Inpatient treatment of suicidal ideation in borderline personality disorder

[notlucid]

Any articles/advice on inpatient management of Borderline personality disorder patients on inpatient unit if they keep making suicidal threats with long history of serious self harm .

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[MBBSMOM]

First of all why are you admitting and keeping them if they only make threats. Plenty of BPD patients make suicide threats that they’ll do x if the you don’t give them what they want . You should only hospitalize for attempt or SI with a plan and intent. Self harm is a risk factor for suicide but it also doesn’t mean to admit . This questions a little too broad but most of the BPD experts say to keep the hospitalization as short as possible. Also are you doing psycho education on the condition? In my experience of taken care of taking BPD patients who are frequent fliers. Most of them start to enjoy being in the hospital because it provides them with safety and a chance to escape their environment. This is not particularly good. But if they are a frequent flier they would benefit more from residential treatment.

 

[Mass Effect]

Any articles/advice on inpatient management of Borderline personality disorder patients on inpatient unit if they keep making suicidal threats with long history of serious self harm .

DBT, DBT, DBT. Keep admission as short as possible. Explain to them what's happening and why they're feeling the way they are (show empathy - borderlines are borderlines for a reason and a lot of them don't understand the illness). Clean up their med regimen. I saw a patient recently on 3 different antipsychotics with her only diagnosis being BPD with a rule out of bipolar. Explain the dangers of their med regimen if it's crazy; they really respond well to the psychoeducation, particularly because someone cares enough to spend the time explaining to them why it's harmful for them. Then discharge to PHP.

 

[notlucid]

Yes, so plan, intent and means. History of serious bodily harm requiring surgeries. But using suicidal threats and get admitted for interpersonal conflict but then repeated admissions. PHP, DBT therapist not available.Cant give more details because of patient confidentiality. Just looking how others deal with it.
Agree with "Most of them start to enjoy being in the hospital because it provides them with safety and a chance to escape their environment."
Any articles or data in managing the patient who is wanting to stay in the hospital for the above reason.
I have went through psyhoeducation, tried to see if there is comorbidity, which I dont believe is. Just severe borderline personality with severe self injurious behavior and trauma. Went through APA guidelines etc.
I think I will have to get DBT training.

 

[Mass Effect]

Yes, so plan, intent and means. History of serious bodily harm requiring surgeries. But using suicidal threats and get admitted for interpersonal conflict but then repeated admissions. PHP, DBT therapist not available.Cant give more details because of patient confidentiality. Just looking how others deal with it.
Agree with "Most of them start to enjoy being in the hospital because it provides them with safety and a chance to escape their environment."
Any articles or data in managing the patient who is wanting to stay in the hospital for the above reason.
I have went through psyhoeducation, tried to see if there is comorbidity, which I dont believe is. Just severe borderline personality with severe self injurious behavior and trauma. Went through APA guidelines etc.
I think I will have to get DBT training.

What do you mean DBT therapist not available? Your area has no DBT therapist or no PHP? Are you in a seriously rural area?

Keeping a borderline for interpersonal conflict and threats is not good. The longer they're in the hospital, the worse they decompensate. You need a safety/behavioral plan for them that ideally includes a PHP with outpatient appointments in place. You document by citing chronic suicidality due to impaired coping skills that are unlikely to be improved on an acute inpatient unit. You cite the potential decompensation in the inpatient setting and the urgency for outpatient DBT to mitigate the acutely elevated risk of self-harm. Never discharge on a Friday! Ideally, you discharge on Monday morning directly to PHP. The only reason to keep him/her is if you fear the patient is at a greater risk than he/she is chronically of suicide that day OR if there's indication for psychopharmacologic intervention.

 

[notlucid]

Locum work in rural area.
Yes, I plan to keep the hospitalization less than 48 hours.
I was curious how others deal with this when no resources available.
I have seen borderline personality disorder patients get ECT, on 3 antipsychotics with no change in course of illness or outcomes.

 

[MBBSMOM]

Yes, so plan, intent and means. History of serious bodily harm requiring surgeries. But using suicidal threats and get admitted for interpersonal conflict but then repeated admissions. PHP, DBT therapist not available.Cant give more details because of patient confidentiality. Just looking how others deal with it.
Agree with "Most of them start to enjoy being in the hospital because it provides them with safety and a chance to escape their environment."
Any articles or data in managing the patient who is wanting to stay in the hospital for the above reason.
I have went through psyhoeducation, tried to see if there is comorbidity, which I dont believe is. Just severe borderline personality with severe self injurious behavior and trauma. Went through APA guidelines etc.
I think I will have to get DBT training.

