• Subscribe
  • Register for free Content
  • Cart
  • Login
  • Browse by Topic
    • 13 Reasons Why
    • ABA
    • Abstinence
    • Acamprosate
    • Addiction
    • Addiction Treatment
    • Addyi
    • Adhansia
    • Adhansia XR
    • ADHD
    • ADHD Attention Deficit Hyperactivity Disorder
    • ADHD Rating Scale-5
    • ADHD-RS-5
    • Adherence
    • Adjunct treatment
    • adolescents
    • Aducanumab
    • Aduhelm
    • Adult ADHD
    • Adverse Childhood Experiences (ACES)
    • adverse events
    • affective disorders
    • Affordable Care Act (ACA)
    • aggression
    • Agitation
    • Aid to capacity evaluation (ACE)
    • AIMS test (Assessment of Involuntary Movement)
    • air pollution
    • Akathisia
    • Alcohol
    • alcohol abuse
    • alcohol dependence
    • Alcohol Poisoning
    • Alcohol related liver disease
    • Alcohol Use
    • Alcohol use disorder
    • alcohol- associated liver disease
    • Alcoholism
    • Alpha Agonists
    • Alternative treatments
    • Alzheimers
    • Amantadine
    • amino acids
    • amphetamine
    • Amphetamines
    • anabolic steroids
    • Andro
    • Androstenedione
    • Anorexia
    • Anorexia Nervosa
    • Anti-NMDA Receptor Encephalitis
    • Antibiotic
    • Anticholinergic burden scale
    • Anticholinergics
    • anticonvulsants
    • Antidepressant
    • Antidepressant Augmentation
    • Antidepressants
    • antihistamines
    • Antipsychotic
    • Antipsychotics
    • Anxiety
    • Anxiety Disorder
    • anxiety disorders
    • APA CE Post-Test
    • Applied Behavioral Analysis
    • Aptensio
    • ARFID
    • Aripiprazole
    • ArModafinil
    • Asenapine
    • Ashton manual
    • Assault
    • Assent
    • Assessment
    • assessments
    • asthma
    • atamoxetine
    • Athletic performance
    • Ativan Challenge Test
    • Atomoxetine
    • Atomoxetine (ATX)
    • Atropine
    • attention
    • Attention Deficit Hyperactivity Disorder
    • Atypical Antipsychotics
    • Austedo
    • Autism
    • Autism Spectrum Disorder
    • Autism Spectrum Disorder
    • Autism Spectrum Disorder autism spectrum disorder
    • Avoidant Restrictive Food Intake Disorder
    • Beers criteria
    • Behavior therapy
    • Behavioral addiction
    • Behavioral therapy
    • Behavioral treatment
    • Belsomra
    • Benzodiazepine
    • Benzodiazepines
    • Benzphetamine
    • Beta-blockers
    • Billing
    • Bipolar Depression
    • Bipolar Disorder
    • Bipolar II
    • birth defects
    • Black youth
    • Bleeding
    • Board Certification
    • body mass index BMI
    • body positivity
    • Borderline Personality Disorder
    • Boredom
    • BPD
    • BPSD (behavioral and psychological symptoms of dementia)
    • Brain Devices
    • Breastfeeding
    • Brexpiprazole
    • Brief psychotherapy
    • brief pulse
    • Brief Strategic Family Therapy (BFST)
    • Bulimia Nervosa
    • Bullying
    • Bumetanide
    • Buprenorphine
    • Buprenorphine Induction
    • Bupropion
    • Bush-Francis Scale
    • Buspirone
    • C-Reactive Protein
    • Caffeine
    • CAM Treatments
    • Cancer
    • Cannabidiol
    • Cannabis
    • Capacity
    • Caplyta
    • Carbamazepine
    • Cardiovascular
    • Cariprazine
    • Catatonia
    • CATIE
    • CBT
    • CBTi
    • Central Alpha Agonists
    • CGI
    • Chantix
    • Child and adolescent
    • Child Psychiatry
    • Child Psychiatry
    • childcare
    • children
    • children and adolescents
    • Chlorpromazine
    • Chokroverty
    • Chromosomal Microarray
    • circadian system
    • Citalopram
    • Clinical Global Impressions
    • Clinical practice
    • Clinical Practice Guidelines
    • clonidine
    • Clozapine
    • CME Post-Test
    • co-morbidities
    • Co-occurring disorders
    • Cocaine
    • Cognition
    • Cognitive Behavioral Therapy
    • Cognitive Behavioral Therapy for Insomnia
    • Cognitive Behavioral Therapy for Insomnia (CBTi)
    • Cognitive Decline
    • Cognitive functioning
    • cognitive impact
    • Cognitive impairment
    • cognitive processing therapy
    • Cognitive Rehabilitation Therapy (CRT)
    • Collaboration
    • Collaborative care
    • Collateral data
    • Combination treatment
    • Combined Pharmacotherapy
    • Commitment
    • community trauma
    • Comorbidity
    • complementary medicine
    • Complementary treatments
    • Complimentary Medicine
    • Complimentary treatments
    • compulsions
    • Computer addiction
    • Computers in Psychiatric Practice
    • Conduct Disorder
    • Confidentiality
    • Connect
    • Connection
    • Connections
    • Consensual
    • Consent
    • consult-liaison
    • Contagion
    • Contempla
    • contingency management
    • contraception
    • contraceptive services
    • control group
    • Coronavirus
    • Cosmetic pharmacology
    • Countertransference
    • court hearings
    • COVID-19
    • COVID19
    • craving
    • creatine
    • creatine monohydrate
    • Creativity
    • Crime
    • Criminal behavior
    • Crisis intervention
    • Crocus Sativus
    • CRP
    • Cultural Competence
    • Culture
    • custody agreement
    • Cymbalta
    • CYP2C19
    • CYP2D6
    • DASH diet
    • Dayvigo
    • De-escalation
    • Debriefing
    • Decisional Capacity
    • Deep brain stimulation (DBS)
    • Degarelix
    • Deliberate foreign body ingestion
    • Delirium
    • Delusional Disorder
    • Dementia
    • Deplin
    • Deprescribing
    • Depression
    • Depressive Disorder
    • designer drugs
    • Detoxification
    • Deutetrabenazine
    • Developmental Relationship Based Intervention
    • DFBI
    • Diabetes
    • diabetes insipidus
    • Diagnosis
    • Diagnostic Testing
    • Dialectical Behavioral Therapy
    • diet
    • Dietary Approaches to Stop Hypertension (DASH)
    • Diethylpropion
    • differential diagnosis
    • Diphenhydramine
    • Disaster
    • Discrepancies
    • Disparities
    • Dispositional capacity
    • Disruptive Mood Dysregulation Disorder (DMDD)
    • Disulfiram
    • Divalproex
    • Diversity
    • Divorce
    • DMDD
    • Dopamine
    • Dosage Timing
    • Dose Response
    • Dosing
    • double blind
    • DRBI
    • Drooling
    • Droperidol
    • drug misuse
    • Drug-assisted psychotherapy
    • DSM
    • Dual diagnosis
    • Duloxetine
    • duty to protect
    • duty to warn
    • Dyanaval
    • Dyslexia
    • Dysregulation
    • E-Cigarettes
    • Eating Disorders
    • eating restriction
    • eCigarettes
    • ECT
    • effect size
    • Effexor
    • efficacy
    • EHR
    • Electroconvulsive therapy
    • Electronic Health Records
    • electronic use
    • Emergency
