Crisis, What Crisis? - Department of Psychiatry

Report
Dr. S. Finch MD,CM, FRCPC, ABAM-Diplomate
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BPD is common disorder, especially in clinical
populations
Prevalence 1-2% general population, up to
10-20% outpatients, 25% agitated
emergency patients
BPD often present in crisis, suicidal and often
in ED
Challenging to work with
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Diagnosis engenders strong reactions
Over diagnosed and under diagnosed
Black and white approach to treatment
Patient’s concerns may be dismissed, suicide
risk minimized and negative outcomes
blamed on patient
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Most literature based on intensive outpatient
treatments
Crisis management strategies usually end
with transfer to ED
Today’s discussion, 3 parts:
 Diagnosis and recognition of BPD
 Crisis presentations
 Strategies to treat BPD in crisis
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DSM-IV-TR defines a PD as: “enduring
subjective experiences and behaviour that
deviate from cultural standards, are rigidly
pervasive, have an onset in adolescence or
early adulthood, are stable through time and
lead to unhappiness and impairment.”
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Borderline between psychosis and neurosis
characterized by extremely unstable affect,
behaviour, mood, self-image and object
relations
ICD-10: emotionally unstable PD
“as-if” personality
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Abandonment
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Mood reactivity
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Stormy relationships
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Emptiness
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Identity disturbance
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Anger/rage
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Impulsivity
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Paranoia/dissociation
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Chronic suicidality
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Negative counter transference reaction
Manipulation
Self-sabotage
Help-seeking, help-rejecting pattern
Transitional objects, “teddy bear” sign
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Just a negative reaction to a patient
A cross-sectional diagnosis
A hopeless case
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more commonly have childhood histories of
physical and sexual abuse, neglect, and early
parental loss and separation
Frequently co-morbid with other PDs
Axis 1: mood disorders, PTSD, SUDs, eating
disorders, ADHD, panic disorder, dissociative
disorders
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Unknown
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 Kernberg – object relations
 Mahler – object constancy
 Bowlby – insecure
 Multifactorial
 heterogeneous
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Genetic/neuroanatomy
 Amygdala/limbic system
 Serotonin 5HTT
attachments
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Dimensional, genetic
phenotypes
 Livesley – four factor model
Bipolar variant
 Recent review
transporter gene
 Heritability inconsistent
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Developmental
(Paris,Gunderson) did not
support
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Complex PTSD
 Herman
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“an unstable period”
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“a crucial stage or turning point”
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A sudden worsening
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“frantic effort to avoid abandonment”
manifests itself in an exaggerated, often
maladaptive response
Attempt to solicit caring response
Present in crisis due to extreme response,
instability, affect dysregulation, lack of social
supports, trauma history
Self harm, suicidality, aggression/anger,
intoxication, risky impulsivity,
psychosis/dissociation
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Loss
Abandonment
Rejection
Financial stress
Impulsive behaviour
Self-loathing
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Conflict in relationships
Intoxication
Being alone
Trauma
 New
 Re-enactment
 Triggers
SPLITTING
Bad
Object
PROJECTIVE IDENTIFICATION
Good
Object
IDEALIZED, GOOD OBJECT
DEVALUED, BAD OBJECT
Rescuer
 Wants to help pt
 Takes over
 Over advocates
 Poor boundaries
 Reinforced by pt.
statements such as: “you
are the only one who has
ever understood”
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Dismisser
Doesn’t listen or empathize
Dismisses patient concerns
Reacts angrily
Challenging,
confrontational
Gives “cookbook”,
unhelpful suggestions
RESCUER
DISMISSER
Feeds into splitting
 Divides team
 Decreased pt.
Responsibility
 Boundary violations
 Isolated with pt.
 Burned out
 Abandon pt.
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Escalate pt.
Anger
Increased suicide risk
Pt. Threats, complaints
Reject pt.
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Interactions can lead to re-enactments of
negative, traumatic relationships
Interactions can make pt. worse and increase
suicide risk
Important to be real, caring, set limits,
enforce boundaries – therapeutic for the
patient
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8-10% of patients with BPD complete suicide
Patients with BPD represent 9-33% of all
suicides
History of suicidal behaviour in 60-78% of
patients with BPD
Chronic suicidality with 4 or more visits to
psych ED, most often diagnosed with BPD,
12% of all psych ED visits
Common co-morbidities increase suicide risk
BPD pts. have multiple suicide risk factors
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McGirr et al., 2007
 BPD suicide associated with higher levels Axis 1 co-
morbidity, novelty seeking, hostility, co-morbid PD, lower
levels harm avoidance
 Fewer psych hospitalizations and suicide attempts but
increased SUD, cluster B co-morbidity
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Pompili et al., 2005
 Higher rates of suicide in short term vs. Long term follow-
up, suggests highest suicide risk in initial phases of illness
Links suggests higher risk of suicide in young pts.
(adolescence to 3rd decade)
 Paris suggests higher risk of suicide in late 30s, no
active treatment, failed treatment
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Zaheer, Links, Liu Psychiatric clinics NA, 2008
▪ RCT, 180 patients, BPD + recurrent suicidal behaviour
▪ Prospective trial to assess risk factors of high lethality vs. Low
lethality attempters
▪ High lethality attempters: older, more children, PTSD, other
PD esp. ASPD, specific phobia, anorexia, lower GAF, more
childhood abuse, more exp to meds, more hospitalizations,
more expectation of fatal outcome
▪ Independent variables: exp fatal outcome, schizotypal dim,
PTSD, lower GAF, specific phobia, # psych admissions last 4
months
▪ “suffering chronic illness course with significant psychosocial
impairment. These patients may be demonstrating an
escalating series of suicide attempts with more and more
suicide intention.”
