Cutting and decision to send inpatient

[sweetlenovo88]

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If you have a borderline superficially cutting, when do you send inpatient? What changes if she has vague suicidal thoughts while doing or suicidal ideation at other times not related to cutting, or no suicidal thoughts at all?. Never felt comfortable with this. Thoughts?

 

[PistolPete]

Refer to DBT. I do not hospitalize those who cut themselves unless they are actively suicidal in that moment. Almost all patients with borderline personality disorder will have chronic intermittent suicidality, and that doesn't mean they have to be hospitalized every single time they cut or endorse suicidal thoughts.

 

[sweetlenovo88]

Thanks, trying to get her back in DBT. But she "graduated DBT already." Back to school you go!


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[smalltownpsych]

Thanks, trying to get her back in DBT. But she "graduated DBT already." Back to school you go!


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Completely agree with what PP said. Also, a big part of DBT are the skills that patient needs to cope with emotional distress, but they also need intensive psychotherapy. This is often overlooked. For example, Marsh Linehan doesn't teach her patients the skills, others do that while she provides psychotherapy. Each patient in DBT has a skills coach and a psychotherapist. If the patient has learned the skills, then they likely just need more intensive psychotherapy from someone familiar with DBT to remind and help apply those skills and also to take it to the next level with the interpersonal component. I have had plenty of referrals just like that.

 

[666357]

Well, you perform a safety assessment. In the context of Axis II pathology, you want to explore why they were cutting and what the cutting did for them. Superficial SIB is typically a poor way of coping with psychological distress. If their wounds don't require sutures and they say something to the effect that the physical pain makes it easier to cope with the psychological pain then it may sound like it's low/lower acuity, but you still need to assess other suicidal risk factors- particularly access to lethal means and planning/intent. DBT is great- IF you can find someone who can work your patient in. That's the main trouble I've had with DBT- is finding therapists who can work someone in on short notice. CBT isn't a bad substitute. Medication needs to be used very judiciously in this population, with SSRI/SNRIs deserving primary considerations. Use caution with TCAs for insomnia, but if you do use them, then choose Doxepin 10mg or either dosing of Silenor- but don't Rx for 90 day supplies (the idea being if they OD on #30 Doxepin the total amount ingested is the upper end of the normal dosing range for antidepressant therapy). You could try Elavil 10mg qhs, but Doxepin is much more antihistaminergic at equivalent doses. Being medically defensive and referring them for inpt hospitalization can very possibly cause them to decompensate further. Some might argue benzos aren't unreasonable because of their high therapeutic index but I find comorbid substance abuse runs high in this group which means you can throw the therapeutic index right out of the window. But always remember that ~8% borderline patients actually complete suicide- so don't be outright dismissive. Close follow-ups and adhering to clearly established therapeutic boundaries are vital.
Oh yeah, document thoroughly, but that goes without saying...

 

[PistolPete]

I would never prescribe Lithium, TCA's or MAOI's to any patient with borderline personality disorder due to their impulsivity and chornic suicidality. Basically I assume they'll overdose on a month's worth of meds, so I want to make sure that they won't die, and usually that won't happen with an SSRI/SNRI. Therapy (preferrably DBT, but if none available in the area then CBT or psychodynamic, or maybe IPT if all else fails) is paramount.

Agree with Down Home about a proper suicide risk assessment.

 

[Bartelby]

Cutting on its own is often a maladaptive coping mechanism. It provides relief from intolerable emotions. Thus, as mentioned above, you do a risk assessment around the cutting. I might send a patient who is cutting to the ER for things like suicidal intent, worrying changes in the way they talk about suicide, actions that show preparation for suicide (giving away their things, writing farewell letters, obtaining the means to attempt suicide), or other traditionally worrisome things.

I agree with trying to get borderline patients who cut into good psychotherapy. DBT is great, but if it isn't available I would still try to connect the patient with something like what Gunderson calls "Good Psychiatric Management" (http://www.borderlinepersonalitydisorder.com/wp-content/uploads/2012/10/Palmer_NEABPD10_14_12a-1.pdf). A *good* therapist who makes a meaningful connection with the patient is key, whether they are DBT-trained or not in my opinion.

 

[Shikima]

Would necessitate having them going to a PHP program initially while waiting on a DBT program. Hospitalization isn't always necessary and it's harder to get justification for continued hospitalization.

 

[thoffen]

There is no absolute right answer. You need to do a risk assessment and document it and decide whether the hospital is the appropriate way to mitigate risk. Otherwise, hospitalization often reinforces the unhealthy dynamics and behaviors which are the treatment focus for borderline personality disorder.

 

[666357]

Would necessitate having them going to a PHP program initially while waiting on a DBT program. Hospitalization isn't always necessary and it's harder to get justification for continued hospitalization.

+1
I'll also add that I don't typically run into coverage issues with either PHP or IOP.

 

[DD214_DOC]

I once received an admission of a borderline who had SI and intent while lightly scratching her wrist with a twig. At every discharge attempt she would play the SI card and spent nearly 3 weeks completely destroying the milieu and making the unit miserable for everyone. It took me coming in as the weekend attending to call her bluff and discharge her to stop the nonsense. Don't be that guy. Be cautious and use good judgment, but also remember that the recipe for borderlines is an occasional pinch of truth mixed thoroughly with a heaping scoop of bs.


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