When they start becoming too comfortable in the hospital that's when you know you need to d/c. I usually keep these patients around 3-7 days with the average being 3-5 days. I work with a younger population 17-30 so I usually do a family session with a parent or spouse/bf/gf. I have them do individual assignments that they show me. I'll give them assignments such as write how you will stay safe outside of the hospital. If you don't have PHP/DBT in your area refer to a residential program.

 

[downwithDTB]

One thing to consider for helping you sleep is the context of the life-threatening self injury: was this was in the context of a contingent threat with hospitalization and subsequent primary or secondary gain, a significant narcissistic injury or personal loss and/or a severe affective, psychotic or other episode.

If the context is different, the acute risk may be different. If the context is the same and hospitalization has failed to modify the risk in the past, it probably won't modify it this time.

 

[FlowRate]

There's the rare very severe borderline patient who might benefit from prolonged state hospital admission.

Otherwise, try not to validate/reward suicide threats or SIB.

 

[theduderino]

check out the gunderson handbook for good psychiatric management of borderline personality. It seems catered towards outpatient but good tidbits nonetheless.

 

[splik]

Keeping a borderline for interpersonal conflict and threats is not good. The longer they're in the hospital, the worse they decompensate.

This is only true up to a certain point. Because our hospitalizations are so brief nowadays borderlines tend to regress and get worse. But in the old days borderlines did benefit from hospitalization because the hospitalizations were much longer. If you keep a borderline in the hospital for months on end, they will get through their regression and eventually improve. One of our most severe borderline pts was hospitalized for months recently and did much better. Regression can be therapeutic (it is of course a major part of psychoanalytic approaches). However regression is mostly unnecesary, which is why it is no longer standard treatment. That said, we mostly want to avoid reinforcing the hospital especially when patients make suicidal threats as a way to gain admission. I will typically admit borderline pts if they explicitly request admission to reward them for articulating their needs. If they are simply stating they are suicidal but won't say what they want, I will discharge them. It is important to set a clear discharge date at the beginning. Typically I do 5 days for these pts (there is no point admitting pts like this for 48 hours, it is likely to lead to repeated presentations). We used to have the patients sign a contract where they acknowledged they would discharged on date x "no matter how suicidal you are."

When deciding whether you can discharge patients, you need to rely on the available data. The more data you have that the patient does not benefit from hospitalization, or that it is harmful, or that they often make contingent threats without serious attempted suicides, the easier it is to not admit them. When you don't have such a database, admit the patient and carefully document the effects of hospitalization. Psychiatric admission does not prevent suicide. Many patients die by suicide on psychiatric units. Our brief hospitalizations if anything, increase the risk of suicide. Thus the real issue becomes whether hospitalization will be helpful or harmful to the patient. If you believe it is the latter, do not admit the patient. Carefully document the rationale. The availability of alternatives to hospitalization is also important. If the patient does not have a regular psychiatrist/therapist, has no access to DBT/MBT/TFP etc, no access to residential treatment/IOP/PHP, then you may have no choice but to admit if their behavior is escalating. If they can be engaged in a treatment plan, then sometimes hospitalization can be containing and beneficial. If they abuse the hospital unit or make the milieu inhospitable for other patients, then they need to be discharged, or you need to sour the milk to make the hospital inhospitable for the patient. Just remember: they can always hurt you more.

 

[Merely]

This is only true up to a certain point. Because our hospitalizations are so brief nowadays borderlines tend to regress and get worse. But in the old days borderlines did benefit from hospitalization because the hospitalizations were much longer. If you keep a borderline in the hospital for months on end, they will get through their regression and eventually improve. One of our most severe borderline pts was hospitalized for months recently and did much better. Regression can be therapeutic (it is of course a major part of psychoanalytic approaches). However regression is mostly unnecesary, which is why it is no longer standard treatment. That said, we mostly want to avoid reinforcing the hospital especially when patients make suicidal threats as a way to gain admission. I will typically admit borderline pts if they explicitly request admission to reward them for articulating their needs. If they are simply stating they are suicidal but won't say what they want, I will discharge them. It is important to set a clear discharge date at the beginning. Typically I do 5 days for these pts (there is no point admitting pts like this for 48 hours, it is likely to lead to repeated presentations). We used to have the patients sign a contract where they acknowledged they would discharged on date x "no matter how suicidal you are."

