Borderline personality disorder can be complicated to treat, especially in frantic and high stress settings like the emergency department or inpatient psychiatric unit. In today’s episode, we’ll address the best practices for managing patients with borderline personality disorder in emergency settings.
Published On: 03/28/2022
Duration: 27 minutes, 57 seconds
Related Article: “Borderline Personality Disorder in the ED,” The Carlat Hospital Psychiatry Report, January/February/March 2022
Victoria Hendrick, MD, Zachary Davis, BS, and Victor Hong, MD, have disclosed no relevant financial or other interests in any commercial companies pertaining to this educational activity.
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Dr. Hendrick: Borderline personality disorder can be complicated to treat, especially in frantic and high stress settings like the emergency department or inpatient psychiatric unit. In today’s episode, we’ll address the best practices for managing patients with borderline personality disorder in emergency settings. And, we have some exciting news for you! You can now receive CME credit for listening to this episode and all new episodes going forward on this feed. Follow the Podcast CME Subscription link in the show notes to get access to the CME post-test for this episode and future episodes.
Welcome to The Carlat Psychiatry Podcast.
This episode is brought to you by the Carlat Hospital Psychiatry team.
I’m Dr. Victoria Hendrick, the Editor-in-Chief of The Carlat Hospital Psychiatry Report, and a clinical professor at the David Geffen School of Medicine at UCLA. I’m also the director of inpatient psychiatry at Olive View -- UCLA Medical Center.
Zachary Davis: And I’m Zachary Davis. I’m a content-coordinator at The Carlat Report. And I’m also a pre-med student who’ll be applying to medical school this year.
Let’s begin with some common issues that clinicians typically encounter when working with borderline patients in the emergency department. It’s important to acknowledge how prevalent individuals with borderline personality disorder are in every psychiatric setting, especially in the emergency department. About 10%–15% of all psychiatric ED patients have borderline personality disorder, and these patients often present repeatedly. That can be very frustrating for clinicians, who might initially think “Wait, didn’t I just see you? You’re here again? You made another suicide attempt?” Adding to the frustration, there’s the issue of chronic suicidality and self-harm behaviors. Many clinicians fear that these patients might attempt suicide if discharged. And , due to the nature of being in a hectic emergency environment mixed with the interpersonal hypersensitivity and short emotional trigger of borderline patients, there’s typically a lot of drama surrounding individuals with borderline personality disorder in the emergency department
So, what interventions work in borderline personality disorder, and what can clinicians in acute care settings do for these patients?
Dr. Hendrick: There are several evidence-based treatments for borderline personality disorder, the most well known being dialectical behavior therapy. There’s also mentalization-based therapy, transference-focused psychotherapy, and other evidence-based treatments. But these modalities are time intensive and require lengthy training, and few practitioners are adequately trained in them. They’re difficult to implement in acute care settings like inpatient units or EDs.
But, overall, it helps to think of patients with borderline personality disorder as a special population who require a distinct, organized approach. Good Psychiatric Management principles, based on APA guidelines, are particularly useful in the emergency setting. Do these principles solve all the problems? Definitely not, but if clinicians and staff have a better understanding about why the patients behave the way they do and how to proactively mitigate that behavior, everyone benefits.
Zachary Davis: What about medications? When should medications be used for borderline personality disorder in an emergency setting?
Dr. Hendrick: I think there’s a tendency to want to give medications to patients when they come to the ED. Generally, we don’t want to give borderline patients the sense that they can’t handle their problems; that they need to turn to medications when in distress. Nevertheless, there are times when the use of certain pharmacotherapies are warranted in this population.
There have been many randomized placebo-controlled trials in borderline personality disorder but most have been short-term studies with inconsistent findings and highly variable samples sizes. There’s only a limited amount of follow-up studies where participants were assessed at 6-, 12-, and 24-months after starting treatment. So, while the evidence is mostly inconclusive for the benefits of pharmacotherapy in borderline personality disorder, there is some evidence supporting the use of certain medications for specific symptom clusters in borderline personality disorder.
There are no FDA-approved medications for borderline personality disorder or any other personality disorder, so everything we’re using is off label. We want to focus on specific symptom clusters, like psychosis or agitation. Low-dose antipsychotics win out for most symptom clusters, like mood dysregulation, paranoia, and dissociation. For patients with comorbid anxiety disorders or a concurrent major depressive episode, SSRIs rise to the forefront. SSRIs sometimes need to be pushed to higher-than-usual doses, whereas for antipsychotics, high doses have not been shown to help more—but of course, they can lead to more side effects.
It’s important to be careful with benzodiazepines. They work well, almost too well, and for a patient who is often distressed and can be easily calmed by a benzodiazepine, that’s a setup for dependence. So, if you use a benzodiazepine, you must be strict about it being very short term.
