Affective and Personality Disorders in the ED

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Affective and Personality Disorders in the ED

• Joann McIlwrick, MD, FRCPC, MSc
• Clinical Medical Director
• FMC Psychiatric Emergency Services

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Adult Learners

• Want to know the information necessary to help do
  your jobs better.
• Goal Review the typical presentations and
  approaches associated with
• Borderline and histrionic PD in the ED
• Antisocial and narcissistic PD in the ED
• MDD in the ED
• Mania in the ED

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What are the three major categories used to
classify personality disorders?
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MAD, BAD, SAD

cluster A (mad) odd or eccentric group
cluster B (bad) dramatic, emotional, erratic group
cluster C (sad) anxious and fearful group
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Cluster A PD

• Schizoid, schizotypal and paranoid ODD OR
  ECCENTRIC
• These patients rarely seek treatment. When
  treatment is sought, the physician should provide
  clear explanations to the patient.
• http//emedicine.medscape.com/article/805930-overv
  iew

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Cluster C

• Avoidant - pattern of social inhibition, feelings
  of inadequacy, and hypersensitivity to negative
  evaluation.
• Dependent - Personality that is predominately
  dependent and submissive
• OCPD - Preoccupation with orderliness,
  perfectionism, and control at the expense of
  flexibility and efficiency.

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Cluster B

• Borderline instability of everything
• Histrionic - excessive emotionality and
  attention-seeking behavior.
• Antisocial - chronic maladaptive behavior that
  disregards the rights of others
• Narcissistic - grandiose, need for admiration,
  lack of empathy

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How will Borderline PD present to the ED?
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BPD in the ED

Biological Sequelae of self-harm Sequelae of reckless behaviour
Psychological Depression (mood instability) Suicidal ideation Intense anger, agitation in the community Stress-related psychosis
Social Therapist is unavailable Caregiver is unavailable Housing crisis Financial crisis (day before AISH cheque) Seeking admission
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A pervasive pattern of instability of
interpersonal relationships, self-image, and
affects, and marked impulsivity beginning by
early adulthood and present in a variety of
contexts, as indicated by five (or more) of the
following

1. frantic efforts to avoid real or imagined
   abandonment. 5.
2. a pattern of unstable and intense interpersonal
   relationships characterized by alternating
   between extremes of idealization and
   devaluation. 
3. unstable self-image or sense of self. 
4. impulsivity in at least two areas that are
   potentially self-damaging (e.g., spending, sex,
   substance abuse, reckless driving, binge eating).
   
5. recurrent suicidal behavior, gestures, or
   threats, or self-mutilating behavior 
6. affective instability (e.g., intense episodic
   dysphoria, irritability, or anxiety usually
   lasting a few hours and only rarely more than a
   few days). 
7. chronic feelings of emptiness 
8. inappropriate, intense anger or difficulty
   controlling anger (e.g., frequent displays of
   temper, constant anger, recurrent physical
   fights) 
9. transient, stress-related paranoid ideation or
   severe dissociative symptoms

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What is this?
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Parasuicidality
An act with nonfatal intent/outcome, in which an
individual deliberately initiates a non-habitual
behaviour that, without intervention from others,
will cause self-harm, or deliberately ingests a
substance in excess of the prescribed or
generally recognized therapeutic dosage, and
which is aimed at realizing changes which the
subject desired via the actual or expected
physical consequences. WHO Working Group on
Preventive Practices in Suicide and Attempted
Suicide, 1986
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• What is the risk of death by suicide for this
  patient?

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• One in ten patients with borderline personality
  disorder can be expected to complete suicide, a
  rate similar to those for patients with
  schizophrenia and patients with major mood
  disorders.
• Joel Paris Psychiatric Services 53738742, 2002

15
Can a patient with borderline personality
disorder be certified under the Alberta Mental
Health Act?
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Form 1 AMHA (all must be met)

• In my opinion the person examined is
• a. suffering from mental disorder
• mental disorder means a substantial disorder
  of thought, mood, perception, orientation or
  memory that grossly impairs(i) judgment, (ii)
  behaviour, (iii) capacity to recognize reality,
  or (iv) ability to meet the ordinary demands of
  life
• b. likely to cause harm to the person or others
  or to suffer substantial mental or physical
  deterioration or serious physical impairment, and
• c. unsuitable for admission to a facility other
  than as a formal patient.

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• Personality disorders, formerly referred to as
  character disorders, are a class of personality
  types and behaviors that the American Psychiatric
  Association (APA) defines as "an enduring pattern
  of inner experience and behavior that deviates
  markedly from the expectations of the culture of
  the individual who exhibits it".

