do you tell your Borderline pts about their diagnosis?

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Originally Posted by OldPsychDoc

Ahh yes, along with the pulmonologists who "occasionally admit" COPDers who haven't been compliant with smoking cessation and cardiologists who keep stenting arteries in those pesky folks who keep eating saturated fats. And don't even get me started on those silly diabetics!

Thank god you're here to set us straight, Dr. V.

all ridiculous examples......the above specalties admit those pts because acute management is needed.

relating that to borderlines, if my acute suicide risk assessment is low enough(as it usually is with these people), then I discharge. If my acute suicide assessment makes me believe admission is warranted, I admit. In almost all the cases with obvious borderlines, it ends up being a discharge.

another obvious difference is that the natural course of an untreated copd exacerbation is further decompensation. The untreated course of catching a borderline at their crisis peak is generally continued up and down fluctuations.......even without hospitalization.

this really brings a larger issue at play here(extending beyond just borderlines), and that is that far too many psychiatrists are way too conservative regarding admit/dc decisions in an er setting. way too many people are admitted in some cases.

Originally Posted by BobA

Dr. V are you sure your management of borderlines isn't influenced by counter-transference?

It seems odd to have such a hard and fast rule about anything in medicine.

Psychiatrist who are open to evaluating their own emotional reactions to patients, who are open to the idea that they can be vulnerable human beings too, are going to be much better psychiatrists.

My management of borderlines is influenced....influenced by wanting to practice psychiatry using reasonable approaches that balances efficiently using resources while looking out for the best interests of patients.

And of course I would never say "never" to a borderline. If a pt I knew to be borderline was brought in after being witnessed playing genuine russian roulette with a loaded gun, I'd keep them. But we all know that isn't always the case. Gosh I don't know how many *obvious* borderlines I saw in the er my pgy2 year....maybe 125-150? I *may* have kept 1 or 2......

and yes, it is *more* work for me to discharge them. Everyone knows it's easier to just admit them. But doing the easy thing and doing the right thing are often different........

Originally Posted by vistaril

all ridiculous examples......the above specalties admit those pts because acute management is needed.

relating that to borderlines, if my acute suicide risk assessment is low enough(as it usually is with these people), then I discharge. If my acute suicide assessment makes me believe admission is warranted, I admit. In almost all the cases with obvious borderlines, it ends up being a discharge.

You have far too much faith in your own ability to predict suicide. The data doesn't really support that psychiatrists are that great at predicting suicide, though we're better than a layman.

Originally Posted by vistaril

another obvious difference is that the natural course of an untreated copd exacerbation is further decompensation. The untreated course of catching a borderline at their crisis peak is generally continued up and down fluctuations.......even without hospitalization.

Data to support that? Borderline pt's kill themselves as much as others, if not more. Sometimes the escalation when not paid attention to is actual suicide, not just coming back to the hospital or up and down periods. Some of that might be accidental, but who knows?

You're prone to a selection bias, generalizing again from the borderline pt's you see as your frequent flyers, presuming that maps out to show that all borderlines not admitted will just come back. You don't know that.

Originally Posted by vistaril

this really brings a larger issue at play here(extending beyond just borderlines), and that is that far too many psychiatrists are way too conservative regarding admit/dc decisions in an er setting. way too many people are admitted in some cases.

Maybe. That's clinical discretion. There's a difference between "must admit," "can benefit from being admitted," and "need to admit to CYA." All can be considered reasonable conditions for admission, in certain circumstances.

When you're put on the stand to testify at your lawsuit, and the attorney asks --
"Dr. Vistaril, this patient came to the ER repeatedly asking for help, in fact cutting on her own wrists to show she was serious, and yet you discharged her over and over again because she has a personality disorder. Now eventually she went through with it and died. Can you really ask this JURY to not blame You, when she came to you again and again, and you said she had a personality disorder and wouldn't do anything if she wasn't admitted?"

What exactly is it that you think psychiatrists are sued for? Suicide suicide suicide. Sex with patients. And suicide.

Originally Posted by vistaril

And of course I would never say "never" to a borderline. If a pt I knew to be borderline was brought in after being witnessed playing genuine russian roulette with a loaded gun, I'd keep them. But we all know that isn't always the case. Gosh I don't know how many *obvious* borderlines I saw in the er my pgy2 year....maybe 125-150? I *may* have kept 1 or 2......

And how many of those 125-150 did you have longitudinal f/u to know they didn't go on to do something? If you don't know, then it's quite possible they suicided. Just because you didn't hear about anything doesn't mean the outcome was neutral or positive. Shame, lack of resources, and lack of autopsies has led to a paucity of reporting of suicides accurately. The director of our county hospital used to get reports regularly from the medical examiner. Even with underreporting you'd be amazed how many suicides and possible suicides occur, but many have no families or contacts or are john/jane does that the information never gets back to their last doctor. Think about it.

I am surprised he was able to discharge that many suicidal patients as a PGY2 since it seems a lot of attendings would push for admission and even if you have a flavor that the patient won't kill themselves, you just don't know - borderline personality disorder carries one of the highest suicide rates. Whether these tortured individuals meant to kill themselves, whether it was revenge phantasy, whether it was self-harm gone too far is irrelevant when you're dead. You seem so sure of yourself.

