[help] Borderline Personality Disorder

[drillers]

Anyone on this sub have a lot of experience with how to help these patients?

I am not used to patients with BPD being frequently readmitted over and over again. Where I work now, there is a lot of CYA (due to past lawsuits from BPD patients?) with these patients. They get admitted, meds get changed, then discharged.

Where I trained, this type of patient would rarely if ever get admitted. As far as boards, we learn admitting these patients (especially frequently) is likely more harm than good. Because of previous lawsuits, and my own fears of being sued, I am not sure realistically there is much I could do about them being admitted. But I feel like more can be done. These patients are usually on a lot of psych meds (clozaril, mood stabilizers, etc.)

I guess I want to know, in a fair world, how would you work and word things to help them stop feeling like they have to come to the hospital?

In reality, what can I do more to help them while they are coming to the hospital frequently.

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[Stagg737]

What kind of therapy is available in your area? We have 2 or 3 centers that specialize in DBT in our area, and everyone within a solid BPD diagnosis gets resources on how to establish with them. While we do get BPD admissions, they’re mostly after suicide attempts and readmissions are pretty uncommon.

 

[romanticscience]

This comes from Gunderson's Good Psychiatric Management for BPD (Gunderson, 2015).

The Patient Seeks Hospitalization for Suicidality, but You Do Not Think He or She Is Suicidal

If your patient will not give any assurance of “being safe” and you refuse to hospitalize him or her, the risk of a suicidal event is escalated. You think that hospitalization will reinforce a maladaptive pattern—and may irritate your colleagues within the hospital. Tell the patient:

“I’m willing to hospitalize you despite my concern that it will not be helpful. I will do this because I fear you will become more suicidal if I don’t. Am I right about that? We would both be better off if we could find an alternative.”

This “false submission” takes the “magic” out of being hospitalized and calls on your patient to discuss why he or she might prefer being there—that is, because it means you really care (are “adopting” the patient) or because he or she covets being cared for without responsibilities. Having this discussion with your patient also helps disarm your emergency department or hospital staff colleagues who would otherwise be justifiably critical of your judgment.

The second GPM book has a section dedicated to working in the ED.

 

[Candidate2017]

Borderline patients have a high risk for accidentally committing suicide. Doesn't hurt to admit them for a few days and get their buy in to DBT follow up.

Be steadfast, kind, and plain with them. They appreciate boundaries even if they throw tantrums. Like a 4 year old projecting their rage and helplessness onto you. Refuse to make promises you can't keep, which builds trust and helps them develop tolerance to uncertainty. Of all types of patients, I find borderline patients have the highest capacity to accept critique of their maladaptive coping strategies, i.e., overtly suicidal or destructive behaviors.

Anyway, these borderline patients on Clozaril, are they really borderline?

 

[splik]

Anyway, these borderline patients on Clozaril, are they really borderline?

clozaril can be helpful for patients who repeatedly engage in high risk suicidal or self-injurious behaviors even in the absence of psychosis. There isn't great data for this but it is commonly done and I do think it is helpful. This is not for all borderline patients, but those who repeatedly engage in dangerous self-injurious behaviors that don't respond to other treatment. This is what such patients receive in state hospitals and long-term care facilities.

 

[splik]

I guess I want to know, in a fair world, how would you work and word things to help them stop feeling like they have to come to the hospital?

In reality, what can I do more to help them while they are coming to the hospital frequently.

It is tricky if you don't work in a system that allows for you to discharge or not admit patients like this. There can be other pernicious incentives - at some facilities the goal is to keep beds filled even if such patients may be harmed by hospitalization.

There are some myths about hospitalizing borderline patients too. Brief hospitalizations are often harmful, but long hospitalizations (e.g. months) can actually be very beneficial. What happens now is patients are kept long enough to regress so they look worse. Whereas in the past (pre-managed care), patients regressed and could then be built up again. It doesn't help that inpatient units are rarely set up provide treatment to patients these days (instead focusing on "stabilization"). It is true hospitalization can be reinforcing and sabotage goals of allowing patients to develop other skills but that doesn't mean you don't want to ever admit them.

I reward patients with hospitalization if they will tell me explicitly they want to be hospitalized. I don't reward patients with hospitalization if they say they are suicidal and will kill themselves if discharged. More often than not, patients imply but do not explicitly request hospitalization. We want to reward patients for asking for what they need, without resorting to threatening, dysregulated, or manipulative behavior. This is the cornerstone of the interpersonal effectiveness module of DBT.

Where I trained, severe borderline patients who were "high utilizers" were rewarded with scheduled inpatient admissions if they didn't come in to the ER demanding hospitalization. These admission were brief, for a defined period of time, at increasing longer intervals, focused on working on DBT skills, and the aim was to break up the association of coming to the ER in crisis with admission.

We also had contracts patients would sign at the beginning of admission outlining the day of discharge, goal of hospitalization and that they would be discharged on x date no matter how suicidal they were.

Regarding fear of litigation/lawsuits, this is not related to whether you hospitalize such patients, but what alternative plans you have. If you don't have access to crisis appointments, DBT programs, MBT, PHP, IOP, or other alternatives to hospitalization, are not documenting the rationale for not admitting patients, and not making other attempts to migitate risk of danger to self etc then it becomes much harder to justify not admitting patients. However it is important to remember that BPD patients have chronically elevated risk of suicide and it is not reasonable to hospitalize patient indefinitely based on the off chance they may one day kill themselves. Especially when such behavior tends to be impulsive, related to mood reactivity and response to perceived or actual threat of abandonment. The courts also mostly understand this and do not usually punish psychiatrists for not hospitalizing such patients if it is clear that doing so is not beneficial and other attempts are made to mitigate the overall risk.

 

[YoungDrummer]

Do your Day Treatment Centers have DBT groups? If so, after the 72 hour hold, they could be discharged to a DBT therapist (make arrangements for them to see one) and possibly a Day Treatment Center with a DBT group.

 

[Mass Effect]

If a borderline is on Clozaril, that's a signal of severe personality disorder and I'd argue they likely are at increased risk, as much so or more, than others who are suicidal in crisis. So yeah, I'd probably admit them if they're suicidal. That said, I like what @splik said regarding planned admissions. I've never seen this done, but it sounds like a solid approach.

 

[Sikrouf]

I m out of topic, but is there any reason to use clozapine over lithium in this situation ?

 

[drillers]

Apologies for the late response to thank everyone for the great advice.

I think the place I am at is aiming to have borderlines dependent on frequent hospitalizations, sigh (for the most part they have good insurance).

 

[FatherPsychiatry]

I think the place I am at is aiming to have borderlines dependent on frequent hospitalizations, sigh (for the most part they have good insurance).

American healthcare system mission accomplished!

 

[AnnoyedByFreud]

When treating borderlines with clozapine, what doses are you all using? Lower than for schizophrenia?