    • Emergency Department
    • emergent suicidality
    • emotion dysregulation
    • Emotional dysregulation
    • EMPOWER trial
    • Encephalitis
    • End of Life Care
    • endocrinological side effects
    • Engagement
    • Equine Assisted Psychotherapy
    • Equine therapy
    • Escitalopram
    • Esketamine
    • Estrogen
    • Eszopiclone
    • eTNS
    • Evekeo
    • excessive exercise
    • Exercise
    • Existing marijuana
    • expressed emotion
    • extended dosing
    • extended-release
    • Eye movement desensitization and reprocessing
    • Fall risk
    • Falls
    • Family Separation
    • Fast-acting
    • fat shaming
    • FDA
    • FDA Warnings
    • Female hypoactive sexual desire disorder
    • Female Issues in Psychiatry
    • fentanyl
    • fetal effects
    • First Generation Antipsychotics (FGAs)
    • fluid restriction
    • Fluoxetine
    • Folate
    • Folic Acid
    • Fragile X
    • Free Articles
    • gabapentin
    • GAD
    • GAMC
    • Gastroenterology
    • GDD
    • Gender
    • Gender & Sexuality
    • Gender Affirming Medical Care
    • Gender Diverse
    • Gender Dysphoria
    • Gender Dysphoric Disorder
    • Gender Identity
    • Generalized Anxiety Disorder
    • Generics
    • GeneSight
    • Genetic Testing
    • Genetics and Psychiatry
    • Geriatric
    • Geriatric Psychiatry
    • Geriatrics
    • Ginkgo
    • GLP-1 Agonists
    • Good Psychiatric Management
    • Guanfacine
    • Hair loss
    • Haloperidol
    • Harm reduction
    • Head Trauma
    • Health Apps
    • Healthy aging
    • Hearing loss
    • Heart health
    • Heart rate
    • Hemorrhagic
    • Hepatitis
    • Heroin
    • Higher-calorie refeeding
    • HIPAA
    • Histamine
    • HIV
    • Hormone Replacement Therapy
    • hospital culture
    • Hospital policy
    • HRT
    • huffing
    • hydroxymethyl butyrate (HMB)
    • Hydroxyzine
    • hyperlipidemia
    • hypersalivation
    • hypersexual behaviors
    • hypertension
    • Hypnotics
    • Hypomania
    • Hyponatremia
    • hypothyroidism
    • IDEA
    • Incarceration
    • Inclusion
    • Inclusion strategies
    • Independent Educational Plan (IEP)
    • induction
    • infant
    • Inflammation
    • Ingrezza
    • Inhalants
    • Innovations
    • Inpatient Psychiatry
    • inquiry
    • Insomnia
    • Insulin resistance
    • Insurance
    • intermittent fasting
    • Internet
    • interpersonal stressors
    • Interpreter
    • Intervention
    • Intra-cerebral hemorrhage
    • Intra-nasal
    • involuntary civil commitment
    • Irritability
    • IV immunoglobulin therapy (IVIG)
    • Jornay PM
    • Keppra
    • Ketamine
    • l-methylfolate
    • Laboratory Testing in Psychiatry
    • lactation
    • Lamictal
    • Lamotrigine
    • Language
    • Lavender
    • Learning & Developmental Disabilities
    • Least Restrictive Environment
    • Legal issues
    • Lemborexant
    • Levetiracetam
    • Lewy Body Dementia
    • LGBT
    • LGBTQ+
    • Life coaching
    • Life expectancy
    • Light and Dark Therapy
    • Light therapy
    • Lightbox
    • Liraglutide
    • Literacy
    • Lithium
    • Longevity
    • lorazepam taper
    • Low calorie refeeding
    • Low libido
    • low sodium
    • Lumateperone
    • Lurasidone
    • Lyrica
    • magnetic seizure therapy (MST)
    • maintenance ECT
    • Malingering
    • Malnourishment
    • Management
    • Mania
    • Mania on Antidepressants
    • MAOIs
    • Marijuana
    • MDMA
    • Media
    • Medical Comorbidities
    • medical comorbidity
    • medical conditions
    • Medical incapacity hold
    • Medication
    • Medication adherence
    • medication capacity hold
    • Medication for Opioid Use Disorder
    • Medication for Opioid Use Disorder (MOUD)
    • medication of opioid use disorder (MOUD)
    • medications
    • Melatonin
    • Memantine
    • memory loss
    • Mental Health
    • Meta-analysis
    • Metabolic syndrome
    • Metformin
    • Methadone
    • Methamphetamines
    • methylfolate
    • methylphenidate
    • Micronutrients
    • mild cognitive impairment
    • Mind-Gut Connection
    • mindful eating
    • Mindfulness
    • Minocycline
    • Minority
    • Mirtazapine
    • Mixed Features
    • Modafinil
    • Mood
    • mood disorders
    • Mood stabilizer
    • Mood Stabilizers
    • Mortality
    • Motivational Interviewing
    • MTA
    • MTHFR
    • muscle dysmorphia
    • Mydayis
    • Naloxone
    • Naltrexone
    • Narcolepsy
    • Natural Medications
    • natural treatments
    • Naturalistic Developmental-Behavioral Intervention
    • NDBI
    • Negative Symptoms
    • Negative symptoms of schizophrenia
    • Netflix
    • neuroleptic malignant syndrome
    • Neurology
    • Neuromodulation
    • Neuroscience in Psychiatry
    • Neurotoxicity
    • New York
    • newborn
    • News of Note
    • nicotine
    • Nightmares
    • NMDA
    • NNH
    • NNT
    • Nomogram
    • Non-pharmacologic
    • Non-suicidal self-injury
    • Norepinephrine
    • Nortriptyline
    • Novel drug
    • Novel Medications
    • Nuedexta
    • null hypothesis
    • number needed to harm
    • number needed to treat
    • Nuplazid
    • Nurses
    • Nutrition
    • Nuvigil
    • Obesity
    • observational study
    • obsessions
    • Obsessive Compulsive Disorder
    • Obsessive compulsive disorder/OCD
    • OCD
    • olanzapine
    • Omega-3
    • Online Learning
    • online therapy
    • Open Label
    • Opioid antagonist
    • Opioid epidemic
    • Opioid Use Disorder
    • Opioids
    • oppositional behavior
    • Oral Contraceptives
    • Orexin
    • Orthostasis
    • Osmolality
    • Osteporosis
    • Outcome tracking
    • Outcomes
    • Outpatient
    • Over the counter
    • Over the counter medication
    • Overdiagnosis
    • Overdose
    • Oxcarbazepine
    • p-value
    • Pain
    • pandemic
    • Panic Disorder
    • Parent Training
    • Parenting Strategies
    • Parents
    • Parkinson’s
    • Parkinson’s Disease
    • Paroxetine
    • Particulate matter
    • Patch
    • Patient relationship
    • PCL-5
    • pediatric
    • Pediatric Acute Onset Neuropsychiatric Syndrome (PANS)
    • Pediatric Autoimmune Neurologic Disorder Associated with Streptococcus (PANDAS)
    • Pedophilic Disorder
    • Performance Enhancing Substances
    • perinatal
    • Perseveration
    • Perseverative Behavior
    • Personality Disorders
    • Pharmaceutical Industry
    • Pharmacogenomics
    • Pharmacology
    • Pharmacology Tips
    • Pharmacotherapy
    • Pharmacy
    • Phendimetrazine
    • Phentermine
    • phonemic awareness
    • Phonics
    • Physician assisted suicide
    • Pica