I do think that usually an inpatient unit is the worst place for borderlines but when you consider that most patients with BPD have another psychiatric comorbidity like bipolar or major depression, then often there is justification for admission. A final point is that it is the nature of the psychiatric unit is often what makes it unsuitable. There are places where the staff are trained and the unit has the resources to do good therapeutic work with these patients, and a crisis is often a good place to start. I'm about to start my first rotation on 'borderline central' (apparently)- somewhere where there are noted faculty in psychotherapy for borderline personality disorder. Should be fun!

Originally Posted by vistaril

My management of borderlines is influenced....influenced by wanting to practice psychiatry using reasonable approaches that balances efficiently using resources while looking out for the best interests of patients.

And of course I would never say "never" to a borderline. If a pt I knew to be borderline was brought in after being witnessed playing genuine russian roulette with a loaded gun, I'd keep them. But we all know that isn't always the case. Gosh I don't know how many *obvious* borderlines I saw in the er my pgy2 year....maybe 125-150? I *may* have kept 1 or 2......

and yes, it is *more* work for me to discharge them. Everyone knows it's easier to just admit them. But doing the easy thing and doing the right thing are often different........

Who doesn't have counter-transference towards patients with borderline personality disorder? The offspring of Carl Rogers and Ghandi?

V- you do realize that when making any decision in life, its not the % of the time your right that matters?

Its the (% Correct x overall benefit of being correct) minus (% Wrong x overall consequences of being wrong). So even if you "correctly" discharge 100 borderlines, the 1 suicide you allow when your wrong undoes all that "good" you did (and might ruin your career ontop of that)

Originally Posted by surftheiop

(% Correct x overall benefit of being correct) minus (% Wrong x overall consequences of being wrong)

Did this have a source? Totally stealing it.

Originally Posted by surftheiop

V- you do realize that when making any decision in life, its not the % of the time your right that matters?

Its the (% Correct x overall benefit of being correct) minus (% Wrong x overall consequences of being wrong)....

I would further divide this result by "# of people I piss off regardless of correctness".
I realize it's part of the consequences, but I think there should be an extra weighting on the interpersonal aspects of how we arrive at our decisions.

Originally Posted by billypilgrim37

Did this have a source? Totally stealing it.

Nothing specific, just kind of a human related application of expected value from stats

http://en.wikipedia.org/wiki/Expected_value

Originally Posted by OldPsychDoc

I would further divide this result by "# of people I piss off regardless of correctness".
I realize it's part of the consequences, but I think there should be an extra weighting on the interpersonal aspects of how we arrive at our decisions.

I agree, definitely a great meta-consideration. How we treat people now has such a huge impact on what we can get done in the future. (in addition to the moral value of just being a decent person)

Originally Posted by nitemagi

You have far too much faith in your own ability to predict suicide. The data doesn't really support that psychiatrists are that great at predicting suicide, though we're better than a layman.


Data to support that? Borderline pt's kill themselves as much as others, if not more. Sometimes the escalation when not paid attention to is actual suicide, not just coming back to the hospital or up and down periods. Some of that might be accidental, but who knows?

You're prone to a selection bias, generalizing again from the borderline pt's you see as your frequent flyers, presuming that maps out to show that all borderlines not admitted will just come back. You don't know that.



Maybe. That's clinical discretion. There's a difference between "must admit," "can benefit from being admitted," and "need to admit to CYA." All can be considered reasonable conditions for admission, in certain circumstances.

When you're put on the stand to testify at your lawsuit, and the attorney asks --
"Dr. Vistaril, this patient came to the ER repeatedly asking for help, in fact cutting on her own wrists to show she was serious, and yet you discharged her over and over again because she has a personality disorder. Now eventually she went through with it and died. Can you really ask this JURY to not blame You, when she came to you again and again, and you said she had a personality disorder and wouldn't do anything if she wasn't admitted?"

What exactly is it that you think psychiatrists are sued for? Suicide suicide suicide. Sex with patients. And suicide.

1) Do you have any data to suggest that constantly admitting borderlines reduces their overall suicide rate?

2) the foundation of my clinical decisions isn't based on what most reduces the lawsuit potential.....not to say that it should never be a consideration, but it's not the main thing. When I discharge a borderline I document the protective factors and explain my decision.

Originally Posted by nitemagi

And how many of those 125-150 did you have longitudinal f/u to know they didn't go on to do something? If you don't know, then it's quite possible they suicided. Just because you didn't hear about anything doesn't mean the outcome was neutral or positive. Shame, lack of resources, and lack of autopsies has led to a paucity of reporting of suicides accurately. The director of our county hospital used to get reports regularly from the medical examiner. Even with underreporting you'd be amazed how many suicides and possible suicides occur, but many have no families or contacts or are john/jane does that the information never gets back to their last doctor. Think about it.

there may have been 1 that killed themselves....I can't be certain. If you see enough patients, some may eventually kill themselves.

Borderlines do have a high overall rate of suicide. We all know this. But there is no evidence that frequent admissions reduces that rate appreciably.

Originally Posted by splik

I am surprised he was able to discharge that many suicidal patients as a PGY2 since it seems a lot of attendings would push for admission and even if you have a flavor that the patient won't kill themselves, you just don't know - borderline personality disorder carries one of the highest suicide rates. !

I selected my er months to coincide with attendings whose philosophy and style is similar to mine.

If a hospital system is going to staff the er with a psych er attendings, that's not a trivial cost. If that person is just going to admit everyone, what the heck is the point of having them there? They could hire someone for 10 dollars an hour to put in admit orders on basically everyone who mentions thoughts of self harm to themselves.....