Zachary Davis: We asked Dr. Victor Hong, who's a Clinical Assistant Professor in the Department of Psychiatry at the University of Michigan, about the principles and benefits of using Good Psychiatric Management for borderline patients in acute care settings. And here’s what he had to say.
Dr. Hong: So you know John Gunderson and his team out in McLean you know they developed this Good Psychiatric Management modality, and really what it’s intended to be is a generalist’s model; something that is easily taught, you know in 8-hour training. There are several specific principles that are certainly relevant for the emergency department so I’ll just say a few. One of the them is making sure that we understand and keep in mind that really the core attribute of these individuals with BPD is this interpersonal hypersensitivity, and as we know and as anyone knows who’s worked in an inpatient unit or in an emergency department the vast majority of crises do come out of some kind of interpersonal stressor: They have an argument; there’s a breakup or a perceived breakup; and the individual self-harms or threatens suicide or attempts suicide and they end up in the emergency department.
So the first thing I would say is that one of the main principles of GPM (the Good Psychiatric Management) modality is this principle of understanding that the core issue is interpersonal hypersensitivity.
So if the clinician can very quickly ask you know sort of “What happened? What brought you in here?” you can really quickly get to the heart of the issue. And I think you know in our experience it helps in a few ways. So one way is that it kind of cuts through all of the white noise and you can kind of quickly see oh, okay, so that’s really why they are there. There is all this other stuff going on in their lives, but this was the acute crisis and it can help you understand if you’ll be able to help them out of that acute crisis and discharge them, or if this crisis is going to last long and is causing such emotion dysregulation that they might need an inpatient unit. So that’s one principle.
The second is, you know, we often think that in the emergency department we don’t have enough time to engage in psychoeducation. So if somebody doesn’t know a lot of BPD or they have not been diagnosed, or they’ve read about it but they’re getting faulty information, I think this is a real opportunity even in that acute care setting to say, “Hey, here are some reading materials. Can we talk about BPD? Does this seem to fit? If so, let’s kind of get you to the most appropriate treatments?” So that’s another principle is this idea of psychoeducation.
And another is really trying to take a very specific approach, which we can go into about suicidality and self-harm. It’s a little bit different with BPD patients given the chronicity of those issues. So there’s a whole set of guidelines that we have about how to approach it specifically for this patient population.
And then the other thing that kind of comes to mind, which is very key, is really trying to understand how you can quickly and effectively develop a rapport with a patient with BPD. And one of the ways that we’ve seen effective is really being almost overly active and engaged more than you might be with other patients. So there was a study that was done where they took BPD patients and then control subjects, and they told them to let their mind wander as their mind-wandering task. And what they showed was that basically if left to their own devices borderline patients compared to the controls usually their mind would wander towards something negative. So we know that if we take sort of a neutral approach to a patient; if we kind of sit back in our chair and aren’t really talking a lot, a lot of the time they will interpret that negatively and think well, this person’s being dismissive; they don’t really care about me. But if you’re sitting forward in your chair you’re active; you’re asking about their life: “Tell me about your relationships,” you know you’re engaging them in a real authentic, active way - that can be another very quick way to develop rapport and trust that you need. Otherwise, you know, it’s just going to be an uphill battle.
Dr. Hendrick: How can clinicians differentiate between the chronic-self harming behaviors associated with borderline personality disorder versus real suicidality?
Dr. Hong: So listen, this is obviously one of the most stressful aspects of managing these patients, you know. Yes, these patients do carry with them an elevated risk of suicide compared to the general population. That’s just a matter of fact. But the problem is that sometimes I think we get confused and we use that chronic risk to sort of guide us in our clinical decision making. And that often leads to unnecessary hospitalizations. It often leads to a lot of interventions that may or may not be helpful. And you know we certainly can talk more about inpatient hospitalization later. So what we really have to do is to try as hard as we can to focus on what the acute risk factors are.
So you have this baseline chronic risk that has been established already. We know that they have this risk, but what are they exhibiting that is above and beyond that and what kind of acute risks do they have which for BPD patients, again to kind of hammer home the point, the specific triggers are things like interpersonal stressors, a loss of a loved one, real or perceived abandonment – obviously that’s one of the criteria for BPD. You know there are patients who will attempt suicide after you know they lose a therapist, or you know they have a significant other who has threatened a breakup. And so we need to kind of be attuned to those specific risk factors for BPD, in addition to all the other standard ones you know: worsening depression, agitation, increased substance use, etc. So that’s one thing of kind of trying to maintain a focus on this acute on top of chronic risk model.
The other thing that you know I always find helpful to point out or to remind people of is that no matter many times the patient has come in, and you know there are cases where somebody’s come in to the emergency department 20 times; no matter how many times we’ve seen them; no matter how many times they’ve threatened suicide, it’s really important to maintain a genuine concern about their safety and to exhibit that in your interactions.