    • PICOT
    • Pimozide
    • Pitolisant
    • Podcast
    • polypharmacy
    • post traumatic stress disorder
    • post-exposure prophylaxis
    • Post-hoc Analysis ADHD Rating Scale-5
    • Post-menopausal
    • Post-stroke depression
    • Posterior Probability
    • Postpartum Depression
    • postpartum mood
    • Potency
    • Practice management
    • Practice Tools and Tips
    • Practice Tools and Tips
    • Pramipexole
    • Prazosin
    • Pregabalin
    • Pregnancy
    • pregnancy testing
    • Prepubescent children
    • prescribing patterns
    • Prescription costs
    • prevalence
    • Prevention
    • Primary care
    • primary outcome
    • Prison
    • Privacy
    • Prodrome
    • Prolactin
    • Prolonged exposure
    • Promethazine
    • Promotoras
    • Pronouns
    • Provigil
    • Prozac
    • pseudobulbar affect
    • Psilocybin
    • Psychedelics
    • psychiatric emergencies
    • Psychiatric interviewing
    • Psychoanalysis
    • Psychodynamic therapy
    • Psychological First Aide
    • Psychopharm Myths
    • Psychopharmacology
    • Psychopharmacology Tips
    • Psychosis
    • Psychotherapy
    • Psychotherapy
    • Psychotic Agitation
    • Psychotic Depression
    • psychotic disorders
    • Psychotropic medication
    • PTSD
    • Public health
    • Qelbree
    • Quality of care
    • quality of life
    • Quetiapine
    • Quillivant
    • Race
    • Raloxifene
    • Randomized controlled trial
    • randomized discontinuation design
    • rapid naming
    • Rapid-acting
    • RCT
    • Reading
    • Reading disorder
    • Reading Disorders
    • Reading remediation
    • recovery time
    • Red Cross
    • Refeeding syndrome
    • Registered Articles
    • Relationships
    • Remediation
    • Repetitive Behavior
    • Repetitive behaviors
    • replication
    • reporting requirements
    • Research
    • Research Update
    • Research Updates
    • Respectful Care
    • restraints
    • restrictive dieting
    • retarded vs excited catatonia
    • retention
    • Retirement
    • retrograde amnesia
    • Riluzole
    • Risk
    • Risk Management
    • Risk of Addiction
    • Risperidione
    • Risperidone
    • Ritalin
    • rTMS
    • Safe Consumption Site
    • safety
    • Safety Planning
    • Saffron
    • SAINT protocol
    • SAMe
    • Samidorphan
    • Saphris
    • Schizoaffective disorder
    • Schizophrenia
    • School Phobia
    • School Refusal
    • screening
    • ScreeninGeg
    • Seasonal Affective Disorder
    • seclusion
    • Second Generation Antipsychotics (SGAs)
    • secondary outcome
    • Secuado
    • Self-injury
    • Self-Regulation
    • Semaglutide
    • Separation
    • Separation Anxiety
    • SERM (Selective Estrogen Receptor Modulator)
    • Serotonin
    • Serotonin Norepinephine Reuptake Inhibitors
    • Serotonin Specific Reuptake Inhibitors
    • Serotonin Specific Reuptake Inhibitors (SSRIs)
    • Sertraline
    • Sex offenders
    • Sex Therapy
    • Sexual Abuse
    • Sexual Dysfunction
    • sexual intercourse
    • Sexual Side Effects
    • sexually transmitted diseases
    • SIADH
    • Side Effects
    • Silexan
    • Skype
    • Sleep
    • Sleep Apnea
    • Sleep Disorders
    • Sleep Onset Insomnia
    • Smoking Cessation
    • Smoking Cessation Agents
    • smoking cessations
    • SNRIs
    • Social Anxiety
    • Social Anxiety Disorder
    • social cohesion
    • sodium supplementation
    • Somnambulism
    • Special populations
    • Specific Phobia
    • SSRIs
    • statistical significance
    • Statutes
    • Stereotypical Behavior
    • steroids
    • STI screening
    • Stigma
    • stimulant
    • Stimulant Medications
    • Stimulant treatment
    • Stimulant use disorder
    • Stimulants
    • Stroke
    • structured literacy
    • Suboxone
    • Substance Abuse
    • Substance Abuse
    • Substance Use
    • Substance Use Disorder
    • Substance use disorders
    • Suicidality
    • Suicide
    • Sundowning
    • Supplements
    • Surrogate decision-maker
    • Suvorexant
    • Swallowing
    • Symptom Assessment
    • Symptom Management
    • Systematic review
    • Tags
    • Tantrums
    • taper
    • Tarasoff
    • Tardive dyskinesia
    • Technology
    • Teen
    • teens
    • Telehealth
    • Telemed
    • Telemedicine
    • Telepsychiatry
    • test cme quiz
    • testifying
    • Tetrabenazine
    • TFCBT
    • TGD
    • Therapy during medication appointment
    • Therapy with Med Management
    • Theta burst stimulation
    • tics
    • TMS
    • Tobacco
    • tobacco research
    • Tobacco use disorder
    • Top 10 Podcasts of 2021
    • Topiramate
    • Toxic Stress
    • Transcranial direct current stimulation (TDCS)
    • Transcranial Magnetic Stimulation
    • Transdermal
    • Transgender
    • Translator
    • transplant surgery
    • Trauma
    • Trauma Informed Care
    • Trauma-focused psychotherapy
    • Traumatic Brain Injury (TBI)
    • Trazodone
    • treatment
    • treatment efficacy
    • treatment pediatric
    • Treatment planning
    • Treatment-Resistant Depression
    • Trigeminal Nerve Stimulation
    • Trintellix
    • unblinded
    • Understanding Psychiatric Research
    • unilateral vs bilateral
    • urinary difficulties
    • urinary tract infections
    • urine toxicology
    • UTI
    • Vagus nerve stimulation (VNS)
    • Valbenazine
    • Valproate
    • Vaping
    • Varenicline
    • Venlafaxine
    • verbal de-escalation
    • videogaming addiction
    • Viloxazine
    • Violence
    • Vitamin B6
    • Vitamin D
    • Vitamin E
    • VMAT2 Inhibitors
    • Vortioxetine
    • Vyleesi
    • Waist circumference
    • Wakix
    • water intoxication
    • water restriction
    • Weed
    • Weight gain
    • Weight Loss Medications
    • Weiss Functional Impairment Rating Scale-Parent (WFIRS-P)
    • Wellbutrin
    • whey protein powders
    • Whole Genome Sequencing
    • Wilderness Therapy Programs
    • Withdrawal
    • women
    • Women's Issues in Psychiatry
    • Women’s Issues in Psychiatry
    • Working With Families
    • workplace
    • Xenazine
    • Youth
    • Z-drugs
    • Zenzedi and ProCentra
    • Ziprasidone
  • HOME
  • STORE
  • CME CENTER
  • Blog
  • Podcast
  • NEWSLETTERS
    • The Carlat Psychiatry Report
    • The Carlat Child Psychiatry Report
    • The Carlat Addiction Treatment Report
    • The Carlat Hospital Psychiatry Report
    • The Carlat Geriatric Psychiatry Report
  • Archive
  • Archive
  • Archive
  • Archive
  • Archive
  • The Carlat Hospital Psychiatry Report
  • Testifying (January/February/March)
  • Borderline Personality Disorder in the ED