Originally Posted by surftheiop

V- you do realize that when making any decision in life, its not the % of the time your right that matters?

Its the (% Correct x overall benefit of being correct) minus (% Wrong x overall consequences of being wrong). So even if you "correctly" discharge 100 borderlines, the 1 suicide you allow when your wrong undoes all that "good" you did (and might ruin your career ontop of that)

I suppose NNT's(in th form of inpatient admissions) in the psych er to prevent 1 suicide is another discussion......I don't really know what is that number.

Also, with borderlines you would only get credit for a "suicide prevention" if they went home and killed themselves within several hours of when they were discharged. If they kill themselves 5 weeks later, you obviously wouldn't have prevented that suicide by admitting them.

again, discharging pts takes more work, but it is the right thing to do. I've worked on inpatient teams where 80% of the patients are borderlines, malingerers, placements, and combinations of malingerers, substances, and placement......those are "easy" services, but that's not what I got into this to do.

Originally Posted by vistaril

again, discharging pts takes more work, but it is the right thing to do. I've worked on inpatient teams where 80% of the patients are borderlines, malingerers, placements, and combinations of malingerers, substances, and placement......those are "easy" services, but that's not what I got into this to do.

Out of curiosity, which aspects or patient population of psych appeals to you the most? Psych is such a broad field that for me as a medstudent it seems to be harder to conceptualize the whole scope of the specialty compared to surgery or something.

Originally Posted by vistaril

again, discharging pts takes more work, but it is the right thing to do. I've worked on inpatient teams where 80% of the patients are borderlines, malingerers, placements, and combinations of malingerers, substances, and placement......those are "easy" services, but that's not what I got into this to do.

Not sure what "placement" means....

I wonder how you would recruit a control group of people who are acutely suicidal w/MDD only but not allowed an admission and only followed for outcomes? You know, to find out if hospitalization for suicidal depressed pts reduces rate of suicide. Without data I guess it would be silly to keep admitting them?

Originally Posted by roubs

I wonder how you would recruit a control group of people who are acutely suicidal w/MDD only but not allowed an admission and only followed for outcomes? You know, to find out if hospitalization for suicidal depressed pts reduces rate of suicide. Without data I guess it would be silly to keep admitting them?

ba-dum ching, case closed.

Originally Posted by Iwillheal

Not sure what "placement" means....

it can refer to a lot of things, but one example would be a 21 yo with MR and autism who has previous admissions for behavioral disturbances, agitation,etc but has been fairly stable(for him at least) the last couple of years on a med regimen. He has been living with his elderly grandparents who are the only ones who were willing to take care of him, but now they've just gotten too old and a run of the mill "episode" for the pt gets them and others to realize this...so they bring him to the ER. He'll need to be placed in a group home, but that can't happen from the ER and he has nowhere to live or nobody to take care of him right now(due to his autism, MR, etc he couldnt make it in a shelter) so he requires admission for placement in that group home.

thats just one example.

Originally Posted by roubs

I wonder how you would recruit a control group of people who are acutely suicidal w/MDD only but not allowed an admission and only followed for outcomes? You know, to find out if hospitalization for suicidal depressed pts reduces rate of suicide. Without data I guess it would be silly to keep admitting them?

fail....on a lot of different levels.

Originally Posted by roubs

I wonder how you would recruit a control group of people who are acutely suicidal w/MDD only but not allowed an admission and only followed for outcomes? You know, to find out if hospitalization for suicidal depressed pts reduces rate of suicide. Without data I guess it would be silly to keep admitting them?

While I agree with your point, epidemiologists make their entire career out of designing research methods to circumvent these issues, and many public health policies are based on these studies. It's not perfect, but we've never actually randomly assigned people to cigarettes or not to see if they would get cancer either.

Originally Posted by billypilgrim37

While I agree with your point, epidemiologists make their entire career out of designing research methods to circumvent these issues, and many public health policies are based on these studies. It's not perfect, but we've never actually randomly assigned people to cigarettes or not to see if they would get cancer either.

Yep there is nothing wrong with drawing conclusions from overwhelming, oft-replicated, 'controlled as much as possible' correlational data.

Is whether hospitalization for suicidal pts "works" to prevent suicide worthy of the kind of investment we put in to link smoking to cancer? I'm only bothering to bring up a silly example because of an appeal to (lack of) research findings ("there is no evidence that frequent admissions reduces that rate appreciably.") to justify non-admission. Misuse of science, imo.

fail....on a lot of different levels.

Ohh wait, nevermind, now I see that I am so wrong.

Originally Posted by vistaril

1) Do you have any data to suggest that constantly admitting borderlines reduces their overall suicide rate?

2) the foundation of my clinical decisions isn't based on what most reduces the lawsuit potential.....not to say that it should never be a consideration, but it's not the main thing. When I discharge a borderline I document the protective factors and explain my decision.

1. No one is talking about constantly admitting. But sometimes it's necessary, and sometimes it can be beneficial.

I didn't need this study to exist to get the point, but maybe you do.

2. You miss the point. Sure medicolegal considerations should be an issue, but to anyone from the outside, you're being neglectful when someone escalates their suicidal behaviors and you don't recognize this and do something differently.

Borderlines aren't the same as malingerers. You seem to conflate the two, mixing in your own counter-transference and anger. Don't get me wrong, I recognize admitting someone every time they complain of SI is reinforcing that behavior (of asking for help with every little crisis), but a discerning clinician sees past the personality disorder and can distinguish emergency from urgency from life as usual, and intervene appropriately. The approach I'm hearing you throw out is "if it's not an emergency I don't have to [or know how to] deal with it."

