Sunday, December 30, 2018

EUPD - Boderline Personality Disorder

What is BPD?
BPD is a type of ‘personality disorder’ in which people struggle with emotions ultimately affecting their relationships with others. It is also called as Emotionally Unstable Personality Disorder (EUPD). It is believed that BPD results from traumatic childhood experiences (neglect or being abandoned, physical, emotional or sexual abuse). People with BPD may experience:
  • feeling isolated/ abandoned 
  • self-harm or suicidal thoughts
  • difficulty coping with stress
  • strong emotions 
  • misusing alcohol and prescription drugs
  • Using illegal drugs and substances
  • Understanding others points of view
  • Being able to maintain a home

People with BPD typically have at least five of the symptoms below:
  • Feeling worried about people abandoning you, and would do anything to stop that happening
  • Feeling intense emotions that last from a few hours to a few days and can change quickly (for example, from feeling very happy and confident to suddenly feeling low and sad)
  • Having a strong sense of who you are, and it can change significantly depending on who you're with
  • Finding hard to make and keep stable relationships
  • Feeling empty a lot of the time
  • Acting impulsively and do things that could harm you (such as binge eating, using drugs or driving dangerously)
  • You often have feeling of self-harm
  • Having intense feelings of anger, which are really difficult to control
  • Feeling paranoia or dissociation

Types of EUPD


  • Borderline- More difficulties with relationships, self-harming and feelings of emptiness.
  • Impulsive- Issues with impulsive behaviour and angry feelings.



Treatment for BPD


1) Dialectical Behaviour Therapy (DBT)
DBT helps to build skills to deal with distress. DBT can help to learn how to control harmful ways of coping with distress, such as self- harming or using drugs or alcohol. DBT usually involves weekly individual and group sessions.

2) Mentalisation-Based-Therapy (MBT)
MBT helps people who make assumptions about what other people think or feel. The goal of MBT is to improve your ability to recognise your own and others' mental states, learn to "step back" from your thoughts and examine them to see if they're valid. MBT is based on the concept that people with BPD have a poor capacity to mentalise. Mentalisation is the ability to think about thinking. 

3) Cognitive Behavioural Therapy (CBT) – Aims to help understand how thoughts and beliefs might affect feelings and behaviour.

4) Cognitive Analytic Therapy (CAT) – Combines CBT's practical methods with a focus on the relationship between the patient and therapist. 

5) Other talking therapies – such as schema-focused cognitive therapy, psychodynamic therapy, interpersonal therapy or arts therapies.


ED visits and typical presentations

  • Self-harm - Do Risk Assessmnet and manage overdoses based on the type of drug taken
  • Drugs and alcohol - Observe, give time to sober up and re-assess
  • Impulsive behaviours (driving erratically, having more sexual partners, and spending money without thinking)
Emergency Medicine Physicians should adopt a calm and non-threatening attitude towards this group of patients. With no rapport, it can be challenging dealing with these sensitive induviduals in the midst of a chaotic ED. People with BPD often find that simply talking to somebody who understands their condition can help bring them out of a crisis. It becomes critical to step back and try to understand the crisis from the person’s point of view and explore their concerns. Use empathetic and open questioning including validating statements. Being a good listener and listening without interrupting goes a long way in such situations. If you come across a frequent attender, then check their anticipatory care plan on records. 

Prior to dishcarge, ensure they have helpline contact details before discharge (Mental Health Nurse, Social Worker) and in case of a severe crisis when behaviour poses a significant risk, discuss with MH team for admission or detention. No medication is currently licensed to treat BPD but medications are often used if you have another associated mental health condition, such as Anxiety/Depression. 




Posted by:


              
     Lakshay Chanana
     
     ST4 Trainee
     Royal Infirmary of Edinburgh
     Department of Emergency Medicine
     Edinburgh
     Scotland

     @EMDidactic



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