Crisis, What Crisis? A Systematic Approach to Crisis Manag

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Dr. S. Finch MD,CM, FRCPC, ABAM-Diplomate. Introduction. BPD is common disorder, especially in clinical populations. Prevalence 1-2% general population, up to 10-20% outpatients, 25% agitated emergency patients. ID: 176839 Download Presentation

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Crisis, What Crisis? A Systematic Approach to Crisis Manag




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Presentations text content in Crisis, What Crisis? A Systematic Approach to Crisis Manag

Slide1

Crisis, What Crisis? A Systematic Approach to Crisis Management of Borderline Personality Disorder in the Emergency Department

Dr. S. Finch MD,CM, FRCPC, ABAM-Diplomate

Slide2

Introduction

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

Slide3

Introduction 2

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

Slide4

Systematic Approach to BPD crisis

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

Slide5

BPD Diagnosis and Recognition

Slide6

Definition of PD

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.”

Slide7

BPD

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

Slide8

BPD: DSM-IV-TR criteria

AbandonmentStormy relationshipsIdentity disturbanceImpulsivityChronic suicidality

Mood reactivity

Emptiness

Anger/rage

Paranoia/dissociation

Slide9

BPD: Associated Features

Negative counter transference reaction

Manipulation

Self-sabotage

Help-seeking, help-rejecting pattern

Transitional objects, “teddy bear” sign

Slide10

BPD is not...

Just a negative reaction to a patient

A cross-sectional diagnosis

A hopeless case

Slide11

Co-morbidities

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

Slide12

BPD Etiology

UnknownMultifactorialheterogeneousGenetic/neuroanatomyAmygdala/limbic systemSerotonin 5HTT transporter geneHeritability inconsistentDimensional, genetic phenotypesLivesley – four factor model

Developmental

Kernberg

– object relations

Mahler – object constancy

Bowlby

– insecure attachments

Bipolar variant

Recent review (

P

aris,Gunderson

) did not support

Complex PTSD

Herman

Slide13

Crisis Presentations

Slide14

What is a Crisis?

“an unstable period”

“a crucial stage or turning point”

A sudden worsening

Slide15

Typical Crisis Presentation

“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

Slide16

What triggers a Crisis?

LossAbandonmentRejectionFinancial stressImpulsive behaviourSelf-loathing

Conflict in relationships

Intoxication

Being alone

Trauma

New

Re-enactment

Triggers

Slide17

Counter transference reactions

Splitting

Projective Identification

Bad

Object

Good

Object

Slide18

How do we respond to a crisis?

Idealized, good object

RescuerWants to help ptTakes overOver advocatesPoor boundariesReinforced by pt. statements such as: “you are the only one who has ever understood”

Devalued, bad object

Dismisser

Doesn’t listen or empathize

Dismisses patient concerns

Reacts angrily

Challenging, confrontational

Gives “cookbook”, unhelpful suggestions

Slide19

Dangers and Pitfalls

Rescuer

Feeds into splittingDivides teamDecreased pt. ResponsibilityBoundary violationsIsolated with pt.Burned outAbandon pt.

Dismisser

Escalate pt.

Anger

Increased suicide risk

Pt. Threats, complaints

Reject pt.

Slide20

Counter transference

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

Slide21

Suicide Risk and Assessment

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

Slide22

Suicide risk 2

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

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 3

rd

decade)

Paris

suggests higher risk of suicide in late 30s, no active treatment, failed treatment

Slide23

Suicide risk 3

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.”

Slide24

Suicide Risk 4

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

Slide25

To Admit or Not to Admit?

Dawson – never admit a patient with BPD

influential

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

Indications for brief hospitalization:

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

Slide26

Admission? 2

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.”

Slide27

Admission? 3 What Actually Happens

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, non-compliance to treatment

Pts. with BPD had greater clinical severity, percent hospitalized lower (11 vs 17%)

Slide28

Admission? 4

General Principles:

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

Slide29

Approach to Crisis management in ED

Slide30

Approach 1: WAIT!

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

Slide31

Approach 2, outpatient strategies

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

Slide32

Approach 3

Listen and empathizeValidate ptHelp pt id emotionsDevelop rapportRogers-empathy, non-judgemental, unconditional + regard Get at underlying trigger and emotionOften pt unawareHelps defuseTherapeuticAvoid, proactive

Suicide assessment

Expression of distress

May shift

Reassess regularly

Acute vs. Chronic

Don’t dwell on it

May reflect escape, control

Slide33

Approach 4: Containment

Relief from emotional pain comes from connection to someone who understandsAlign with pt’s distress and offer support and understandingWeakened by failure to acknowledge distress, lengthy attempts to clarify feelings, interpretationsStrategies Praised for seeking helpHelp pt id strengths

Survival skillsPut situation into perspective

Interpretation

Confrontation

Clarification

Encouragement

to Elaborate

Empathic Validation

Advice and Praise

Affirmation

Slide34

Approach 5: Plan

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

Slide35

Approach 6: Simple CBT techniques

Reinforce successful adaptive strategies

Distraction

+ self talk

Thought stopping

Substitution

Grounding

Journalling/artwork

Emotion log/ emotion sheets

Slide36

Medications 1

BenzodiazepinesAntidepressantsMood stabilizersAntipsychotics

AVOID except acutely

Dependency

SSRIs>MAOIs

Low mood, anxiety, impulsivity, anger

Anger management

Safety risks – OD,

preg

Helps all symptoms

Low dose,

prn

, ongoing

Side effects

Typical vs. atypical

Slide37

Medications 2: General Principles

Meds are tools to help with symptom control

Meds symptom based vs. generally helpful

First do no harm

OD potential

Pregnancy risk

Med dependency/diversion

withdrawal

Prescriptions for small amounts

Slide38

Medications 3: what happens in practice

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

Slide39

Medications 4: Atypical Antipsychotics in ED

Damsa et al, 2007

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 40-160mg/day, monitored up to 2 weeks

Overall significant improvement, well tolerated

Slide40

Transitional Objects

Helpful to give the patient something

Follow-up appointment

Crisis line number

Prescription/meds

Voice mail

Treatment plan

Written note

Slide41

Contracting for Safety

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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