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What would the approach to a BPD patient in the
ED be?
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Approach to BPD in the ED

1. Medical clearance untold parasuicidal or
   suicidal gestures
2. Mental state clearance look for new features to
   this presentation (is this the same old same
   old?)
3. Supportive interventions
4. Ask the patient what would be helpful
5. Nicorette, warm blanket, food
6. Recognize and reinforce healthy choices
7. Watch your own countertransference (helplessness
   anger)
8. Take responsibility for the patients treatment,
   but not the patients behaviours.

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• Explain care truthfully and simply.
• Remove anxiety.
• Frequently, these patients use the defense
  mechanism of "splitting," (describing individuals
  as all good or all bad). Such patients may be
  expert at manipulating staff and can also divide
  ED caregivers against each other. Be especially
  sure to have clear communication lines among ED
  caregivers. 
• http//emedicine.medscape.com/article/805930-overv
  iew

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• Be aware that emotional volatility may be
  precipitated by the news that a requested
  treatment or disposition is not possible or
  appropriate. Involve the patient in his or her
  evaluation by asking the patient to be specific
  as to what the expectation or hope was when he or
  she came to the emergency department. The goal is
  to have the patient take ownership of his or her
  presenting symptoms, rather than transferring all
  solutions to the health care provider.
• http//emedicine.medscape.com/article/805930-overv
  iew

22
How will aspd/Narcissistic pd present to the ED?
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ASPD presents to the ED as
Physical health? Mental health? Legal
Facing charges and is now suicidal Yes Maybe Yes
Facing charges and is acting bizarrely Yes Maybe Yes
Assaultive Yes Maybe Maybe
Intoxicated Yes Maybe Maybe
Demanding abusable substances Yes Maybe Yes
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What are the four most important risk-factors for
violent behaviour in a patient?
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1. Previous violence
2. Threats of violence
3. Psychiatric diagnoses, including PD
4. Intoxication

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What is the approach to the ASPD/narcissist in
the ED?
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1. Medical clearance untold parasuicidal or
   suicidal gestures injuries from altercations
2. Mental state clearance i.e. rule-out psychosis
   as the reason for grandiosity
3. Supportive interventions
4. Ask the patient what would be helpful
5. Nicorette, warm blanket, food
6. Recognize and reinforce healthy choices
7. Watch your own countertransference
8. Take responsibility for the patients treatment,
   but not the patients behaviours.

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• Set behavioral limits when needed. Portray
  streetwise approach without being punitive.
• Deal with transitions from being overidealized to
  being devalued by patient. Avoid being defensive
  about mistakes. Narcissistic personality may
  share similar qualities with antisocial
  personality. The main difference appears to be by
  the degree of grandiosity, with narcissistic
  patients tending to exaggerate their talents.
• http//emedicine.medscape.com/article/805930-overv
  iew

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• The ED team are the experts in determining
  physical and mental state abnormalities that
  require intervention.
• Manage only the problems that you are required,
  and trained, to manage. If you dont know what to
  do next, it might be because it is no longer your
  job to do anything further.
• Ensure that the authorities (police, Child and
  Family Services, etc) handle everything else

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Duty to warn and protect

• The Supreme Court of Canada set out the following
  three factors that must be considered when
  deciding when the concern for public safety could
  warrant the breaching of confidential information
  collected by a physician or attorney
• Is there a clear risk to an identifiable person
  or group of persons?
• Is there a risk of serious bodily harm or death?
• Is the danger imminent?
• (Smith v. Jones, 1999, scc.)

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• In light of the Supreme Court of Canada decision
  in Smith v Jones, the CPA takes the position that
  its members have a legal duty to protect intended
  victims of their patients. This duty to protect
  may include informing intended victims or the
  police, or both, but may more easily be addressed
  in some circumstances by detaining and possibly
  treating the patient. The CPA recognizes that
  informing the intended victim may be insufficient
  action to prevent harm in certain circumstances.
• http//ww1.cpa-apc.org/Publications/Position_Paper
  s/duty.asp

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A patient presents to the ED for the 91st time.
The patient has a longstanding diagnosis of XYZ
personality disorder. What is the role for a
consult to psychiatry in this case?
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Psychiatric Management of PD in the ED

• Document mental state findings
• Urgent medication recommendations
• Connection to outpatient services
• Admission to inpatient unit for management of
  new-onset mental state changes
• They will be back.

