How do you determine whether borderline personality disorder patients require hospitalization?

[Psychferlyfe3000]

I am noticing that, in my program, whether or not borderline patients are hospitalized after impulsive suicidal or parasuicidal acts is dealt with very inconsistently. It seems like most providers try to discern whether or not the patient is "in crisis" or "decompensated". However, in my opinion there is often unreliable data to discern this with, which leads to very subjective impressions of this and inconsistencies in management. My assumption in writing this is that the purpose of hospitalization for borderline patients is only to keep them safe for some period of time and that there is little long-term therapeutic benefit (which I'm sure some people disagree with). Does anyone have any insight into how I can have a more reliable method for determine whether these patients need inpatient? Thank you for any wisdom!

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[calvnandhobbs68]

I am noticing that, in my program, whether or not borderline patients are hospitalized after impulsive suicidal or parasuicidal acts is dealt with very inconsistently. It seems like most providers try to discern whether or not the patient is "in crisis" or "decompensated". However, in my opinion there is often unreliable data to discern this with, which leads to very subjective impressions of this and inconsistencies in management. My assumption in writing this is that the purpose of hospitalization for borderline patients is only to keep them safe for some period of time and that there is little long-term therapeutic benefit (which I'm sure some people disagree with). Does anyone have any insight into how I can have a more reliable method for determine whether these patients need inpatient? Thank you for any wisdom!

Because the whole conversation about hospitalizing patients with borderline personality disorder is 99% of the time around suicide risk assessment. Which in and of itself is very inconsistent since there’s terrible evidence around short term suicide risk and prediction of risk. I’m not sure you’re gonna get many better answers than that.

 

[Crayola227]

Seems like some of it is driven by a desire to reduce medical legal liability risk. That might be the more easily applied yardstick.

 

[Psychferlyfe3000]

Because the whole conversation about hospitalizing patients with borderline personality disorder is 99% of the time around suicide risk assessment. Which in and of itself is very inconsistent since there’s terrible evidence around short term suicide risk and prediction of risk. I’m not sure you’re gonna get many better answers than that.

True. So then are we left just picking the MOST conservative option Everytime? Just admit, admit, admit. If we have no predictive power, then this would seem to be the best option, no?

 

[docksan]

The real question is, if we don't admit a borderline patient who assumes liability if this is the time they actually kill themselves?

 

[Psychferlyfe3000]

The real question is, if we don't admit a borderline patient who assumes liability if this is the time they actually kill themselves?

And what did the answer to that depend upon?

 

[NickNaylor]

Risk drives admission, not diagnosis. The challenge is that if you don't have some sense of the patient's risk "baseline," it can be difficult to make the argument that they are safe for discharge depending on the circumstances that led to them presenting in the hospital. When I work in our ED, I not uncommonly see patients with clear borderline pathology that can be easily discharged with collateral. Others are more difficult; even if there are clear borderline traits, perhaps they did something quite dangerous prior to presentation, have no meaningful psychosocial supports in place to support them during crisis, aren't engaging in any meaningful outpatient treatment, and on and on. No, you're not going to "fix" someone's personality structure in an inpatient admission, but you can certainly implement interventions to reduce the patient's risk in a fairly brief admission. If nothing else, you at least get more information that can better inform a risk assessment.

 

[J ROD]

Whether or not they have insurance! ...and the above.

Recently, saw one not much information on the patient. Admitted. Came back in today. Services in place. Now have some hx on patient. Relation issues with mother. Makes SI comments all day long without intent/plan due to that relationship etc. Hospitalization will not help. Follow up with therapist. Try to resolve social stressor. etc.

 

[tr]

DBT approach is to avoid hospitalization as much as possible, on the theory that admission often acts as a reward/reinforcer for the behavior.
A defensive-medicine, 'if in doubt, admit' approach is clinically counterproductive in this case. If pt is already in appropriate DBT based tx, it should be possible to review with pt their relevant skills and the plan they have developed to deal with recurring SI. If pt is not in any kind of appropriate therapy, a social admission in order to get them connected may be a reasonable approach, but repeated hospitalizations are not usually productive.

 

[clausewitz2]

DBT approach is to avoid hospitalization as much as possible, on the theory that admission often acts as a reward/reinforcer for the behavior.
A defensive-medicine, 'if in doubt, admit' approach is clinically counterproductive in this case. If pt is already in appropriate DBT based tx, it should be possible to review with pt their relevant skills and the plan they have developed to deal with recurring SI. If pt is not in any kind of appropriate therapy, a social admission in order to get them connected may be a reasonable approach, but repeated hospitalizations are not usually productive.

You can include text in your risk assessment that given the diagnosis and previous pattern of hospitalizations the most effective means of modifying the risk factors contributing most heavily to risk of self-injury is continued and consistent participation in long term outpatient care with the same treatment team.

Assuming you are confident in diagnosis and do actually have information about previous hospitalizations, of course.

 

[jbomba]

I try to reinforce very clearly that I am not in favor of a hospitalization and question whether a hospitalization will actually be useful to them (assuming I don't believe risk is imminent). This allows me to discuss other ways in which I want to help them. I find this approach takes some of the allure out of the hospital as well as allows them to see how I still want to care for them in other, less restrictive ways. This is sometimes enough to bring them back down to a less dysregulated baseline.

 

[comp1]

I like the idea of understanding the patient's baseline. Our bar for admission is VERY low for even a clear borderline PD admission if we don't know the patient personally. It gets successively higher with repeated similar/identical presentations. After awhile, there is clear documented evidence of lack of benefit from hospitalization and the literature shows the evidence for harm. Of course people with borderline PD have an elevated risk of completed suicide, but most states recognize that we have extremely limited ability to predict future behavior.