Borderline PD emergencies

[helloimathrowaway]

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Hi, it’s me again!

I imagine this topic has come up a whole bunch before, but I would love to hear tips from people who have succeeded in consistently discharging patients with borderline personality disorder/traits from the ED. I know these cases aren’t a monolith (e.g. not every patient with borderline PD who presents to the ED may be stable enough to be discharged), but perhaps I can illustrate some of my struggle with this with a case example that I still think about.

I saw an older teen a week or two back who came in reporting worsening of baseline suicidal ideation in the setting of recent perceived abandonment within an interpersonal relationship. They had also cut themselves superficially the night before for the first time in a while. I don’t like to jump to giving teens the BPD diagnosis, but it was clear from my evaluation that this teen had several borderline personality traits at the very least. I wasn’t convinced they would imminently kill themself if they were discharged, though they did have some acute and chronic risk factors. A major issue was that they’d fallen through the cracks in the system and had never really managed to connect with outpatient follow up, though they’d had 2-3 lifetime hospitals stays up to that point (the last being months prior to my eval). When I attempted to discuss a lower, but still comprehensive level of care with them (partial or IOP), they responded “but I’m not looking for partial, I need to be inpatient.” The other major issue was that they had a fractured and inconsistent family system (likely underlying the pathology) who had a poor understanding of the patient’s mental health. The guardian present with the patient at the time of the evaluation had trouble understanding why there was a chance a hospitalization may be detrimental, and was not the person the teen was living with anyway (that particular family member was unavailable).

Given the lack of outpatient treatment, the need for more immediate work with the family system, and of course the reportedly worsening suicidal ideation and depressive symptoms (though it wasn’t clear to me that the depression was much worse than it had always been, despite the recent stressor), I decided to admit the teen voluntarily. They ended up on my institution’s adolescent unit, so I’ve been following their case a bit. Like many BPD patients, they appear to be trying to sabotage treatment and conveying to providers repeatedly that they can’t possibly leave the hospital because “I just do better when I’m in inpatient.” The team seems to be managing all of that well, but I can’t help but feel bad for my role in contributing to this patient’s dependency on the hospital. I try to remind myself that my decision made sense to me in the moment given the circumstances (namely, I saw this patient at the tail end of a busy shift, didn’t have a ton of time to be working harder than the patient and family), but other psychiatrists may have discharged this patient easily. I would love to learn from those psychiatrists if they’re in here! I worry about being looked down upon as a psychiatrist who is too afraid to discharge these patients, even though I know that I’ve discharged plenty of tough cases from the ED who would not have benefited from an inpatient admission. I find it’s easier to discharge these patients directly from the ED when they already have established outpatient provider(s) that I can coordinate with, but would appreciate hearing how people handle these cases when patients don’t have that connection.

 

[smalltownpsych]

The patient is probably telling the truth that they do better in a structured setting. It shows how dysfunctional the family system is. That’s why I don’t like jargon like sabotaging the treatment. Make your recommendation and let it go. We can’t fix their family and we can’t fix the system that provides little or inappropriate levels of support for kids like this. “You can’t live here and my medications aren’t going to change much. What you need is lot of help so this is what you need to do kid.”

 

[comp1]

Omph, hopefully you get some good advice from CAP people because I almost certainly would have admitted the teen too. It would take almost nothing for me to admit a teen (immensely glad I don't see them in the ED or inpatient). That said, adults are quite a different matter. The setup you described is really why I prefer my staff to both do ED consults and then follow any patients they admit onto the unit. You get a much better visceral feel for if that patient benefits and THAT is what should guide your decision for admission. I'm glad you are at least tracking their inpatient progress so you will be familiar with them for their next inevitable presentation. If the benefit outweighs the harm, in this case dependency, you should indeed admit a patient. In terms of patients you don't know, the bar for admission should be relatively low. The exception would be for not admitting frequent patients is where there have been specific staff meetings and discussions about those patients and it has been made clear they do not benefit/are significantly harmed by admissions. Hopefully your team of clinicians has such meetings and develops templated language tailored to those patients, particularly if they aren't following patients from the ED on to the medical floor.