When deciding whether you can discharge patients, you need to rely on the available data. The more data you have that the patient does not benefit from hospitalization, or that it is harmful, or that they often make contingent threats without serious attempted suicides, the easier it is to not admit them. When you don't have such a database, admit the patient and carefully document the effects of hospitalization. Psychiatric admission does not prevent suicide. Many patients die by suicide on psychiatric units. Our brief hospitalizations if anything, increase the risk of suicide. Thus the real issue becomes whether hospitalization will be helpful or harmful to the patient. If you believe it is the latter, do not admit the patient. Carefully document the rationale. The availability of alternatives to hospitalization is also important. If the patient does not have a regular psychiatrist/therapist, has no access to DBT/MBT/TFP etc, no access to residential treatment/IOP/PHP, then you may have no choice but to admit if their behavior is escalating. If they can be engaged in a treatment plan, then sometimes hospitalization can be containing and beneficial. If they abuse the hospital unit or make the milieu inhospitable for other patients, then they need to be discharged, or you need to sour the milk to make the hospital inhospitable for the patient. Just remember: they can always hurt you more.

Boy I can see a lawyer having an absolute field day with what you just said..You document that you’re discharging the pt on Friday “no matter how suicidal” the pt goes home and suicides, wow that’s not gonna look good to a jury

 

[notlucid]

This is the issue that how to convince in documentation that hospitalization is harmful. I am convinced hospitalization leads to avoidance of real interpersonal conflict and that is being played out in hospital milieu. In this case therapist is not convinced and wants the patient "safe".

 

[Jules A]

This is the issue that how to convince in documentation that hospitalization is harmful. I am convinced hospitalization leads to avoidance of real interpersonal conflict and that is being played out in hospital milieu. In this case therapist is not convinced and wants the patient "safe".

And why hasn't the therapist been using DBT with this patient? There is no requirement of certification to employ the skills.

 

[whopper]

If you happen to purchase Marsha Linehan's treatment material on Borderline PD she mentions real situations with Borderlines and not some superficial and mild problem. E.g. the patient who throws a chair during the meeting. She also has real options such as avoiding hospitalization for many of them.

What I very much respect about her is many teachers give you very superficial guidelines that don't go into the very headache-inducing stress provoking BPD patient. No she goes into the nitty gritty.

Where I did residency there was not DBT therapist assigned to the department. There were none that we knew of that we referred towards. DBT was simply the answer on the multiple choice test as the treatment for BPD but no one in the department knew how to do it.

And at that time, cause I didn't know better, I thought it was a good program. About half the people coming to the ER were Borderline patients not needing hospitalization but the ER psychiatrist was too chicken to discharge them and the inpatient psychiatrist kicked them out but then there was not DBT therapy for these patients to utilize. While I'm sure many of the patients wouldn't have showed up for DBT, some of them would've, and at least we would've done the right thing on our part, but it wasn't (at that time) being done.

 

[Jules A]

While I'm sure many of the patients wouldn't have showed up for DBT, some of them would've, and at least we would've done the right thing on our part, but it wasn't (at that time) being done.

Anecdotally in my experience the attendance rate seems quite good for PHP and group therapy type situations. Many haven't ever gotten the diagnosis explained to them and that in itself seems to be a positive step toward identifying their maladaptive behaviors and cognitive distortions. I have seen significant results over time including the ability to tolerate a marked reduction in the borderline cocktail so many presented with.

 

[Merely]

Anecdotally in my experience the attendance rate seems quite good for PHP and group therapy type situations. Many haven't ever gotten the diagnosis explained to them and that in itself seems to be a positive step toward identifying their maladaptive behaviors and cognitive distortions. I have seen significant results over time including the ability to tolerate a marked reduction in the borderline cocktail so many presented with.

What’s the borderline cocktail?

 

[Merovinge]

What’s the borderline cocktail?

Starter tier
SSRI &
Antipsychotic &
Mood stabilizer

Advanced tier
SSRI &
Antipsychotic &
Mood stabilizer &
Benzodiazapine

Pro Tier
SSRI &
Antipsychotic &
Mood stabilizer &
Benzodiazapine &
Stimulant

God-like Tier (I've seen once)
SSRI + Remeron + Atypical +Lithium +VPA +BZD + Stimulant

 

[Jules A]

What’s the borderline cocktail?

Around here a combination of an antipsychotic, an antidepressant, Buspar, a mood stabilizer, vistaril prn, usually a benzo and/or stimulant and Trazodone/Seroquel qhs in a patient who is not in a manic or mixed state and has never met criteria for bipolar.

Edited to add: When I posted I didn't see Merovinge's excellent explanation, which is only missing the Buspar in every tier, lol.

 

[Merely]

Is this cocktail effective or why are people starting them on all of this?

 

[Jules A]

Is this cocktail effective or why are people starting them on all of this?