So even though for you as a clinician or a staff member it may be frustrating, you know this is the 20th time, how come they haven’t sort of figured this out yet, for them, for the patient with BPD it’s very fresh; it’s very new. And if they’re coming to the emergency department or inpatient unit sort of as a last line of hope or defense and they’re met with that hostile or dismissive attitude, I really feel that it can actually increase their suicide risk. So you really have to – no matter how frustrated you might be; no matter how emotionally dysregulated you might be by the patient - to really try to focus on like this is somebody who’s in crisis. Yes, it’s the 20th time, but you know I need to genuinely demonstrate that I’m concerned about their safety.
And then the final thing I guess I could point out is that BPD patients often need us to sort of interpret what they’re saying. They almost need like a translator. And what I mean by that is so if somebody says, “I’m suicidal” or “I want to die,” or cuts themselves or takes pills they may indeed be saying I actually want to die imminently and I’m gonna do something to kill myself imminently. They may actually be saying that, but the majority of the time what they’re probably saying is something more like “I’m lonely. I’m depressed. I feel abandoned. I’m upset and I don’t know what to do about.” And so oftentimes we sort of have to in an active way force them and say, you know, “Translate this for me. Was this behavior really that you 100% wanted to die or were you just feeling distressed and you didn’t know what to do?” And a lot of times, you know, taking that active approach you can get a little bit more of an accurate answer as opposed to taking their words or behaviors at face value. So, for example, last week I interviewed a patient in the emergency department and she was sent there by her therapist, and the reason was you know she told the therapist that she was suicidal. And she was frustrated that the therapist had forced her to go to the emergency department. And I asked her why and she basically said, “Well, of course, I’m suicidal; I’m borderline. That’s what we do. It’s not that I was gonna do anything. I was just feeling that upset.” And so, again, sometimes we need that little bit of translation to get a little more of an accurate understanding of where they are.
Dr. Hendrick: In Dr. Hong’s 2016 paper, he points out that inadequate outpatient care can contribute to borderline patients being admitted multiple times to the psychiatric emergency department. So, what steps should clinicians take to improve the outpatient care for borderline patients?
Dr. Hong: So, yeah, this can be tricky. I think this goes back to the idea that for a lot of BPD patients, recurrent hospitalizations really not only are not helpful, but in some cases can be harmful. And we know that some patients develop a dependence on the hospital system – so anytime they’re in distress they run to the emergency department: “I need inpatient hospitalization.” And over time, you know if they spend enough time on the inpatient unit where they’re wrapped up in care; a lot of people are giving them attention, it can handicap their brain in developing self-soothing techniques.
And so what I would say about recurrent hospitalization, and this is not easy work; it takes time; is that if somebody is truly coming time after time after time - and we all have patients that we know are like that - it is really important to look at it not from a siloed perspective of what do we do for this patient now or what do we do with them in the outpatient setting. But let’s all maybe get on a conference call. Let’s collaborate so that everyone’s on the same page, including the patient by the way, has an understanding of when should I be calling my therapist or my psychiatrist for counseling; when should I go to the emergency department; when should I try to use my self-regulation and self-soothing techniques; and if I do come to the emergency department what should the expectations be? You know what are the real criteria for hospitalization? And if they are hospitalized what specific goals should be set for their hospitalization so that we can get them back out into the world quickly and reduce the possibility of that fostering of dependence.
Zachary Davis: Should the patient’s family be involved in these collaborative outpatient team meetings?
Dr. Hendrick: Yes, whenever possible. These families are often desperate for help. Sometimes they don’t have a good understanding of BPD; sometimes they’re terrified that they’re going to lose their loved one to suicide. So, it is crucial to engage families in the care. It’s also a good liability risk reducer to involve families in the care, but this isn’t always easy. BPD often runs in families, so family members themselves might have BPD or other cluster B traits, which obviously can complicate family meetings. There are also a lot of cases, given BPD’s ties to trauma, where family members have engaged in overt abuse of the patient. But as much as possible, I try to have the families engaged.
We hand out educational material for families in the ED, which I think is very helpful. These materials include tips like being aligned as a family unit to avoid splitting. And if families need more assistance, there’s a program called Family Connections offered through the National Education Alliance for BPD, and they provide education and support groups for families.
Zachary Davis: What are your thoughts on reducing clinicians’ liability risks when working with patients with borderline personality disorder?
Dr. Hong: Another very I think stressful aspect of managing BPD is you know I’m by definition treating a patient that is at higher risk of suicide. Are my liability risks higher?