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Contracting for safety

• Arose from poorly conducted study in 1973
• Was NEVER meant to be used as proof of a
  patients safety or risk for suicide
• Despite a lack of empirical evidence and an
  abundance of literature warning against its use
  in an isolated context, many clinicians continue
  to use the contract for safety.
• A legal review revealed that contracting for
  safety is never enough to protect against legal
  liability and may lead to adverse consequences
  for the clinician and the patient.
• J Am Acad Psychiatry Law 3736370, 2009

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What are the diagnostic features for MDE?
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Depressed or irritable mood plus

• Sleep decreased (Insomnia with 2-4 am awakening)
• Interest decreased in activities (anhedonia)
• Guilt or worthlessness (Not a major criteria)
• Energy decreased
• Concentration difficulties
• Appetite disturbance or weight loss
• Psychomotor retardation/agitation
• Suicidal thoughts

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How will a depressive mood disorder present to
the ED?
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• Obvious suicidality, reports of depressed mood
• Have higher index of suspicion for patients with
  vague physical health complaints in the absence
  of physical health explanation (stigma of mental
  health problems)
• Anxiety and depressive disorders are often
  co-morbid

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Thinking Inability to make decisions Lack of concentration or focus Loss of interest in activities, people, and life Self-criticism, self-blame, self-loathing Pessimism can be a sign of depression Preoccupation with problems and failures Thoughts of self-harm or suicide
Feeling Sadness, misery Overwhelmed by everyday tasks (eg, cooking dinner) Numbness or apathy Anxiety, tension, irritability Helplessness Low confidence and poor self-esteem Disappointment, discouragement, hopelessness Feelings of unattractiveness or ugliness Loss of pleasure and enjoyment
Behaving Withdrawal from people, work, pleasures, activities Spurts of restlessness Sighing, crying, moaning Difficulty getting out of bed Lower activity and energy levels Lack of motivation when everything feels like an effort
Body Fatigue, low energy, exhaustion Poor sleeping patterns waking early, not sleeping even when exhausted Loss of appetite or, occasionally, increased appetite Loss of sexual interest
40
What are the common physical health findings
associated with depression?
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Physical findings in depression

• Head CNS (stroke epilepsy tumour MS)
• Neck Thyroid and parathyroid
• Chest Heart disease lung disease (smokers)
• Abdomen Diabetes
• Pelvis Peri menstrual peri-menopausal
• New-onset depression after age 40 physical
  health problem until proven otherwise

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Urine tox screens and bloodwork for psychiatric
disorders in the ED

• There were 502 patients who met inclusion
  criteria, and 50 of them had completely normal
  laboratory studies. Laboratory studies were
  performed in the ED for 148 patients. The most
  common abnormalities identified were positive
  urine drug screen (221), anemia (n 136), and
  hyperglycemia (n 139). There was one case
  (0.19) identified in which an abnormal
  laboratory value would have changed ED management
  or disposition of the patient had it been found
  during the patients ED visit. Conclusions
  Patients presenting to the ED with a psychiatric
  chief complaint can be medically cleared for
  admission to a psychiatric facility by qualified
  emergency physicians using an appropriate history
  and physical examination. There is no need for
  routine medical screening laboratory tests.
• Journal of Emergency Medicine Bruce D. Janiak,
  MD and Suzanne Atteberry, DO

43
What is the association between antidepressant
use and suicide?
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• The advisory committee considered the results of
  comprehensive meta-analyses of an enormous data
  set data on 99,839 participants who had enrolled
  in 372 randomized clinical trials of
  antidepressants conducted by 12 pharmaceutical
  companies during the past two decades.
• There were 8 suicide deaths in 5 of 39,729
  participants assigned to the investigational
  drug, 2 of 27,164 assigned to placebo, and 1 of
  10,489 assigned to an active comparator. In
  addition, 501 participants had suicidal feelings
  or thoughts or nonfatal suicide attempts 243
  while receiving an investigational drug, 194
  while receiving placebo, and 64 while receiving
  an active comparator.
• No increased risk of suicidal behavior or
  ideation was perceptible when analyses were
  pooled across all adult age groups. In
  age-stratified analyses, however, the risk for
  patients 18 to 24 years of age was elevated,
  albeit not significantly (odds ratio, 1.55 95
  confidence interval, 0.91 to 2.70).

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Should you prescribe antidepressant meds from the
ED?
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• Would you start definitive, long term treatment
  for other illnesses in the ED?
• Patient needs
• Gp to follow-up
• Instructions on management of ADE
• Instructions on dosing adjustments

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When should a depressed patient in the ED be
admitted?
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Consider admission if

Bio Serious suicide attempt. New onset mood disorder Physical co-morbidities Substance use co-morbidities
Psychological Psychotic features Post-partum Suicidality Homicidality
Social No supports in the community No gp for follow-up
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How does mania present to the ED?
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DIG FAST

• DistractibilityIndiscretion (DSM-IV's
  "excessive involvement in pleasurable
  activities") GrandiosityFlight of
  ideasActivity increaseSleep deficit (decreased
  need for sleep)Talkativeness (pressured speech)

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What are the options for chemical restraint of a
manic patient in the ED?
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(No Transcript)
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When would you admit a manic patient from the ED?
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• Probably every time
• Reckless
• Deterioration
• Psychotic (grandiose)
• Hypomania admission not always needed

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Comments and questions