I haven't found it to be effective and their complaints of "racing thoughts", severe anxiety, insomnia and obvious affective dysregulation seem to drive their insistence that doses are increased or additional medications are added. It seems to me that prescribers get uncomfortable with patients who are uncomfortable and rather than attempt to encourage non-pharm coping skills or insist on discontinuing medications that are obviously ineffective, which invariably results in tears, threats, agitation... the path of least resistance is to cave and give them more. There are also probably a few who actually think the patient is bipolar despite not actually meeting criteria but I think more are just afraid to challenge the patient.

 

[MBBSMOM]

Is this cocktail effective or why are people starting them on all of this?

1. People with BPD have a heightened placebo effect so you might see short term improvement. But this improvement will not last long so then you'll want to try another med. How does the placebo effect affect the treatment for borderline personality disorder (BPD)?
2. It's much easier to just throw a pill at a problem than get to the root of the actual problem.
3. Some of the behaviors these patients engage in are so severe you can't help but prescribe something.

 

[calvnandhobbs68]

Is this cocktail effective or why are people starting them on all of this?

Cause everyone who comes into contact with these patient starts them on a new med and then when they proclaim “med worked doc I’m not suicidal anymore!” continues it forever....until they’re suicidal or dysregulated again.

 

[MBBSMOM]

Cause everyone who comes into contact with these patient starts them on a new med and then when they proclaim “med worked doc I’m not suicidal anymore!” continues it forever....until they’re suicidal or dysregulated again.

Exactly the research tells us most of these patients suffer from a heightened placebo effect. They will improve short term but then the placebo effect stops and they're back to feeling worse so you want to start something new.

 

[calvnandhobbs68]

Starter tier
SSRI &
Antipsychotic &
Mood stabilizer

Advanced tier
SSRI &
Antipsychotic &
Mood stabilizer &
Benzodiazapine

Pro Tier
SSRI &
Antipsychotic &
Mood stabilizer &
Benzodiazapine &
Stimulant

God-like Tier (I've seen once)
SSRI + Remeron + Atypical +Lithium +VPA +BZD + Stimulant

SSRI are noob tier the real experts get some Pristiq on board.

 

[thoffen]

Same as any other patient. You do an assessment of their risk factors for suicide and address anything that is modifiable while being sure to understand why you are pegging thinks as unmodifiable. You observe long enough to show that someone is at a stable/chronic level of function. You get collateral to screen for any acute modifiable new risk or for external evidence of a mood disorder separate from BPD. You coordinate with outpatient providers if possible. If you come up empty on things you can actually change, you document all that and discharge the patient.

 

[FlowRate]

Is this cocktail effective or why are people starting them on all of this?

There is OK evidence that SSRI's, atypicals, and mood stabilizers (esp LTG) have some benefit for treatment of irritability and impulsivity associated with of BPD/EUCD.

That said, the only thing that really works is long-term therapy starting with something like DBT/ACT.

I'm currently peeling off all the meds that one of my BPD patients takes because she doesn't think they've been effective and neither do I. We'll see if something gets worse when she's off of the drugs. I'm sure that someone will blame her next hospitalization on the med discontinuation but it's not like the meds kept her out of the hospital in the first place. (In this case I'm actually talking about medical hospitalizations for frequent complications of a specific condition which is responsive to things the patient has to monitor on their own. I'm obfuscating but there aren't many conditions where that's obviously the case.)

 

[downwithDTB]

Your God tier seems a little weak! If you're not on clozapine, you're not on a real psych med!

I've seen lithium, clozapine, ssri, lamictal, benzo and gabapentin, all at hefty doses in a non-sedated walking talkin' clearly long term diagnosed borderline pd patient.

I'm sure we'll be needing to add ketamine into the mix soon for everyone who's failed prozac 20 for a week.

 

[Merely]

Your God tier seems a little weak! If you're not on clozapine, you're not on a real psych med!

I've seen lithium, clozapine, ssri, lamictal, benzo and gabapentin, all at hefty doses in a non-sedated walking talkin' clearly long term diagnosed borderline pd patient.

I'm sure we'll be needing to add ketamine into the mix soon for everyone who's failed prozac 20 for a week.

Clozapine for BPD? Is that malpractice?

 

[downwithDTB]

Why would clozapine be any more malpractice than any other off label atypical? A negligable risk of agranulocytosis? At least it's got evidence for decreasing suicide risk in another disorder (I'm sure that was the logic).

To be clear, I'm not advocating for this practice, but if you spend enough years in a state hospital without any evidence of psychosis and keep trying to kill yourself there, the doctors will probably get fed up and try anything. The patient was actually remarkable stable on the regiment for a long time.