The short answer is technically yes they are, but there are definite ways to mitigate the risk of liability enough that you know it’s relatively safe. And the few things that we try to educate people on, and by the way, I know a lot of practitioners and a lot of us do where they basically will actively avoid treating BPD patients: “I don’t want that risk.” And that’s unfortunate because we don’t have enough, you know, well-trained practitioners treating this illness and we need all the help we can get. But in terms of reducing liability, I think a lot of it does go back to appropriately managing our own excessive countertransference reactions.
So you know we know this from way back in the day from John Gunderson and Glen Gabbard’s work. They’ve talked a lot about feelings of frustration and fear and hostility; a dismissiveness toward these patients. And if we don't recognize those reactions in ourselves and don’t check those reactions and don’t process them appropriately, it can very easily influence what we say to patients. It can easily influence clinical decisions. And we all have personal examples of how we’ve all fallen prey to those excessive countertransference reactions.
I think one of the ways to reduce liability is to make sure we have an outlet for those feelings. Another way, and I’ll just go back to the family thing, you know you don’t want the first time you’re meeting a family to be in the ICU after a patient has taken an overdose. You will want to have met them before that to say, “Listen, I’m concerned about your family member. There is a real risk of suicide in this illness. We’re gonna do the best we can. These are the evidence-based practices.” And you know if somebody does die by suicide, you know typically there’s the family members’ filing a malpractice lawsuit, and if you have that connection with them and an honest, frank appraisal of the situation it can reduce liability at many levels.
And then the last thing I’ll say about reducing liability really goes down to use of conversations with supervisors, with colleagues. You know we as a profession, I think don’t do these enough, especially if you’re a more experienced clinician. But we can also use a second opinion, no matter how many times we’ve dealt with a borderline patient or how many years of experience we have. We all have blind spots. And so I’m a big proponent, if you’re feeling shaky about a case; you’re not sure what to do; you know, phone a friend; call a colleague: “Can I run this by you?” If you’re in training, talk to a supervisor, get a second opinion, process it through, and that can be a very big risk reducer as well.
Dr. Hendrick: Do you have any final thoughts on this topic, Dr. Hong.
Dr. Hong: Yeah, I think maybe the only other thing I’ll point out is a few more words on the issue of countertransference because it is really the source of a lot of inappropriate interventions whether it be prescribing of medications; whether it be involuntary hospitalizations and things of that sort. You know it’s a whole conversation by itself, I think.
But I think it’s really important first of all, as I said before, to recognize or sort of take your own temperature before you’re interacting with a BPD patient or afterward or during. You know I think if we’re not aware that these reactions are quite common, like we should expect them in ourselves, we can get caught off guard. But if we’re prepared for it, we have sort of steeled ourselves that you know that I could be triggered by this patient; I think we can more easily manage it in the moment.
And then afterward, I really highly value the process of venting. You know you don’t want to do that in front of the patient, but with a trusted colleague I think it’s okay to vent a little bit, to get it off your chest. I mean these are very stressful situations, and that way you can then again with a little bit of a cooler head interact with that patient.
The other thing I would say about that is often the cause of these countertransference reactions can be born out of this sense that the patient is intentionally trying to cause problems. You know we hear a lot of terms like manipulative: you know, “They’re trying to manipulate me,” which if you look at a definition of manipulative you know it has to be sort of intentional, well thought out, organized approach to try to trick somebody. That’s rarely the case in these patients. You know they may seem like they’re being overly dramatic to get attention or something like that, but really it’s a little bit more nuanced. They often don’t really know how to express their emotions in a more regulated way. They may truly actually be feeling that distress. And you ask them, “How high is your distress?” or “How anxious are you?” and they may say 100 out of 10. That actually may be accurate for them.
And so I think the more that we recognize that these individuals in their own awkward, sometimes dysfunctional way are doing the best that they can and that these behaviors whether it’s splitting or otherwise are symptoms of the illness. It’s not like they’re bad people who are trying to hurt us or trying to make us upset. They’re doing the best they can to navigate a very stressful situation. I think the more we can remember that, perhaps the more we can approach them in a little bit of a more supportive, understanding, more dispassionate way.
Dr. Hendrick: Check out our January 10th, 2022, episode titled “Countertransference Hate and the Suicidal Patient” for more on how to recognize and beneficially use countertransference reactions in psychotherapy sessions with borderline patients. And, the newsletter interview with Dr. Hong is available for subscribers to read in The Carlat Hospital Report. Subscribers get print issues in the mail and email notifications when new issues are available on the website. Subscriptions also come with full access to all the articles on the website and CME credits.
Zachary Davis: Go to www.thecarlatreport.com to sign up.
And don’t forget, you can now earn CME credits for listening to our podcasts. Just click the link in the description to access the CME post-test for this episode.
As always, thanks for listening and have a great day!