And way to go on selecting attendings that think the same as you. You'll definitely grow that way.

Originally Posted by nitemagi

1. No one is talking about constantly admitting. But sometimes it's necessary, and sometimes it can be beneficial.

I didn't need this study to exist to get the point, but maybe you do.

2. You miss the point. Sure medicolegal considerations should be an issue, but to anyone from the outside, you're being neglectful when someone escalates their suicidal behaviors and you don't recognize this and do something differently.

Borderlines aren't the same as malingerers. You seem to conflate the two, mixing in your own counter-transference and anger. Don't get me wrong, I recognize admitting someone every time they complain of SI is reinforcing that behavior (of asking for help with every little crisis), but a discerning clinician sees past the personality disorder and can distinguish emergency from urgency from life as usual, and intervene appropriately. The approach I'm hearing you throw out is "if it's not an emergency I don't have to [or know how to] deal with it."

And way to go on selecting attendings that think the same as you. You'll definitely grow that way.

When I hear people say stuff like that, there "sometimes" with borderlines ends up being like 30-35% or more.....lol.

not sure how you assume I conflate borderlines and malingerers. Nothing I wrote indicates anything of the sort. The only thing they have in common is that they shouldnt be admitted for the most part.

Also, not sure how you get the anger part. I've already stated that I like a lot of borderlines. I also have a lot of compassion for them as I do recognize that their suffering is real.

As for selecting attendings, I prefer to work with the best clinicians. You learn more from them. The only thing I would learn from mediocre clinicians is how to be mediocre, which I'm not interested in.

Talked with a borderline polysubstance abuser this afternoon. She had injured her back and was craving opiates big time...and wanting to be discharged.

Me: "I'm afraid you'd be using the minute you hit the streets."
Patient: Giving a sly smirk.
Me: "Wait, you'd be using prior to getting off the hospital grounds wouldn't you?"
Patient: "Yes, I have a stash hidden outside the hospital. And you know XXX who was discharged yesterday and came back to the ER an hour later? He had some hidden also."

Originally Posted by zenman

Talked with a borderline polysubstance abuser this afternoon. She had injured her back and was craving opiates big time...and wanting to be discharged.

Me: "I'm afraid you'd be using the minute you hit the streets."
Patient: Giving a sly smirk.
Me: "Wait, you'd be using prior to getting off the hospital grounds wouldn't you?"
Patient: "Yes, I have a stash hidden outside the hospital. And you know XXX who was discharged yesterday and came back to the ER an hour later? He had some hidden also."

Seems more like a hardcore addict than a borderline pt. Addicts who behave with maladaptive coping mechanisms in the context of intoxication or to obtain drugs are a different category than those that do it without any drugs in the picture. Like someone that commits crimes to get money or drugs only for that purpose, vs. a sociopath that commits crimes just because he likes hurting people.

When addicts get desperate, they can regress to the most primitive of behaviors, including shouting, throwing a tantrum, whatever. I consider that an aspect of their addiction, not their baseline personality functioning (evidenced when seeing these same "borderline" people after being sober 5 or 10 years and they seem mature and well adapted).

and for anyone thinking of prescribing Suboxone...this happens often with such patients. Expect several Suboxone patients to call you or your receptionists often screaming at you and threatening a lawsuit when you did nothing wrong.

I see it as a Maslov's pyramid thing. If the person is denied Suboxone they are regressed to the bottom level of the pyramid. Of course they are getting their food and air, but the psychological equivalent, a substance they need just to feel normal is being denied to them.

And unfortunately when these things happen, often-times I feel obligated to terminate their treatment. When someone is screaming at us because I won't provide them with Suboxone because they were arrested for trafficking drugs and I see on the court website they were found guilty since my last meeting with them, game over. On more than one occasion I've had a screaming person in the waiting area of the office screaming while other patients were staring at him or her in fear, and I told them to either quiet down and leave or they'd be leaving by force via the police.

Originally Posted by Iwillheal

I wish we did not have to use the bpd label, given the stigma. It's to the point I would even prefer something as simpleminded as "fragile" personality, though ultimately I'd prefer something like "Complex post-traumatic stress disorder" (had the research supported a stronger correlation between childhood trauma and bpd.)

Or use "borderline personality organization" from the psychodynamic lit accompanied by the personality label (e.g. histrionic). Not because it creates less stigma but because I think it's more accurate.

Another point: I think there is more tolerance for treating people who have suffered war trauma, or purely physical trauma (terrible accident), than bpd patients. They're all needy in a way, but there are differences. I think bpd pts need a lot of help but they often reject it. I think it's also quite painful for me personally to provide that help because often I feel like...I feel like I'm cleaning the wound of an injured animal that switches back and forth between a wolf and a lamb, so if I'm not completely grounded, I can lose touch with reality (of the situation) myself and buy into what I'm presented with. Yes, I'm new to the field but I can't help feeling the need to be hypervigilant around these patients lest I say something or do something or use a certain body language that they can reveal a certain "hook" on which they can hang their ****. I genuinely care for these people but it's emotionally draining for me to deal with them. Not all of them of course but a large portion of them. I feel like only a stronger mind can dance their dance. Maybe in due time I can too but right now I rather not.