Borderline Personality Disorder in the ED

The Carlat Hospital Psychiatry Report, Volume 2, Number 1&2, January 2022
https://www.thecarlatreport.com/newsletter-issue/chprv2n1-2/

From The Carlat Hospital Psychiatry Report, January 2022, Testifying

Issue Links: Learning Objectives | Editorial Information | PDF of Issue

Topics: Borderline Personality Disorder | Countertransference | Emergency Department | emotion dysregulation | Good Psychiatric Management | interpersonal stressors | Personality Disorders | Suicidality | Working With Families

Print Friendly, PDF & Email

Victor Hong, MDVictor Hong, MD

Clinical Assistant Professor, Department of Psychiatry, University of Michigan, Ann Arbor, MI.

Dr. Hong has disclosed no relevant financial or other interests in any commercial companies pertaining to this educational activity.

CHPR: What are some common issues that you encounter with patients with borderline personality disorder (BPD) in the psychiatric emergency department (ED)?
Dr. Hong: First, we should remember that individuals with BPD are prevalent in every psychiatric setting, but especially the ED. About 10%–15% of all psychiatric ED patients have BPD, and these patients often present repeatedly (Pascual JC et al, Psychiatr Serv 2007;58(9):1199–1204). That can be very frustrating for clinicians, who might have the attitude of “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. We worry about patients killing themselves if we discharge them. There’s typically a lot of drama surrounding individuals with BPD. And the frenetic nature of EDs adds to the challenge of working with these patients, since they’re interpersonally hypersensitive and easily triggered emotionally.

