Understanding Borderline Personality Disorder (BPD) Crisis Presentations

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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% outpatients, 25% agitated
emergency patients
BPD often present in crisis, suicidal and often
in ED
Challenging to work with
 
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
 
 
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
undefined
 
 
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.”
 
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
 
Abandonment
 
Stormy relationships
 
Identity disturbance
 
Impulsivity
 
Chronic suicidality
 
Mood reactivity
 
Emptiness
 
Anger/rage
 
Paranoia/dissociation
 
 
Negative counter transference reaction
Manipulation
Self-sabotage
Help-seeking, help-rejecting pattern
Transitional objects, “teddy bear” sign
 
Just a negative reaction to a patient
A cross-sectional diagnosis
A hopeless case
 
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
 
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
undefined
 
 
“an unstable period”
 
“a crucial stage or turning point”
 
A sudden worsening
 
“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
 
Loss
Abandonment
Rejection
Financial stress
Impulsive behaviour
Self-loathing
 
Conflict in relationships
Intoxication
Being alone
Trauma
New
Re-enactment
Triggers
 
SPLITTING
 
PROJECTIVE IDENTIFICATION
 
Bad
Object
 
Good
Object
 
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
 
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.
 
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
 
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
 
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 3
rd
 decade)
Paris 
suggests higher risk of suicide in late 30s, no
active treatment, failed treatment
 
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.”
 
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
 
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
 
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.”
 
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%)
 
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
undefined
 
 
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
 
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
 
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
 
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
 
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
 
Reinforce successful adaptive strategies
Distraction
+ self talk
Thought stopping
Substitution
Grounding
Journalling/artwork
Emotion log/ emotion sheets
 
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
 
 
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
 
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
 
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
 
Helpful to give the patient something
Follow-up appointment
Crisis line number
Prescription/meds
Voice mail
Treatment plan
Written note
 
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
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Borderline Personality Disorder (BPD) is a common and challenging disorder, especially in clinical populations. With prevalence varying from 1-2% in the general population to up to 25% in agitated emergency patients, BPD often presents in crisis situations, leading to suicidal behavior and frequent visits to the Emergency Department. Diagnosis of BPD can evoke strong reactions, with issues of both over and under-diagnosis. Treatment approaches may sometimes oversimplify the complex needs of patients. This discussion delves into recognizing BPD, managing crisis presentations, and effective strategies to treat BPD during crisis episodes.


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

  2. 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. 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. 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. 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.

  6. 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

  7. Abandonment Mood reactivity Stormy relationships Emptiness Identity disturbance Anger/rage Impulsivity Paranoia/dissociation Chronic suicidality

  8. Negative counter transference reaction Manipulation Self-sabotage Help-seeking, help-rejecting pattern Transitional objects, teddy bear sign

  9. Just a negative reaction to a patient A cross-sectional diagnosis A hopeless case

  10. 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

  11. 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

  12. an unstable period a crucial stage or turning point A sudden worsening

  13. 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

  14. Loss Abandonment Rejection Financial stress Impulsive behaviour Self-loathing Conflict in relationships Intoxication Being alone Trauma New Re-enactment Triggers

  15. SPLITTING PROJECTIVE IDENTIFICATION Good Object Bad Object

  16. IDEALIZED, GOOD OBJECT DEVALUED, BAD 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 Dismisser Doesn t listen or empathize Dismisses patient concerns Reacts angrily Challenging, confrontational Gives cookbook , unhelpful suggestions

  17. RESCUER DISMISSER Feeds into splitting Divides team Decreased pt. Responsibility Boundary violations Isolated with pt. Burned out Abandon pt. Escalate pt. Anger Increased suicide risk Pt. Threats, complaints Reject pt.

  18. 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

  19. 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

  20. 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

  21. 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.

  22. 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

  23. 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

  24. 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.

  25. 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%)

  26. 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

  27. 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

  28. 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

  29. 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

  30. 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

  31. 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

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

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

  34. 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

  35. 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

  36. 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

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

  38. 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

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