I've been debating whether to respond to this, but on the off chance that it might be helpful -- I no longer meet the diagnostic criteria, but from a former borderline patient's point of view I'd say the best thing you can do is just be consistent. When I was in treatment it really helped that I knew no matter how many times I said, or did something it would elicit the same response each time. After a while having that consistency allowed me to relax, and start trusting the therapeutic process. Maybe I had more insight than the average borderline patient back then as well, I don't know, but I certainly didn't expect my therapist to be perfect and not put a single foot wrong around me. I mean I wanted a therapist I could relate to, and who gave me a sense of stability, not someone who never said or did anything wrong. We are a very difficult population to work with, believe me, I know that, we can be a therapists worst nightmare, especially in terms of manipulation, but most of the time we're just scared, and full of self loathing, and we don't know how to feel or behave in most normal situations, because we weren't raised with the proper tools. Put it another way, I spent a fair portion of my life walking on egg shells lest I set off my mentally unstable, and abusive mother, I don't, therefore, wish to repeat that same feeling of having to tip toe around my therapist. Make sense?

Originally Posted by nitemagi

Seems more like a hardcore addict than a borderline pt. Addicts who behave with maladaptive coping mechanisms in the context of intoxication or to obtain drugs are a different category than those that do it without any drugs in the picture. Like someone that commits crimes to get money or drugs only for that purpose, vs. a sociopath that commits crimes just because he likes hurting people.

When addicts get desperate, they can regress to the most primitive of behaviors, including shouting, throwing a tantrum, whatever. I consider that an aspect of their addiction, not their baseline personality functioning (evidenced when seeing these same "borderline" people after being sober 5 or 10 years and they seem mature and well adapted).

I believe BPD came first with this lady, then addiction. Certainly makes for an interesting combination.

....

In many parts of the US, the coroner's report is public information. Is it in Australia? Becuase if it's not it violates the patients' privacy. Someone please answer this ASAP because I'm thinking of deleting the above post.

As for borderline PD, I am willing to admit some (though very few) patients with it if I do believe it truly is a life or death matter.

On the other hand there are some patients who are parasuicidal to the degree of very extreme and I've still discharged them because I believed there was a factitious disorder component to it. E.g. I had a patient who, while in long-term hospitalization, regularly threw herself off down the stairs only in the presence of other people. She would go on a bridge and threaten suicide almost every few days.

She's been doing it for 20 years. I knew this patient well because while in the long-term hospital I'd go to the code where she'd fall down the stairs, pretend to be unconcious but a pinch test got her up and saying "oww! why did you pinch me!?!?!"

Originally Posted by whopper

In many parts of the US, the coroner's report is public information. Is it in Australia? Becuase if it's not it violates the patients' privacy. Someone please answer this ASAP because I'm thinking of deleting the above post.

As for borderline PD, I am willing to admit some (though very few) patients with it if I do believe it truly is a life or death matter.

On the other hand there are some patients who are parasuicidal to the degree of very extreme and I've still discharged them because I believed there was a factitious disorder component to it. E.g. I had a patient who, while in long-term hospitalization, regularly threw herself off down the stairs only in the presence of other people. She would go on a bridge and threaten suicide almost every few days.

She's been doing it for 20 years. I knew this patient well because while in the long-term hospital I'd go to the code where she'd fall down the stairs, pretend to be unconcious but a pinch test got her up and saying "oww! why did you pinch me!?!?!"

Yes, it was an Australian Coroner's report. The report appeared to be available publicly, but on the off chance that it wasn't meant to be, I've deleted the previous post. I'm not 100% sure of the laws surrounding such things, so if there's a chance of it being a problem, I'd prefer to err on the side of caution.

That being said, out of a personal interest, I would still be interested in understanding where that determining line is - between admitting a borderline patient, and not admitting them, especially if the patient has a history of acting out, and has made several 'cry for help' type attempts on their life prior, as was the case with Julia Morris, the girl I mentioned in my previous, deleted, post. I suppose as friends and family the one thing we all tended to struggle with in the wake of Julia's death was not knowing why on earth no one had seen fit to admit her for any real length of time, when it was so obviously clear, at least to many of those around her, that she intended to take her own life.

I'll link to a news report of Julia's case to at least give reference/background, this I know is definitely available for public viewing.

http://www.abc.net.au/pm/content/2010/s3008784.htm

Edited to add: Obviously there's the, I assume, easier cases, like someone making parasuicidal gestures for 20 years, with no escalation as with the example given. What about when the case isn't so clear, what's the determining factor when the line between 'patient is a danger to themselves' and 'patient is just engaging in attention seeking behaviours' appears to be blurry.

Originally Posted by Ceke2002

I've been debating whether to respond to this, but on the off chance that it might be helpful -- I no longer meet the diagnostic criteria, but from a former borderline patient's point of view I'd say the best thing you can do is just be consistent. When I was in treatment it really helped that I knew no matter how many times I said, or did something it would elicit the same response each time. After a while having that consistency allowed me to relax, and start trusting the therapeutic process. Maybe I had more insight than the average borderline patient back then as well, I don't know, but I certainly didn't expect my therapist to be perfect and not put a single foot wrong around me. I mean I wanted a therapist I could relate to, and who gave me a sense of stability, not someone who never said or did anything wrong. We are a very difficult population to work with, believe me, I know that, we can be a therapists worst nightmare, especially in terms of manipulation, but most of the time we're just scared, and full of self loathing, and we don't know how to feel or behave in most normal situations, because we weren't raised with the proper tools. Put it another way, I spent a fair portion of my life walking on egg shells lest I set off my mentally unstable, and abusive mother, I don't, therefore, wish to repeat that same feeling of having to tip toe around my therapist. Make sense?