CHPR: So how can we best work with these patients in EDs?
Dr. Hong: It helps to think of patients with BPD 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 (Hong V, Harv Rev Psychiatry 2016;24(5):357–366). 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.

CHPR: Can you review the fundamental points of Good Psychiatric Management?
Dr. Hong: There are several evidence-based treatments for BPD, 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. John Gunderson and his team at McLean Hospital developed the Good Psychiatric Management modality (Gunderson J et al, Curr Opin Psychol 2018;21:127–131). It’s intended to be a generalist model that can be easily taught in an eight-hour training. There are several principles that are relevant for the ED (Editor’s note: For more information, see the “Good Psychiatric Management Fundamentals” table).

Table: Good Psychiatric Management Fundamentals

Table: Good Psychiatric Management Fundamentals

(Click to view full-size PDF.)

CHPR: Which are the main principles?
Dr. Hong: The most essential principle is that the core attribute of individuals with BPD is interpersonal hypersensitivity, and most crises come out of interpersonal stressors. For example, the patient has an argument or there’s a breakup or a perceived breakup, and in response the individual self-harms or threatens or attempts suicide, ending up in the ED. To help these patients, we need to get straight to the heart of the issue and explore their interpersonal stressors.

CHPR: What’s another important principle?
Dr. Hong: A second key principle is that you want to provide psychoeducation, including a review of evidence-based treatments. The acute care setting provides an opportunity to review the diagnosis if it is already established, and to bring up the possibility of BPD if it is suspected. You can review the DSM criteria together and see if the patient thinks the diagnosis fits. Another way, if the patient is frustrated that medications don’t seem to be helpful, is to ask, “Might something else be going on? Has anyone ever mentioned BPD?” And then a third key principle is to quickly work to develop rapport with a patient with BPD.

CHPR: How do you do that?
Dr. Hong: One effective way is to be more active and engaged than you might otherwise be. There was a study that took patients with BPD and control subjects and told them to let their minds wander. It showed that the minds of patients with BPD, compared to controls, tended to wander toward negative thoughts (Kanske P et al, Psychiatry Res 2016;242:302–310). So, if you take a neutral approach to a patient and sit back in our chair and don’t say much, patients with BPD will often interpret that behavior negatively and think, “This person is being dismissive and doesn’t care about me.” But if you sit forward and make it very clear that you’re interested and engaged, asking about their lives and their relationships, that approach helps develop rapport and trust.

CHPR: So, it helps to be highly engaged in our interviewing. And back to your comment about patients’ self-harming behavior: How do you distinguish between chronic self-harming behaviors and real suicidality?
Dr. Hong: This is one of the most stressful aspects of managing patients with BPD. Yes, these patients do carry an elevated risk of suicide compared to the general population. But too often we use that chronic risk to guide us in our clinical decision making, and that can lead to unnecessary hospitalizations. It helps to look at the patient’s acute risks. For patients with BPD, to hammer home the point, the triggers are typically interpersonal stressors, like real or perceived abandonment. There are patients who will attempt suicide after they lose a therapist or after their significant other threatens a breakup. So, we need to be attuned to those specific risk factors for suicidality in patients with BPD.

CHPR: Anything else we should be mindful of?
Dr. Hong: No matter how many times the patient has threatened suicide, it’s important to provide validation and hope, and maintain and exhibit a genuine concern about their safety. Even though you might be seeing a patient for suicidality for, say, the 20th time, from the patient’s perspective their suicidality is very fresh. And if they’re coming to the ED or inpatient unit as a last line of defense and they’re met with a hostile or dismissive attitude, that can increase their suicide risk. So, no matter how frustrated you might be with the patient, you need to remember that they’re in crisis. Additionally, patients with BPD often need us to interpret what they’re saying. So, if somebody says “I’m suicidal” or “I want to die,” or cuts themselves or takes pills, they may be communicating: “I’m lonely. I feel abandoned. I’m upset and I don’t know what to do about it.”

CHPR: It must be very reassuring for a patient to hear someone put their feelings into words. By helping patients develop greater self-awareness, does that help reduce their visits to the psych ED?
Dr. Hong: Over time, if patients can gain a sense of what triggers emotional reactions, understand how they can self-soothe, and remember that whatever they are feeling will likely pass, they’ll have a better chance of avoiding an ED visit. This is an important point because for a lot of patients with BPD, recurrent visits to the psych ED and hospitalizations can be harmful. Some patients develop a dependence on the hospital system to the point that they run to the ED whenever they’re in distress, and this can handicap them in developing self-soothing techniques.

CHPR: Is there anything else we can do to minimize recurrent visits to psych EDs?
Dr. Hong: For somebody who is coming to the ED time after time, it’s important to collaborate with everyone involved in the patient’s care—the outpatient therapist, the outpatient psychiatrist, and the patient. Everyone should understand when the patient should call the therapist or psychiatrist, when they should go to the ED, and when they should use self-regulation and self-soothing techniques. And if they do come to the ED, everyone should be on the same page regarding the expectations of an ED visit, the criteria for hospitalization, and the goals for discharge if the patient is hospitalized.

CHPR: In these collaborative meetings, do you include family members?
Dr. Hong: 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.

CHPR: Do you provide any psychoeducation to family members?
Dr. Hong: 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 (Editor’s note: See “Tips for Family Members” table). 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 (Editor’s note: For more information, see www.borderlinepersonalitydisorder.org/family-connections).

Table: Tips for Family Members

Table: Tips for Family Members

(Click to view full-size PDF.)

CHPR: You mentioned liability concerns. Are there any other thoughts you have about reducing liability risk?
Dr. Hong: In terms of reducing liability, an important point is to appropriately manage countertransference reactions. These reactions are often born out of a sense that the patient is intentionally trying to cause problems. We hear terms like, “They’re being manipulative.” Patients may seem like they’re being overly dramatic to get attention, but often the truth is that they don’t know how to express their emotions in a more regulated way. I highly value the process of venting with a trusted colleague. These patients create stressful situations, and venting can help you have a cooler head when you interact with them.

