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

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

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

Systematic Approach to BPD crisisMost literature based on intensive

outpatient treatmentsCrisis management strategies

usually end with transfer to EDToday’s discussion, 3 parts:

Diagnosis and recognition of BPD Crisis presentations Strategies to treat BPD in crisis

BPD Diagnosis and Recognition

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.”

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

BPD: DSM-IV-TR criteria

Abandonment

Stormy relationships

Identity disturbance

Impulsivity

Chronic suicidality

Mood reactivity

Emptiness

Anger/rage

Paranoia/dissociation

BPD: Associated FeaturesNegative counter transference

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

sign

BPD is not...

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

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

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

Crisis Presentations

What is a Crisis?

“an unstable period”

“a crucial stage or turning point”

A sudden worsening

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

What triggers a Crisis?

Loss Abandonment Rejection Financial stress Impulsive

behaviour Self-loathing

Conflict in relationships

Intoxication Being alone Trauma

New Re-enactment Triggers

Counter transference reactionsSPLITTING PROJECTIVE

IDENTIFICATIONBadObject

GoodObject

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

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.

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

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

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

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.”

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

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

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.”

Admission? 3 What Actually HappensPascual 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%)

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

Approach to Crisis management in ED

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

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

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

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

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

Approach 6: Simple CBT techniques

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

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

Medications 2: General PrinciplesMeds are tools to help with symptom

controlMeds symptom based vs. generally

helpfulFirst do no harm

▪ OD potential▪ Pregnancy risk▪ Med dependency/diversion▪ withdrawal

Prescriptions for small amounts

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

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

Transitional Objects

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

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