Thank you for taking the time to reply and I'm glad you did because I do find it helpful. I just read over my original post and I apologize if I came across as crass in some parts. I was letting off steam really. Yes, therapists are human too and we make mistakes, we hurt people's feelings sometimes (which happens more often if you are someone like me, quite new to the field and still learning and adjusting). But you're right, consistency is key, as are boundaries--set in a consistent and compassionate way. I have to watch out for my own tendency to overcommit, to get overly involved in attempting to help a person with borderline features, and then needing to pull back in an attempt to protect myself from rage or loathing that sometimes comes out of the blue and finds me its target. I am quite sensitive and caring, despite how may have come across, and it is my zeal for helping that can lead to quite counter-productive behavior in certain situations. I have become more and more mindful of that and hope to continue improving. Thanks again.

I would still be interested in understanding where that determining line is - between admitting a borderline patient, and not admitting them, especially if the patient has a history of acting out, and has made several 'cry for help' type attempts on their life prior, as was the case

This would be an undertaking to make such a post, and during a moment of passion I'd consider doing it. I'm on call today, a bit sick and I'm dungeon mastering a game session today.

The short is just like you mentioned above (and I believe your advice is highly valuable and is a fundamental of DBT), the doctor needs to be consistent as well.

While borderlines are at increased risk of suicide, hospitalization usually doesn't help. In fact if the borderline likes hospitalization (some do, some don't), but it's not therapeutic, that's a reason to consider against it because it could reinforce/reward the person for going into the hospital when in fact they should not be going in. As we all know, one could like being in the hospital or other forms of treatment but it's really not helping the person.

Each person is different, and that's what makes treating this disorder especially difficult because you could happen upon a borderline that could benefit from hospitalization as well though it's more rare than common.

I think if I undertake this post the best I could do is just lay it down for factors for admitting, factors not because it is a complex decision making process.

Originally Posted by nitemagi

Seems more like a hardcore addict than a borderline pt. ).

I have pretty consistent no admission policy for both BICs and ASDs(addicts seeking detox), but gun to my head, I'd probably be more open to admitting the addict exagerrating the degree of his personal safety risk with the hope of being detoxed in the hospital. At least with the addict if they can get plugged into the right recovery program after dc they may at least have benefited somewhat......still, ASDs I almost never admit either. I'm really good at asking a line of questions in such a way that I can get them to tell me(even if they didnt intend to) that they arent really going to kill themselves....

the key with the addict seeking detox is to be very straightforward about the fact that you don't run a detox unit. some of our residents and attendings like to try a different approach where they emphasize that if they do get admitted, they will only be given symptomatic treatment and not started on suboxone or whatever....and no benzos for their anxiety during opiate withdrawl. Their hope is that the pt will come off the suicidal stuff when they are told they arent getting any of the "good stuff" that will make them more comfortable......the problem with this strategy is that the ER person doesn't have any control over what the pt will get on the floor, and ASDs know this......

there was nothing more frustrating when you're on an inpatient unit than having a bunch of addicts there for (really) detox and placement along with some BICs. Just a complete waste of resources. Furthermore, once the ASDs get up to the floor their tune changes and they immediately start demanding controlled substances....one of my favorite attendings had a brilliant strategy. 8 hrs after coming to the floor one of them asked for suboxone or ativan or something(cant remember)......the attending said "yeah, we arent going to do that here". The pt then threw a big fit, said "you just don't understand what it's like for me" and then said "if you arent going to do anything I could just go home and suffer"....the attending then called the nurse into the room, told her to start processing this pt's discharge paperwork, and that was that.......

I learned so much more on that service because the ratio of learning cases with interesting cases was so high....simply because the attending would just DC BICs and ASDs once they got to the floor.

I think all psychiatrists, whether you are an intern or in your 45th year, need to really ask themselves- "what would an inpatient hospitalization benefit this patient?" Thats true for borderlines, addicts, schizophrenics who are very low functioning but may not really be that far from baseline, etc.......

Sometimes you will get stuck with placement admissions, and you just have to suck those up sometimes. But the ASDs and BICs are not going to take up slots on my pt list

Originally Posted by whopper

This would be an undertaking to make such a post, and during a moment of passion I'd consider doing it. I'm on call today, a bit sick and I'm dungeon mastering a game session today.

The short is just like you mentioned above (and I believe your advice is highly valuable and is a fundamental of DBT), the doctor needs to be consistent as well.

While borderlines are at increased risk of suicide, hospitalization usually doesn't help. In fact if the borderline likes hospitalization (some do, some don't), but it's not therapeutic, that's a reason to consider against it because it could reinforce/reward the person for going into the hospital when in fact they should not be going in. As we all know, one could like being in the hospital or other forms of treatment but it's really not helping the person.

Each person is different, and that's what makes treating this disorder especially difficult because you could happen upon a borderline that could benefit from hospitalization as well though it's more rare than common.

I think if I undertake this post the best I could do is just lay it down for factors for admitting, factors not because it is a complex decision making process.

Sorry to hear you're not feeling well. Off topic for a moment, but DnD? Cool I was more of a WoD VtM person myself, but I had some friends who were mad keen on Dungeons and Dragons.