CHPR: Those are good tips.
Dr. Hong: And going back to the question of liability, 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, “I’m concerned about your family member. There is a real risk of suicide in this illness. We’re going to do the best we can. These are the evidence-based practices.” If somebody does die by suicide and you have that connection with the family, then an honest, frank appraisal of the situation can reduce liability. And the last thing I’ll say about reducing liability involves conversations with supervisors and colleagues. Many of us don’t do these consultations enough, especially if you’re a more experienced clinician. But we can all use a second opinion, no matter how many times we’ve dealt with a patient with BPD or how many years of experience we have. We all have blind spots. That is a very important liability risk reducer.

CHPR: If you get to the point where you need a medication, do you have any tips for psychopharmacology management?
Dr. Hong: There are no FDA-approved medications for BPD or any other personality disorder, so everything we’re using is off label. Try 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 (Black DW et al, Am J Psychiatry 2014;171(11):1174–1182).

CHPR: What about benzodiazepines?
Dr. Hong: 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.

CHPR: Thank you for your time, Dr. Hong.

Suggested Articles

  • Assessing and Treating Catatonia March 23, 2022 Patients experiencing catatonia often improve quickly with benzodiazepines, but how can we help patients who…

Powered by Contextual Related Posts

Share this page!
Subscribe
Register for free content

Register For Free Articles

Register to receive free email newsletters with concise, practical advice for busy clinicians. You will also have access to select article content on the website and you will receive notifications of new books and special discount offers.




Courses and Book CME
Medication Fact Book for Psychiatric Practice, Sixth Edition (2022)
2022 Carlat Psychiatry Report Self-Assessment Course
Prescribing Psychotropics: From Drug Interactions to Pharmacogenetics
The Child Medication Fact Book for Psychiatric Practice (2018)
Issues Archives

2022

  • Minimizing Use of Restraints (July/August/September)
  • Catatonia (April/May/June)
  • Testifying (January/February/March)

2021

  • Agitation (October/November/December)
  • Metabolic Side Effects (July/August/September)
  • Capacity Assessments (April/May/June)
  • Psychiatric Emergencies (Jan/Feb/Mar)

2020

  • Esketamine (January)
  • Telepsychiatry (May)
  • Mind-Gut Connection (January)
  • Practical Psychotherapy (November/December)
  • Mood and Menopause (October)
  • When to Use Lithium (September)
  • Traumatic Brain Injury (August)
  • Borderline Personality Disorder (June/July)
  • Psychopharmacology Algorithms (April)
  • Bipolar II (March)
  • Inflammation and Depression (February)

2020

  • Mood Disorders in Children and Adolescents (Oct/Nov/Dec)
  • Identity & Culture in Children and Adolescents (July/August/September)
  • Psychosis in Children and Adolescents (April/May/June)
  • ADHD in Children and Adolescents (Jan/Feb/Mar)

2020

  • Harm Reduction (January/February)
  • Substance Use in Health Professionals (March/April)
  • Alternative Treatment in Addiction (November/December)
  • Social Aspects of Addiction (September/October)
  • Opioid Use Disorder Treatment (July/August)
  • Emerging Risks for Old Medications (May/June)

2019

  • Depression (May)
  • Adult ADHD (November/December)
  • Mental Health Apps (October)
  • How to Talk about Medication (September)
  • Side Effects Part II (August)
  • Side Effects Part I (June/July)
  • Sleep (April)
  • Parenting, Pregnancy, and Prevention (March)
  • Dark and Light Therapy (February)
  • Deprescribing (January)

2018

  • Drug Metabolism (November/December)
  • Working With Transgender Patients (October)
  • Emergency Psychiatry (September)
  • Treatment-Resistant Depression (July/August)
  • Neurobiology (June)
  • Anxiety (May)
  • Neurofeedback (April)
  • Antipsychotics Update (March)
  • Working With Families (February)
  • Bipolar Disorder (January)

2017

  • PTSD (December)
  • Retirement (November)
  • Intellectual Disability (September/October)
  • Antidepressants (July/August)
  • Personality Disorders (June)
  • Dementia (May)
  • Cognitive Behavior Therapy Techniques (April)
  • Pharmacogenetics (March)
  • Treating Psychosis (February)
  • Adult ADHD (January)

2016

  • Complementary and Alternative Medicine in Psychiatry (November/December)
  • Side Effects (October)
  • Pain Management (September)
  • Medication in Pregnancy (July/August)
  • Psychoanalysis in Modern Psychiatry (June)
  • Correctional Psychiatry (May)
  • Antidepressant Roundup (April)
  • Burnout (March)
  • Private Practice (February)
  • Bipolar Disorder (January)

2015

  • Psychiatry and General Medicine (November/December)
  • Biomarkers in Psychiatry (May)
  • Telepsychiatry (October)
  • Sleep Disorders (September)
  • Interventional Psychiatry (July/August)
  • Eating Disorders (June)
  • Psychotherapy Updates (April)
  • Topics in Geriatric Psychiatry (March)
  • Antipsychotics Update (February)
  • Risk Management (January)

2014

  • Bipolar Disorder (November/December)
  • Pharmacogenetics (October)
  • Keeping up in Psychiatry (September)
  • Research in Psychiatry (July/August)
  • Marijuana (June)
  • Psychiatric Diagnosis (May)
  • Issues in Psychopharmacology (April)
  • Schizophrenia (March)
  • Women’s Psychiatry (February)
  • Ethics in Psychiatry (January)

2013

  • Military Psychiatry (December)
  • Depression (November)
  • Treatment of Dementia (October)
  • Anxiety Disorders (September)
  • Natural and Alternative Treatments in Psychiatry (July/August)
  • Autism Spectrum Disorder (June)
  • Practice Tips (May)
  • Substance Abuse (April)
  • Medicolegal Topics (March)
  • End of Life Care (February)
  • Antipsychotic Update (January)