 

[Merovinge]

I would admit that patient and make sure that you and the IP team is setting the expectation of short-term stabilization and being largely to setup PHP. A few IP stays, the last of which being several months ago, is not the type of dependency on IP units that would be red flag concerning. If a teen is asking to be hospitalized and shows acute risk factors, you need a compelling reason to NOT admit them. Now if on this admission they are inappropriate for the milieu and not benefitting from the admission, that would be something to discuss with the IP and document for future references. Unfortunately none of us can see the future, you need to judge your decision making based on the information you had at that time, which is a clear admit to me.

 

[helloimathrowaway]

Thanks all for the discussion and validation! I tend to stand by my clinical decisions, but I’m still relatively early career and work around a lot of very confident acute care physicians, some of whom it seems only admit if the person had an actual suicide attempt or is like actively trying to harm themselves or someone else in the ED. Culturally too, I feel, ED and consult psychiatrists get lauded the more people they discharge, at least in the places I’ve worked. I don’t know if I necessarily agree with this, and I always always go off of my own clinical judgment, but it’s what I’ve experienced.

Then there’s of course everything we’ve learned in training about BPD and hospitalization….but of course the reality can be different depending on the case and available services. Our system really is a tough one to work in.

 

[Merovinge]

Thanks all for the discussion and validation! I tend to stand by my clinical decisions, but I’m still relatively early career and work around a lot of very confident acute care physicians, some of whom it seems only admit if the person had an actual suicide attempt or is like actively trying to harm themselves or someone else in the ED. Culturally too, I feel, ED and consult psychiatrists get lauded the more people they discharge, at least in the places I’ve worked. I don’t know if I necessarily agree with this, and I always always go off of my own clinical judgment, but it’s what I’ve experienced.

Then there’s of course everything we’ve learned in training about BPD and hospitalization….but of course the reality can be different depending on the case and available services. Our system really is a tough one to work in.

What you are saying would be applicable to adult psychiatry, particularly in cases of known BPD (I have seen many patients who literally have >100 ED visits for SI).

This patient is an adolescent, who does not have a known dx of BPD although may have BPD traits, and is facing complex psychosocial considerations where their available options are different than adults.

There are no karmic points of discharging kids with SI asking you to be admitted, reporting acute risk factors, and recently escalating stakes. There will be no one there to defend you if you discharge a kid asking to be voluntarily admitted for SI who then goes home and kills themselves (or maybe worse grievously wounds themselves with permanent disability). Suicide is going to the number 1 or number 2 cause of death for most kids you are seeing. If you are spending a lot of time around board certified CAP who take pride in how many kids they discharge from the ED, please let me know what part of the country you are in, because that would be wildly different than my experience across many different hospital systems in my geography.

 

[clozareal]

Gunderson has a good chapter on this in his book on borderline personality disorder on managing these behaviors in the emergency room. It's worthwhile to read that chapter in full. In short, the hospital setting is what makes therapy possible, which is the mainstay of the treatment. To quote the book:

Hospitals serve as the place for initiating or changing therapies or for managing crises. lmost all borderline patients do best with brief (1- to 3-day) to no more than 2-week hospitalizations. It is wise to establish this time frame at the point of admission to discourage regressive, idealized, or dependent attachments. Usually, longer stays in a hospital occur not because of their therapeutic value but because appropriate step-down services (residential, IOP, PHP programs) are unavailable.

There's a principle of false submission that I like to use with chronic suicidality since it's difficult as a physician to judge the seriousness of their intentions if they have been so recurrent/chronic and this creates a moral/ethical dilemma for us. Quoting the book again:

The clinician usually feels that questioning the seriousness of the patient’s suicidal intentions could magnify the likelihood and lethality of an attempt. Beyond this, the clinician will know that hospitalizations—the usual response to suicidality— can rarely address the underlying causes of the suicidality and might in fact perpetuate the borderline patient’s allegations of suicidality (as a result of the secondary gains of being rescued, getting attention, and avoiding the problems of living in the community).