Anyway, I can imagine the reality of deciding who to admit in any individual case is a lot harder than what friends and family imagine it to be. And of course there's the consideration, I would assume at least, that in some cases it's not really going to matter what you do, if someone is that determined to kill themselves they will find a way -- you can't keep someone locked up forever. Besides Julia's case, I've lost several other friends and acquaintances to suicide, all of who were being treated for BPD, and in at least one of those cases I know the girl had family support, community nursing support, she'd been inpatient several times for Anorexia and SI, she was an active member of a mental health support community, and despite all that she still topped herself. In her situation I really don't think anything else could have been done to save her.

I know in Julia Morris's case the police were issued with a warning (basically a list of names of people known to be actively suicidal) that was supposed to be distributed to shooting ranges, but they failed to do so in a timely enough manner. So I know at least there were attempts made to ensure her safety to a degree, without admitting her to hospital. Then again, like I said, if someone's that determined to take their own life, they'll probably find a way no matter what protections you try and put in place. And to my mind at least, it really doesn't get more determined than putting a gun to your head, and pulling the trigger. Of course that's the logical, rational, 'try and see it from all sides' part of my brain, the part that lost a friend tends to be more on the 'why the hell was she not admitted, she could have been saved' side of the fence.

Originally Posted by Iwillheal

Thank you for taking the time to reply and I'm glad you did because I do find it helpful. I just read over my original post and I apologize if I came across as crass in some parts. I was letting off steam really. Yes, therapists are human too and we make mistakes, we hurt people's feelings sometimes (which happens more often if you are someone like me, quite new to the field and still learning and adjusting). But you're right, consistency is key, as are boundaries--set in a consistent and compassionate way. I have to watch out for my own tendency to overcommit, to get overly involved in attempting to help a person with borderline features, and then needing to pull back in an attempt to protect myself from rage or loathing that sometimes comes out of the blue and finds me its target. I am quite sensitive and caring, despite how may have come across, and it is my zeal for helping that can lead to quite counter-productive behavior in certain situations. I have become more and more mindful of that and hope to continue improving. Thanks again.

I'm glad it was helpful. I didn't think you were being crass, there's a lot worse things you could be than a therapist who sounds like they really care about doing the right thing by their patients.

Originally Posted by Ceke2002

Sorry to hear you're not feeling well. Off topic for a moment, but DnD? Cool I was more of a WoD VtM person myself, but I had some friends who were mad keen on Dungeons and Dragons.

Anyway, I can imagine the reality of deciding who to admit in any individual case is a lot harder than what friends and family imagine it to be..

it's usually not a hard decision for me, and usually in a different way than the family or friends assume.

I often have patients bring themselves and/or people bring pts to "check themselves in to the psych hospital". most of these pts end up not being appropriate for psych admission, and I've actually worked with the medical er to have them send many of these pts home without a psych consult if it doesn't merit it. another common chief complaint is "I've come to see a psychiatrist to finally get some help". I'll get the medical er to give these pts and their families a list of outpt providers in the area....

when you explore what some of these pts expect from an inpt psych admission when they bring themselves "to finally get some help", you'll see that they expect lots of intensive 1 on 1 therapy in some cases. I then explain that an inpatient admission would actually prevent them from getting the help they came for.....of course in many cases pts dont have resources for (decent) outpt mental health care. This is unfortunate, but just as I can't walk on water I can't create resources out of thin air....and I explain this to pts and their families.

most areas do have some very low cost to sliding school outpt therapy services with lpcs, lcsws, and psychologists.....the quality can be very hit or miss and many of the people doing it are still in training, but it's an option I offer pts when I discharge them.

Thanks for the insight. I guess what the average lay person thinks is in the best interest of the patient, and what actually is in the patient's best interest, can be two different things. I also suspect you get at least a few requests for admission from parents, or caregivers, who are looking to make it someone else's problem for a while. I know they have carer respite programs in the community where I live, mainly for people with physical disabilities and dementia, not sure if that extends to respite programs for those people who are caring for someone with mental health issues.

Originally Posted by Ceke2002

Thanks for the insight. I guess what the average lay person thinks is in the best interest of the patient, and what actually is in the patient's best interest, can be two different things. I also suspect you get at least a few requests for admission from parents, or caregivers, who are looking to make it someone else's problem for a while. I know they have carer respite programs in the community where I live, mainly for people with physical disabilities and dementia, not sure if that extends to respite programs for those people who are caring for someone with mental health issues.

Well I dislike geriatric psych, so I really can't comment so much on that. From my limited experience in geri psych, seemed like a lot of those admits were placement admits. For whatever reason SW/medicaid people tell us it's basically impossible around here to get an progressively demented pt into a snf from home without being first admitted, so whatever.....

are you in australia? Not sure what the malingering is like down there. Here in some parts of the US of A, malingering in psych er's is the central issue of any day. It's a big problem where I'm at. At some other places not as big a problem I understand from other residents and attendings.

Originally Posted by vistaril

Well I dislike geriatric psych, so I really can't comment so much on that. From my limited experience in geri psych, seemed like a lot of those admits were placement admits. For whatever reason SW/medicaid people tell us it's basically impossible around here to get an progressively demented pt into a snf from home without being first admitted, so whatever.....

are you in australia? Not sure what the malingering is like down there. Here in some parts of the US of A, malingering in psych er's is the central issue of any day. It's a big problem where I'm at. At some other places not as big a problem I understand from other residents and attendings.

