S. Finch MD,CM, FRCPC, ABAM-Diplomate.  BPD is common disorder, especially in clinical populations  Prevalence 1-2% general population, up to 10-20%

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

Page 22: Dr. S. Finch MD,CM, FRCPC, ABAM-Diplomate.  BPD is common disorder, especially in clinical populations  Prevalence 1-2% general population, up to 10-20%

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

Page 23: Dr. S. Finch MD,CM, FRCPC, ABAM-Diplomate.  BPD is common disorder, especially in clinical populations  Prevalence 1-2% general population, up to 10-20%

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.”

Page 24: Dr. S. Finch MD,CM, FRCPC, ABAM-Diplomate.  BPD is common disorder, especially in clinical populations  Prevalence 1-2% general population, up to 10-20%

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

Page 25: Dr. S. Finch MD,CM, FRCPC, ABAM-Diplomate.  BPD is common disorder, especially in clinical populations  Prevalence 1-2% general population, up to 10-20%

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

Page 26: Dr. S. Finch MD,CM, FRCPC, ABAM-Diplomate.  BPD is common disorder, especially in clinical populations  Prevalence 1-2% general population, up to 10-20%

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.”

Page 27: Dr. S. Finch MD,CM, FRCPC, ABAM-Diplomate.  BPD is common disorder, especially in clinical populations  Prevalence 1-2% general population, up to 10-20%

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%)

Page 28: Dr. S. Finch MD,CM, FRCPC, ABAM-Diplomate.  BPD is common disorder, especially in clinical populations  Prevalence 1-2% general population, up to 10-20%

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

Page 29: Dr. S. Finch MD,CM, FRCPC, ABAM-Diplomate.  BPD is common disorder, especially in clinical populations  Prevalence 1-2% general population, up to 10-20%

Approach to Crisis management in ED

Page 30: Dr. S. Finch MD,CM, FRCPC, ABAM-Diplomate.  BPD is common disorder, especially in clinical populations  Prevalence 1-2% general population, up to 10-20%

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

Page 31: Dr. S. Finch MD,CM, FRCPC, ABAM-Diplomate.  BPD is common disorder, especially in clinical populations  Prevalence 1-2% general population, up to 10-20%

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

Page 32: Dr. S. Finch MD,CM, FRCPC, ABAM-Diplomate.  BPD is common disorder, especially in clinical populations  Prevalence 1-2% general population, up to 10-20%

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

Page 33: Dr. S. Finch MD,CM, FRCPC, ABAM-Diplomate.  BPD is common disorder, especially in clinical populations  Prevalence 1-2% general population, up to 10-20%

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

Page 34: Dr. S. Finch MD,CM, FRCPC, ABAM-Diplomate.  BPD is common disorder, especially in clinical populations  Prevalence 1-2% general population, up to 10-20%

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

Page 35: Dr. S. Finch MD,CM, FRCPC, ABAM-Diplomate.  BPD is common disorder, especially in clinical populations  Prevalence 1-2% general population, up to 10-20%

Approach 6: Simple CBT techniques

▪ Reinforce successful adaptive strategies▪ Distraction▪ + self talk▪ Thought stopping▪ Substitution▪ Grounding▪ Journalling/artwork▪ Emotion log/ emotion sheets

Page 36: Dr. S. Finch MD,CM, FRCPC, ABAM-Diplomate.  BPD is common disorder, especially in clinical populations  Prevalence 1-2% general population, up to 10-20%

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

Page 37: Dr. S. Finch MD,CM, FRCPC, ABAM-Diplomate.  BPD is common disorder, especially in clinical populations  Prevalence 1-2% general population, up to 10-20%

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

Page 38: Dr. S. Finch MD,CM, FRCPC, ABAM-Diplomate.  BPD is common disorder, especially in clinical populations  Prevalence 1-2% general population, up to 10-20%

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

Page 39: Dr. S. Finch MD,CM, FRCPC, ABAM-Diplomate.  BPD is common disorder, especially in clinical populations  Prevalence 1-2% general population, up to 10-20%

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

Page 40: Dr. S. Finch MD,CM, FRCPC, ABAM-Diplomate.  BPD is common disorder, especially in clinical populations  Prevalence 1-2% general population, up to 10-20%

Transitional Objects

Helpful to give the patient something▪ Follow-up appointment▪ Crisis line number▪ Prescription/meds▪ Voice mail▪ Treatment plan▪ Written note

Page 41: Dr. S. Finch MD,CM, FRCPC, ABAM-Diplomate.  BPD is common disorder, especially in clinical populations  Prevalence 1-2% general population, up to 10-20%

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