Vignette
Patient: Are you saying that you really think it’s a mistake to go into the hospital?
Clinician: Not if you’d otherwise kill yourself, but if you stay alive you’d be better off without it.
Patient: Are you saying you won’t put me in a hospital?
Clinician: No, of course not. It would be “suicidal” for me to try to pre- vent a potentially suicidal patient like you [note that therapist does not
question her suicidal potential] from entering a hospital if you want to [note that therapist moves the patient’s impulse for action into the arena of the patient’s wanting, giving the patient agency for whatever happens]. I just don’t believe it will be good for you. If you were to make a suicide attempt after leaving here, it could be difficult for me personally and professionally; potentially, I could even be sued. So if you tell me that you intend to kill yourself, that’s very powerful. Then in you have to go. But, if you go, don’t go thinking that I’ve done what I think is the right thing for you—or that it’s because I care for you. It doesn’t mean either of these things. I would think that you are just hoping for an adoption.

This illustrates the principle of false submission: by ostensibly giving the patient what he or she wants but disarming it of its hoped-for meaning, the cycle of repeated admissions can be broken. This change will not usually happen the first time: the patient will almost always go into the hospital after first having this exchange. But the action now has a different meaning: the patient is going because he or she wants to go, not because the doctor said so. When this stance is followed up and reinforced by others on the patient’s treatment team, it diminishes the treaters’ sense of being manipulated or coerced by the patient and breaks down the patient’s fantasies of rescue or love. The therapist “gives in” but robs the patient of much of the expected satisfaction. It is particularly important that the staff on the inpatient unit be aware of and feel comfortable “being used” this way. If they are unaware, they may offer unnecessary secondary gains. If they are aware but angry, they are likely to provoke a hostile control struggle that unnecessarily extends the duration of the hospitalization.

The language may be a bit too far though in telling the patient that they are hoping for an "adoption" but much of the principles carry I think.

His other book, Good Psychiatric Management also has a good chapter on managing non-suicidal and suicidal behaviors.

 

[clozareal]

In terms of your case specifically, with borderline teens I like to focus on the relationship conflicts. They often will talk at length about those relationships but once you ask them about depressive symptoms, their eyes gloss over. This is where interpersonal therapy, some DBT skills related to the domain of managing interpersonal conflicts, and family therapy can be helpful. They sound like they need basic psychoeducation on levels of care and what the hospital is and isn't used for. They are hoping for some miracle in the hospital setting for 3 days that just doesn't exist.

I would caution against diagnosing borderline in the emergency or hospital setting based on one or two encounters during a crisis. People can often look borderline during a breakup, a crisis, a conflict, an actual abandonment by family/friends. The principle of false submission above holds even more true in this case. They can't be adopted by the hospital. The goal is to get them functioning back in society (i.e., outside the hospital). Your social worker should be working hard to connect the teen to lower levels of care.

 

[comp1]

Hated the vignette, but loved the concepts before it. The vignette seems to assume a person with borderline PD that has a much, much higher degree of insight and conversational ability than I typically see. It sounds more like someone who has done a great deal of DBT and can work on balancing conflicting ideas while in a crisis. The people I see would often appear quite psychotic to the lay eyes and you have to spend most of your time digging down through that to get to anything beyond I'm going to kill myself. And wow, yes, getting the whole inpatient team on board with this plan is a challenge even if the ED MD is the same as the inpatient MD. I think you can assume the hostile control struggle, at least in adults. I don't know dynamics on an inpatient unit with teens.

 

[clausewitz2]

The language may be a bit too far though in telling the patient that they are hoping for an "adoption" but much of the principles carry I think.

Can you think of a well-known BPD specialist who isn't low-key infamous for saying stuff that seems shocking? Cf. Kernberg's "I don't want you to kill yourself but my life will go on if you do" or Linehan's "This is not an emergency, I look forward to hearing about how you used your skills to address this when we meet."

 

[comp1]

I'm thinking that if people transcribed my or a lot of provider's discussion with borderline patients in a self described crisis...they might end up sounding a bit like Kernberg or Linehan. They sound shocking without the context, but in context of repeated discussions about the same exact thing they sound entirely appropriate.

 

[clausewitz2]

I'm thinking that if people transcribed my or a lot of provider's discussion with borderline patients in a self described crisis...they might end up sounding a bit like Kernberg or Linehan. They sound shocking without the context, but in context of repeated discussions about the same exact thing they sound entirely appropriate.

Don't get me wrong, I don't think any of the examples of the utterances of those three great worthies are necessarily bad or wrong-headed. In fact I'd argue that as long as you are doing it in the spirit of being utterly transparent instead of punitive or retaliatory it is great mentalization fodder.