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

Patients requiring "medical clearance"

Majority of the disease burden that we see in Emergency Departments includes Geriatric pathologies and Psychiatric issues. Whenever Psychiatry evaluates any patient, they always ask for "medical clearance" and want us to mention this specifically on the chart. I often come across patients who visit Emergency Department more than I do as an A&E physician. Regardless, they go through this process of "medical clearance" every time. 

Frequently, it gets difficult to document "medically cleared". For instance, when psych patients have slightly high blood glucose but do not need anything besides some IV fluids or they might come up with a BP of 180/90 due to agitation. Additionally, getting a precise drug history can be a challenge in this subgroup of patients as they frequently take several medications for underlying chronic illnesses. It can be problematic if we document medically cleared on the chart and I believe "No acute medical concerns at this point or Fit for Psychiatric assessment" is a better way to clear these patients. Medical evaluation is used to determine whether the patient has a medical condition that is causing or exacerbating the psychiatric illness. 

At any cost we do not want to miss an underlying medical pathology. Things that we need to look for to r/o organic cause of Psych symptoms:

• ABCs as always
• Vital Signs (PR, BP, RR, Temp, SpO2, Glucose) - Do not ignore abnormal VS
• Pupils and Skin exam (pick cues for toxidromes)
• Focused History (Next of Kin/Paramedics) and Physical exam
• Focus on underlying Psych issues (Drugs/Alcohol, Sexual, Suicidal, Homicidal, Social aspects)
• Medications and Co-Morbidities 
• Document Mental Exam - Appearance, Behaviour, Cognition, Speech, Mood, Insight, Thoughts, Hallucinations

Most of them do not require blood tests. Bloods are done in those with:
1. New-onset psychiatric complaints
2. Abnormal vital signs
3. Elderly
4. Known co-morbid conditions. 

Even Urine Drug Sceen is not  required routinely for all. Most of them will tell you what drugs they have recently taken. Also remember, UDS may have false positive and negatives which can be misleading.


Signs suggesting underlying medical pathology are:

• Abnormal Vital Signs
• Clouded Consciousness 
• Age >40 with no previous Psych issues
• Focal deficits on exam
• Abnormal Physical examination 
• Visual Hallucinations 

Visual hallucinations can also occur in psychiatric illnesses but assume medical pathology until proven otherwise

Take Home:

• Spend more time on history and exam rather than doing bloods on everyone
• Do not ignore abnormal Vital Signs
• Look at issues that often co-exist with Psych illnesses - Drugs/Alcohol, Sexual, Suicidal, Homicidal, Social aspects

Further Reading:

• Korn CS, Currier GW, Henderson SO: Medical clearance of psychiatric patients without medical complaints in the emergency department. J Emerg Med 18: 173, 2000. 
• American Psychiatric Association: Practice guideline for psychiatric evaluation of adults. Am J Psychiatry 152: 63, 1995. 
• Korn CS, Currier GW, Henderson SO: “Medical clearance” of psychiatric patients with- out medical complaints in the emergency department. J Emerg Med 18: 173, 2000. 
• Olshaker JS, Browne B, Jerrard DA, Prendergast H, Stair TO: Medical clearance and screening of psychiatric patients in the emergency department. Acad Emerg Med 4: 124, 1997. 
• Broderick KB, Lerner B, Mccourt JD, Fraser E, Salerno K: Emergency physician practices and requirements regarding the medical screening examination of psychiatric patients. Acad Emerg Med 9: 88, 2002. 

Posted by:

              

     Lakshay Chanana

     

     Speciality Doctor

     Northwick Park Hospital

     Department of Emergency Medicine

     England

     @EMDidactic

Anti-NMDA Encephalitis

Anti-NMDA receptor encephalitis is an acute form of lethal encephalitis which has a high probability for recovery with timely diagnosis and treatment. Therefore, as frontline physicians it is important for us to be aware of this disease. 

Anti-NMDA Encephalitis is an autoimmune disease, where the primary target is NR1/NR2 subunit of the NMDA receptor (N-Methyl D-Aspartate). This disease has recently received press over the last decade but it is suspected that this entity still remains under-recognised. 

Clinical Presentation

Typically NMDA-Encephalitis starts with a flu like illness(weeks to months before) followed by personality changes, psychotic behaviour, disorientation, confusion, paranoia, dyskinesia, seizures, hallucinations and autonomic dysfunction. The condition is associated with tumours, mostly teratomas of the ovaries. Male to Female ratio is 9:1 and the typical patient is a young female. 

Work-up

• Routine Bloods (CBC, Renal, Liver, Kidney Profiles, TSH)
• Head Imaging (SOLs, r/o other causes
• Lumbar Puncture - NR1 and NR2 antibodies in CSF
• Pelvic ultrasound (to look for teratomas)

Differential Diagnosis

• Psychiatric Illnesses 
• Substance Abuse
• Other forms of Viral Encephalitis
• Limbic System Encephalitis

Treatment

• Pelvic Tumor Removal
• Immunotherapy - corticosteroids, intravenous immunoglobulin and plasmapheresis
• Rehabilitation 

The recovery process usually takes several months and paradoxically, the symptoms can reappear but as the recovery process continues, the psychosis eventually fades away. 

Take Home:

It is important to consider anti-NMDA receptor encephalitis as a possible cause of acute psychosis in young patients with no past neuropsychiatric history before we label it as a "Mental Health" problem. 

Posted by:

              

     Lakshay Chanana

     

     Speciality Doctor

     Northwick Park Hospital

     Department of Emergency Medicine

     England

     @EMDidactic