2012

  • Screening Tools and Tips (December)
  • Medical Comorbidities (November)
  • Devices in Psychiatry (October)
  • Eating Disorders (September)
  • Bipolar Disorder (July/August)
  • Risk Management (June)
  • Antidepressant Roundup 2012 (May)
  • Gender and Sexuality (April)
  • Personality Disorders (March)
  • ADHD (February)
  • Natural Treatments in Psychiatry (January)

2011

  • Electronic Medical Records (December)
  • Insomnia (November)
  • Psychotherapy (October)
  • Alcoholism (September)
  • Anxiety Disorders (July/August)
  • Schizophrenia (June)
  • Managing Side Effects (May)
  • Antidepressant Roundup 2011 (April)
  • DSM-5 and Diagnostic Issues (March)
  • Drug-Drug Interactions (February)
  • Bipolar Disorder (January)

2010

  • Hospital Psychiatry (December)
  • Psychiatric Medication in Pregnancy (November)
  • Maintenance of Certification (October)
  • The Neuroscience of Psychotherapy (September)
  • Treatment of Depression (July/August)
  • Email and the Internet in Psychiatry (June)
  • Substance Abuse (May)
  • The Diagnosis and Treatment of Dementia (April)
  • Ethics in Psychiatry (March)
  • Natural Treatments in Psychiatry (February)
  • ADHD (January)

2009

  • Treating Schizophrenia (December)
  • Treatment for Anxiety Disorders (November)
  • The Latest on Antidepressants (October)
  • Topics in Neuropsychiatry (September)
  • The Interface of Medicine and Psychiatry (July/August)
  • Generic Medications in Psychiatry (June)
  • The Treatment of Eating Disorders (May)
  • Healthcare Policy and Psychiatry (April)
  • Antipsychotic Roundup 2009 (March)
  • Psychiatric Medication in Pregnancy and Lactation (February)
  • Transcranial Magnetic Stimulation (January)

2008

  • Treating Fibromyalgia and Pain in Psychiatry (December)
  • Issues in Child Psychiatry (November)
  • Improving Psychiatric Practice (October)
  • Treating Personality Disorders (September)
  • Bipolar Disorder (July/August)
  • Antipsychotic Roundup 2008 (June)
  • Atypical Antipsychotics in Clinical Practice (February)
  • Neuropsychological Testing (May)
  • Psychiatric Medications: Effects and Side Effects (April)
  • Update on Substance Abuse (March)
  • Anticonvulsants in Psychiatry (February)
  • Brain Devices in Psychiatry (January)

2007

  • The Treatment of Insomnia (December)
  • Avoiding Malpractice in Psychiatry (November)
  • Update on Eating Disorders (October)
  • Complex Psychopharmacology (September)
  • Laboratory Testing in Psychiatry (August)
  • Psychotherapy in Psychiatry (July)
  • Posttraumatic Stress Disorder (June)
  • Topics in Geriatric Psychiatry 2007 (May)
  • Pregnancy and Menopause in Psychiatry (Apil)
  • Antipsychotic Roundup 2007 (March)
  • Understanding Psychiatric Research (February)
  • Antidepressant Round-up 2007 (January)

2006

  • Technology and Psychiatric Practice (December)
  • The Use of MAOIs (November)
  • Medication Treatment of Depression (January)
  • Seasonal Affective Disorder (October)
  • Treatment of ADHD (September)
  • Topics in Bipolar Disorder (August)
  • Neurotransmitters in Psychiatry (July)
  • Treating Substance Abuse (June)
  • The STAR*D Antidepressant Trial (May)
  • Natural Treatments in Psychiatry (April)
  • Medication Treatment of Anxiety (March)
  • Panic Disorder: Making Treatment Work (March)
  • Antipsychotic Roundup 2006 (February)
  • Antidepressant Roundup 2006 (January)

2005

  • Self-Help Books and Psychiatry (December)
  • Genetics and Psychiatry (November)
  • Pregnancy and Psychiatric Treatment (October)
  • Benzodiazepines and Hypnotics in Psychiatry (September)
  • Geriatric Psychiatry Update (August)
  • Chart Documentation in Psychiatry (July)
  • The Treatment of Bipolar Disorder (June)
  • Weight Loss and Smoking Cessation in Psychiatry (May)
  • Treating ADHD (April)
  • Drug Industry Influence in Psychiatry (March)
  • Atypical Antipsychotics 2005 (February)
  • Antidepressant Roundup 2005 (January)

2004

  • Sexual Dysfunction (December)
  • Suicide Prevention (November)
  • To Sleep, To Awake (October)
  • Women’s Issues in Psychiatry (September)
  • OCD: An Update (August)
  • Chronic Pain and Psychiatry (July)
  • Neuroimaging in Psychiatry (June)
  • Natural Medications in Psychiatry (May)
  • Posttraumatic Stress Disorder (April)
  • Treatment of Alcoholism (March)
  • Battle of the Atypicals (February)
  • Antidepressant Roundup, 2004 (January)

2003

  • Research Methods in Psychiatry (December)
  • Antidepressants in Children (November)
  • The Treatment of Dementia (October)
  • Bipolar Disorder, Part II: The Novel Anticonvulsants (September)
  • Bipolar Disorder: The Basics (August)
  • Drug-Drug Interactions in Psychiatry (July)
  • Managing Antidepressant Side Effects (June)
  • Antidepressants in Pregnancy and Lactation (May)
  • ADHD: Medication Options (April)
  • Panic Disorder: Making Treatment Work (March)
  • Atypical Antipsychotics in Clinical Practice (February)
  • Medication Treatment of Depression (January)

2019

  • Autism in Children and Adolescents (November/December)
  • Depression in Children and Adolescents (May/June/July/August)
  • Substance Use in Children and Adolescents (September/October)
  • Trauma in Children and Adolescents (March/April)
  • Anxiety in Children and Adolescents (January/February)