As a counterpoint, I was skeptical about geriatric psychiatry as well until my rotation during residency. The care was so detailed and so well thought out, I consider it the gold standard of care. I would see pt's go from ATC 4-pt restraints to the belle of the ball. Even the design of the unit was incredible, making floor tiles with a pattern go to a certain point and then stop (alzheimer's pt's track the pattern but stop where the pattern stops), meaning they don't wander too far. Meds were used intelligently, and not just atypicals. Even the ambient lighting was purposely meeting the lux for light therapy.

I would reiterate vist that your experience is a limited take on the field based on your experience. It's common to feel like you want to be "the wall" to block admissions from people that "abuse" the system, especially early in training (I was that way during intern year). In my personal experience, it's better to move beyond that and figure out what you can offer everyone. Taking someone inappropriately using an ER as a personal slight is frankly putting yourself in a position for burnout. We are not the hospital. We are not the system. While I in no way give people what they're asking for, I also recognize that behind the asking is a different request. Meet THAT request and you may do the person some good. A malingerer for housing really wants housing. Help him/her with the resources to find housing (while encouraging independence and self-reliance, of course), and the resentment just fades away. When you've identified yourself With the system, then every little issue becomes personal. Rigidity, IMO, is not the way to be a better doctor. Consistency may be the way to do behavioral conditioning and keep someone out of the ER, but you're not doing anyone any real favors aside from saving yourself a future consult.

Originally Posted by nitemagi

As a counterpoint, I was skeptical about geriatric psychiatry as well until my rotation during residency. The care was so detailed and so well thought out, I consider it the gold standard of care. I would see pt's go from ATC 4-pt restraints to the belle of the ball. Even the design of the unit was incredible, making floor tiles with a pattern go to a certain point and then stop (alzheimer's pt's track the pattern but stop where the pattern stops), meaning they don't wander too far. Meds were used intelligently, and not just atypicals. Even the ambient lighting was purposely meeting the lux for light therapy.

I would reiterate vist that your experience is a limited take on the field based on your experience. It's common to feel like you want to be "the wall" to block admissions from people that "abuse" the system, especially early in training (I was that way during intern year). In my personal experience, it's better to move beyond that and figure out what you can offer everyone. Taking someone inappropriately using an ER as a personal slight is frankly putting yourself in a position for burnout. We are not the hospital. We are not the system. While I in no way give people what they're asking for, I also recognize that behind the asking is a different request. Meet THAT request and you may do the person some good. A malingerer for housing really wants housing. Help him/her with the resources to find housing (while encouraging independence and self-reliance, of course), and the resentment just fades away. When you've identified yourself With the system, then every little issue becomes personal. Rigidity, IMO, is not the way to be a better doctor. Consistency may be the way to do behavioral conditioning and keep someone out of the ER, but you're not doing anyone any real favors aside from saving yourself a future consult.

sure I am- I am forcing them to not depend on the ER.,,,,

Now that's not to say that if it's business hours and the ER SW is in house I won't get her to go by and see the pt. I would, although I wonder whether it's a good idea. But a lot of these people come at night, and they do so because they think they are going to trap you because SW isn't available during the day.

One of my favorite messages(to give a malingering pt when he states if we dc him he is going to kill himself)- "we prefer you not do that, but unfortunately we have nothing to offer you here". Firm, compassionate, and assertive.

Of course when I worked er it was up to the er people how long they would let them hang out, eat a turket sandwich, etc......I just signed off very quickly once they consulted and I was done, and if they want to give them some tlc hey it's their er

Originally Posted by vistaril

are you in australia? Not sure what the malingering is like down there. Here in some parts of the US of A, malingering in psych er's is the central issue of any day. It's a big problem where I'm at. At some other places not as big a problem I understand from other residents and attendings.

Yes I'm in Australia. Not being a health professional myself (yet, or at least until I work out if I'm going ahead with studies), I can't say exactly how the rates of malingering here compare to the United States, but sure there are plenty of people who try and scam the system, in one way or another. Most of the people I've known with legitimately diagnosed mental health issues though haven't really tried scamming in terms of actually being admitted to hospital -- except maybe some Schizophrenics I used to know, who had enough insight to know when they were headed into a really bad phase, and would request hospitalisation as a safety measure. Even the borderlines I've known, despite frequent flyer points in the ER, would very rarely agree to enter hospital as an inpatient without kicking up a huge amount of fuss.

Originally Posted by Ceke2002

Yes I'm in Australia. Not being a health professional myself (yet, or at least until I work out if I'm going ahead with studies), I can't say exactly how the rates of malingering here compare to the United States, but sure there are plenty of people who try and scam the system, in one way or another. Most of the people I've known with legitimately diagnosed mental health issues though haven't really tried scamming in terms of actually being admitted to hospital -- except maybe some Schizophrenics I used to know, who had enough insight to know when they were headed into a really bad phase, and would request hospitalisation as a safety measure. .

well that wouldnt be scamming the system then......

I was more referring to people without any real illness(apart from substances and/or just being antisocial) who seek admission or drugs....I prefer not to even see those pts in the er. When I do, they are discharged shortly from the er.

Originally Posted by vistaril

well that wouldnt be scamming the system then......

I was more referring to people without any real illness(apart from substances and/or just being antisocial) who seek admission or drugs....I prefer not to even see those pts in the er. When I do, they are discharged shortly from the er.

Rereading that sentence I realise I didn't word that properly. I can imagine seeing people come into the ER for bogus reasons must be incredibly frustrating, especially when the ER is dealing with some truly sick people who need your full attention.