 

[watto]

What you need to do is create an infinite loop of placebo effects. Build a strong therapeutic relationship so they have so much confidence in a drug taper, they enjoy some benefits of the placebo effect when off medication. Then jump from benign substance to benign substance into perpetuity, confident in each approach to the bitter end. Enjoy even the placebo effects of the therapeutic relationship itself!

Why let the naturopaths take all the credit?

 

[downwithDTB]

Because the more invasive your placebo, the more effective it is! You start with vitamins, then run through ssri's, antipsychotics and benzos, lithium and depakote, pretty soon after your borderline pt runs through clozapine, ketamine and ect they are in a new trial for DBS! Then the only thing left is to go really old school and try a prefrontal lobotomy or poney up your own money to send them to kernberg.

 

[whopper]

There are also probably a few who actually think the patient is bipolar despite not actually meeting criteria but I think more are just afraid to challenge the patient.

And there's the bad psychiatrist that even knows the patient has Borderline PD, knows it's not Bipolar Disorder, but still medicates them into oblivion, and then writes Bipolar Disorder into the chart anyways, their logic? Don't ask me cause nothing about it makes sense.

 

[FlowRate]

Because the more invasive your placebo, the more effective it is! You start with vitamins, then run through ssri's, antipsychotics and benzos, lithium and depakote, pretty soon after your borderline pt runs through clozapine, ketamine and ect they are in a new trial for DBS! Then the only thing left is to go really old school and try a prefrontal lobotomy or poney up your own money to send them to kernberg.

This is why botox works so well for migraines.

And there's the bad psychiatrist that even knows the patient has Borderline PD, knows it's not Bipolar Disorder, but still medicates them into oblivion, and then writes Bipolar Disorder into the chart anyways, their logic? Don't ask me cause nothing about it makes sense.

If inpatient, because it's easier/more lucrative to bill for BPAD.

 

[calvnandhobbs68]

This is why botox works so well for migraines.

If inpatient, because it's easier/more lucrative to bill for BPAD.

Yup exactly. Especially if it’s an iffy admission and they’re worried insurance might not cover it anyway (ex. Borderline admitted for cutting or something). Adjust their depakote and carry forward the bipolar diagnosis. Then discharge in a couple days but end up with “Bipolar Disorder” as the discharge diagnosis.

Part of the reason I don’t really like inpatient. If you don’t do it you don’t get paid.

 

[Merely]

Yup exactly. Especially if it’s an iffy admission and they’re worried insurance might not cover it anyway (ex. Borderline admitted for cutting or something). Adjust their depakote and carry forward the bipolar diagnosis. Then discharge in a couple days but end up with “Bipolar Disorder” as the discharge diagnosis.

Part of the reason I don’t really like inpatient. If you don’t do it you don’t get paid.

So inpatient docs are forced to practice poor medicine due to the system?

 

[clausewitz2]

There is OK evidence that SSRI's, atypicals, and mood stabilizers (esp LTG) have some benefit for treatment of irritability and impulsivity associated with of BPD/EUCD.

That said, the only thing that really works is long-term therapy starting with something like DBT/ACT.

I'm currently peeling off all the meds that one of my BPD patients takes because she doesn't think they've been effective and neither do I. We'll see if something gets worse when she's off of the drugs. I'm sure that someone will blame her next hospitalization on the med discontinuation but it's not like the meds kept her out of the hospital in the first place. (In this case I'm actually talking about medical hospitalizations for frequent complications of a specific condition which is responsive to things the patient has to monitor on their own. I'm obfuscating but there aren't many conditions where that's obviously the case.)

There was a big naturalistic study out of the UK recently that I have see people arguing demonstrates no utility for LTG in BPD but a)the doses were on the small side as they so often are in clinical practice b) it was almost hilariously underpowered based on expected effect sizes and c) the placebo and active conditions both involved people coming to the patient's homes to talk to them on a regular basis so of course this swamped the medication effect.

 

[OldPsychDoc]

SSRI are noob tier the real experts get some Pristiq on board.

Only after pharmacogenetic testing, though.

 

[clausewitz2]

Only after pharmacogenetic testing, though.

+/- SPECT scan Amen-style

 

[whopper]

Why PBS lets AMEN on is beyond me. I

 

[notlucid]

There is also possibility of co-morbid Major depressive disorder, Bipolar disorder , ADD, substance use and psychosis to be considered.
Incidence of completed suicide in Borderline personality disorder is high. So then are SSRI, stimulant, atypical antipsyhotics and lithium to treat comorbid
illnesses appropriate?