2018

  • Psychotropic Risks in Children and Adolescents (May/June)
  • ADHD in Children and Adolescents (November/December)
  • Depression in Children and Adolescents (September/October)
  • Autism in Children and Adolescents (July/August)
  • Anxiety in Children and Adolescents (March/April)
  • Suicide in Children and Adolescents (January/February)

2017

  • Adolescents (November/December)
  • ADHD in Children and Adolescents (September/October)
  • Psychosis in Children and Adolescents (August)
  • PANDAS, PANS, and Related Disorders (June/July)
  • Marijuana in Children and Adolescents (May)
  • Tourette’s and Other Tic Disorders in Children and Adolescents (March/April)
  • Autism in Children and Adolescents (January/February)

2016

  • Gender Dysphoria in Children and Adolescents (November/December)
  • Technology Issues With Children and Adolescents (September/October)
  • Mood Dysregulation in Children and Adolescents (July/August)
  • Eating Disorders in Children and Adolescents (May/June)
  • Conduct Disorder in Children and Adolescents (April)
  • Sleep Disorders in Children and Adolescents (March)
  • ADHD in Children and Adolescents (January/February)

2015

  • Antidepressant Use in Children (November/December)
  • Foster Care and Child Psychiatry (September/October)
  • Autism (July/August)
  • Trauma (May/June)
  • Anxiety Disorders (April)
  • Schools and Psychiatry (March)
  • Emergency Psychiatry in Children (January/February)

2014

  • Antipsychotics in Children (December)
  • ADHD (November)
  • Gender and Sexuality (September/October)
  • Psychotic Symptoms (Summer)
  • Medication Side Effects (May)
  • Food and Mood (April)
  • Learning and Developmental Disabilities (February)

2013

  • Complex Practice Issues (December)
  • Diet and Nutrition (November)
  • Child Psychiatry in DSM-5 (August/September)
  • Medication Side Effects and Interactions (June/July)
  • Problematic Technology (March/April)
  • Autism Spectrum Disorders (January/February)

2012

  • Bipolar Disorder (December)
  • Substance Abuse (October/November)
  • Transitional Age Youth (July/August)
  • Rating Scales (May/June)
  • Eating Disorders (March/April)
  • Behavioral Disorders (February)

2011

  • Treatment of Anxiety Disorders (December)
  • Trauma (November)
  • Bullying and School Issues (October)
  • Hidden Medical Disorders (August)
  • OCD and Tic Disorders (June)
  • Suicide and Non-Suicidal Self Injury (April)
  • Sleep Disorders (March)
  • ADHD (January)

2010

  • Use of Antipsychotics in Children and Adolescents (December)
  • Learning and Developmental Disabilities (October)
  • Major Depression (September)
  • Treating Children and Families (July)
  • The Explosive Child (May)

2019

  • Dual Diagnosis in Addiction Medicine (May/June)
  • Medical Issues in Addiction Practice (November/December)
  • Alcohol Addiction (September/October)
  • Legal Issues in Addiction Medicine (July/August)
  • Traumatic Brain Injury and Addiction (March/April)
  • Board Certification in Addiction Medicine (January/February)

2018

  • Opioid Addiction (November/December)
  • Addiction in Older Adults (October)
  • Sleep Disorders and Addiction (September)
  • Adolescent Addiction (July/August)
  • Pain and Addiction (May/June)
  • Cannabis and Addiction (March/April)
  • Stigma and Addiction (January/February)

2017

  • Pregnancy and Addiction (November/December)
  • Detox (Sepember/October)
  • Dual Diagnosis (August)
  • Alternatives to 12-Step Programs (June/July)
  • Recovery (May)
  • Psychiatric Uses of Street Drugs (March/April)
  • Sex Addiction (January/February)

2016

  • Prescription Drug Monitoring Programs (PDMPs) (November/December)
  • Addiction in Health Care Professionals (September/October)
  • Dialectical Behavior Therapy in Addiction (August)
  • Motivational Interviewing (June/July)
  • Benzodiazepines (May)
  • Opioid Addiction (March/April)
  • Families and Substance Abuse (January/February)

2015

  • The Twelve Steps (November/December)
  • Designer Drugs (September/October)
  • Residential Treatment Programs Decoded (July/August)
  • Nicotine and E-Cigarettes (June)
  • Drug Screening (April/May)
  • Integrating Therapy and Medications for Alcoholism (March)
  • Detoxification Protocols (January/February)

2014

  • Behavioral Addictions (December)
  • Risk and Reimbursement (November)
  • Stimulant Abuse (September/October)
  • Self-Help Programs (June)
  • Opioid Addiction (May)
  • Coping with Bad Outcomes (March)
  • Change Management in Addiction Treatment (January/February)

2013

  • Cocaine Addiction (December)
  • Relapse Prevention (November)
  • Cannabis Addiction (August/September)
  • Addiction in DSM-5 (June/July)
Editor-in-Chief

Victoria Hendrick, MD

Dr. Hendrick is a clinical professor at the David Geffen School of Medicine at UCLA and is the director of inpatient psychiatry at Olive View—UCLA Medical Center, where she carries a caseload of patients and provides teaching and supervision for medical students and psychiatry residents. After completing medical school and psychiatric residency at UCLA, she spent several years working as a principal investigator and co-investigator on N.I.M.H. funded research studies. She has authored or co-authored over 75 research papers, editorials, books and other publications. She has a long-standing interest in the needs of severely mentally ill patients from underserved populations and has worked in community mental health settings her entire career.

Full Editorial Information

About

  • About Us
  • CME Center
  • FAQ
  • Contact Us

Shop Online

  • Subscriptions
  • Books
  • Online Courses

Newsletters

  • The Carlat Psychiatry Report
  • The Carlat Addiction Treatment Report
  • The Carlat Child Psychiatry Report
  • The Carlat Hospital Psychiatry Report

Contact

  • info@thecarlatreport.com
  • 866-348-9279
  • PO Box 626, Newburyport MA 01950

Follow Us

© 2022 Carlat Publishing, LLC and Affiliates, All Rights Reserved.

Please see our Privacy Policy and the Hardware/Software Requirements to view our website.

×