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Acute on chronic risk
Acute stressors and acute risk factors increase
acute risk
Many BPD pts. meet criteria for Form 1/3
chronically
Current Axis 1 co-morbidity, substance use,
stressors, lack of protective factors and supports
3 signs that immediately precede pt. Suicide: a
precipitating event, intense affective state,
changes in behaviour patterns
▪ Hendin et al., 2001
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Dawson – never admit a patient with BPD
▪ influential
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Paris, Linehan – recommend against admission
▪ Positively reinforcing socially
▪ Reinforces suicidal and self-destructive behaviours
▪ Regression
Sometimes patients admitted due to lack of
connection with resources
 APA Guidelines 2001
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 Indications for brief hospitalization:
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Imminent danger to others
Serious suicide attempt, loss of control suicidal impulses
Psychotic episodes with poor judgement/ poor impulse control
Severe unresponsive symptoms interfering with functioning
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Patient quote from Williams, 1998
▪ “Do not hospitalize a person with BPD for more than 48
hours. My self-destructive episodes – one leading right
into another – came out only after my first and
subsequent hospital admissions, after I learned the
system was usually obligated to respond....When you as
a service provider do not give the expected response to
these threats, you’ll be accused of not caring. What you
are really doing is being cruel to be kind. When my
doctor wouldn’t hospitalize me, I accused him of not
caring if I lived or died. He replied, referring to my cycle
of repeated hospitalizations, “That’s not life.” And he
was 100% right.”
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Pascual et al., 2007
▪ 11,578 consecutive visits to psych ED
▪ BPD diagnosed for 9% (1032 visits), 540 individuals
▪ 11% hospitalized – suicide risk, danger to others,
symptom severity, difficulty with self-care, noncompliance to treatment
▪ Pts. with BPD had greater clinical severity, percent
hospitalized lower (11 vs 17%)
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General Principles:
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Try to discharge
Admit as briefly as possible
Overnight in ER or holding beds
Keep voluntary
Carefully assessed diagnosis essential
Care plans
Good discharge planning
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Triage BPD patients last as long as safely
contained in ED
Some pts leave before seen
Some pts settle, use own resources to
manage crisis
+ reinforcement of positive behaviour, reinforcement extreme behaviours
 Linehan, 1993
▪ Listen to emotional content of sucidality/crisis and validate
feelings
▪ Identify circumstances leading to feelings
▪ Dialogue with pt to develop alternative solutions
 Livesley, 2005
▪ Safety and managing crises
▪ Containment
▪ Control and regulation
▪ Interventions to reduce self-harming behaviours
▪ Controlling and regulating dysphoria
▪ Reframing triggering situations
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Listen and empathize
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Validate pt
Help pt id emotions
Develop rapport
Rogers-empathy, nonjudgemental,
unconditional + regard
Get at underlying
trigger and emotion
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Often pt unaware
Helps defuse
Therapeutic
Avoid, proactive
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Suicide assessment
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Expression of distress
May shift
Reassess regularly
Acute vs. Chronic
Don’t dwell on it
May reflect escape, control
▪ Relief from emotional pain comes from connection to
someone who understands
▪ Align with pt’s distress and offer support and
understanding
▪ Weakened by failure to acknowledge distress, lengthy
attempts to clarify feelings, interpretations
▪ Strategies
▪ Praised for seeking help
▪ Help pt id strengths
Interpretation
Confrontation
Clarification
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Survival skills
Put situation into perspective
Encouragement
to Elaborate
Empathic
Validation
Advice and
Praise
Affirmation
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Mobilize supports-family, friends, professionals
Stepwise way to approach crisis
Follow-up arrangement
Caring statements, photographs
Can always come back to ED
Joint Crisis Plans: pt and are team prepare ahead of time
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Reinforce successful adaptive strategies
Distraction
+ self talk
Thought stopping
Substitution
Grounding
Journalling/artwork
Emotion log/ emotion sheets
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Benzodiazepines
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Antidepressants
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Mood stabilizers
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Antipsychotics
▪ AVOID except acutely
▪ Dependency
▪ SSRIs>MAOIs
▪ Low mood, anxiety,
impulsivity, anger
▪ Anger management
▪ Safety risks – OD, preg
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Helps all symptoms
Low dose, prn, ongoing
Side effects
Typical vs. atypical
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Meds are tools to help with symptom control
Meds symptom based vs. generally helpful
First do no harm
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OD potential
Pregnancy risk
Med dependency/diversion
withdrawal
Prescriptions for small amounts
 Pascual et al, 2008
▪ 11,578 consecutive visits to psych ED over 4 years
▪ 1032 (9%) visits diagnosed BPD, 540 individuals
▪ Prescribe benzos
 Male sex, anxiety, good self care, few med or drug problems,
housing instability
▪ Prescribe antipsychotics
 Male sex, danger to others, psychosis
▪ Prescribe antidepressants
 Depression, little premorbid dysfunction
 Damsa et al, 2007
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25 pts, severe agitation + BPD
Received 10mg im olanzapine
Reduced agitation, good tolerance within 2hrs
16% required second dose
 Pascual et al, 2004
▪ 12 BPD pts
▪ Received ziprasidone 20mg im then oral ziprasidone 40160mg/day, monitored up to 2 weeks
▪ Overall significant improvement, well tolerated
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Helpful to give the patient something
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Follow-up appointment
Crisis line number
Prescription/meds
Voice mail
Treatment plan
Written note
 Beware
 No medico-legal value
 Does not replace assessment, treatment plan,
documentation
 Helpful when ongoing therapeutic relationship
 Sometimes helpful as part of suicide assessment
 Do not base clinical decisions on contract

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