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Tuesday, March 7, 2017

Borderline Personality Disorder

One of the aspects of my job that I like most is that each case closes very fast, that is, usually in about two to three hours. This means that there's not much opportunity to spend endless amounts of time with patients or family members who are particularly challenging to work with. Many patients among this group have borderline personality disorder.

What is borderline personality disorder? The most common and most outstanding characteristics I've noticed in those patients with this disorder, both as a social worker and in my current role as an emergency clinician are as follows. The following characteristics certainly are not apparent in all patients with borderline personality disorder.
  • Many of them make many suicidal gestures (falling between wanting to kill oneself and making a suicide attempt, these include holding a knife close to one's wrist) - the teen who frequently ties clothing around her neck just tight enough to not lose consciousness in the presence of residential staff members. 
  • Many of them make suicide attempts with a high chance of rescue, that is, in front of others - the man who hangs himself on a closely supervised inpatient unit. 
  • Many of them are not able to identify any new stressor or precipitant that could've contributed to their worsened mental functioning - the young adult who reports being in conflict with her loved ones again. 
  • Many of them feel the need to be patients on inpatient units inappropriately, thus can appear desperate to get there - the woman who overdoses on medications in front of me because I'm not willing to meet her demand of inpatient.
  • Many of them are passively suicidal without any suicidal plan on a daily basis - the man who reports praying to never wake up again every night at bedtime. 
  • Many of them superficially injure themselves intentionally - the woman who's arms are scarred beyond repair resulting in nerve damage. 
  • Many of them have no intention to die by suicide - the woman who overdoses on pills forty-five times while passively suicidal, and then dies in the forty-sixth time she does this. 
In Massachusetts, unless a patient is needing a forensic evaluation, such as in determining whether one is criminally responsible for a crime or innocent due to mental illness, a patient needing "long" term inpatient care funded by the state must typically go through a non-state inpatient unit first. A large percentage of the patients on my inpatient caseload (I only worked for non-state units) who were waiting for entry into state-funded inpatient units had borderline personality disorder. This was not a coincidence. Among those patients waiting for this entry, this disorder was the second most common behind illnesses involving psychosis.

As I increasingly realized how serious borderline personality disorder is, it struck me as odd that borderline personality disorder would be this common among those waiting for state-funded inpatient care. They often didn't present with severe signs of mood disorders. They often didn't present with mania. They often were not psychotic. So why were they getting admitted to expectedly the most intensive and most restrictive level of inpatient care possible?

It turns out that they are most dangerous when they've recently increased the potential lethality of their self-injurious behaviors. Their danger involves being most at risk for accidentally killing themselves. I usually do not grant inpatient admission to the patient who is desperately wanting this, but who hasn't engaged in serious self-injury recently and doesn't have a suicidal plan. On the other hand, I ensure that the patient who swallows an object besides food or medication, such as a pen cap, gets transferred to safe confinement.

They can be unpredictable. In emergency services, a patient with borderline personality disorder demands that she be granted an inpatient admission while she is not meeting the criteria for this. Although passively suicidal, she is functioning safely. I try redirecting her to use healthy coping strategies, to no avail. She continues to press for an inpatient admission. She presses for this again until she pours large handfuls of her pills into her mouth, gradually swallowing these in my view. I grant inpatient to her. Even though personality disorders are, by formal definition, less problematic than major mental illnesses, the only mental illness that this patient presents is borderline personality disorder. 


Anonymous said...

When you make diagnoses based only on interacting and observing a patient for 2-3 hours, what harm might be done? Is there care in ruling out other possible triggers for the behavior including prescription and non-prescription drugs, head injury, etc? Thanks.

Lynn said...

None. I'm not saying that diagnosing someone isn't important. It is important, but not the most important part of my assessment. When I have to decide whether or not a patient is in danger, diagnosing is not as important. For instance, let's say a patient presents only with scant signs of depression (eg, depressed mood), but expresses a strong intention to complete suicide with a specific plan and means available. I will arrange for an inpatient hospitalization and later diagnose this patient just with "Depression -unspecified" rather than "Major depression," which includes many other signs of depression (eg, anhedonia, disturbed sleep, low motivation to attend to usual tasks, etc.). Getting a patient to safety trumps diagnosing.

The concern you raise about not seeing the whole picture is one of the reasons I ALWAYS review other clinical records, especially recent records from psychiatrists and other emergency clinicians in the agency I work for. Mental health professionals sometimes don't diagnose the same patient consistently. It's common to find a patient's record showing a variety of diagnoses from a variety of professionals.

Another reason diagnosing is not the most important part of my job is that these days, medications can be used for a variety of disorders. For example, anti-psychotic medications can be used to treat mood disorders.

I have to diagnose each patient with something at the end of the documentation. Occasionally this is especially difficult because the symptoms presented don't neatly fall into any particular diagnostic category. So I do my best with choosing something. The DSM-5 police are not going to come after me if I accidentally diagnose someone with the wrong thing on a rare occasion. Other times, the diagnosis is clear.

Lynn said...

There's care in ruling out other possible sources of mental dysfunction. This is why patients often have to go through medical clearance at hospital emergency departments prior to getting accepted to psychiatric inpatient units. I'm not a neurologist and not a medical doctor, thus I have only basic knowledge of medications' side effects and the negative effects of traumatic brain injuries. Other sources of behavioral dysfunction include dementia and use of illegal drugs or alcohol. I rule out alternative causes of dysfunctional symptoms that appear mental on the surface during the interviewing process.

Side effects of medications - This is often not the most significant piece of assessments. Side effects can be either physical or mental (eg, agitation, hallucinations, restlessness, mood instability), or both of these. There are hundreds of medications available. If a medication gives a patient a side effect that's too difficult to tolerate, the hope is that the patient or legal guardian will be motivated enough to advocate for another medication. The side effects of medications can be managed with other medications (eg, cogentin). These are some reasons for not seeing many side effects being reported by patients.

Traumatic brain injuries - If the patient reports that decreased impulsivity with an increase in violence began immediately following the brain injury, then I'm suspicious. Rather than concluding that the brain injury caused the behavioral impairments, I would note the relationship.

Dementia - With the exception of Lewy Body Dementia, dementia doesn't typically manifest itself with hallucinations. A more common "mental" sign of dementia is paranoia. I don't deal with dementia a lot because nursing homes all have their own psychiatric teams, considering that the onset of dementia is usually much later in life.

Substance misuse - Substance misuse is very common in emergency mental health. The time that illegal drugs or alcohol was used must be considered. I often tell these users that diagnosing mental illness when there's active substance misuse is close to impossible. I tell them that this is because the street drugs or alcohol cover up mental problems. If someone has been using heroin on a daily basis in the last two years, was functioning well during extended periods of sobriety without psychotherapy or medication, and just now is reporting anxiety, I would diagnose opiate dependence as the only diagnosis. This patient should go through a detoxification before considering long-term mental health services.

Kitt O’Malley said...

Borderline personality disorder is misnamed. Those with the diagnosis are misunderstood and often vilified by clinicians. There is growing evidence that it is a serious mental illness involving brain, genetic, environmental, and social factors.