Affective and Personality Disorders in the ED

Affective and Personality Disorders in the ED

Joann McIlwrick, MD, FRCPC, MScClinical Medical Director

FMC Psychiatric Emergency Services

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

WHAT ARE THE THREE MAJOR CATEGORIES USED TO CLASSIFY PERSONALITY DISORDERS?

MAD, BAD, SAD

cluster A(mad)

odd or eccentric group

cluster B (bad)

dramatic, emotional, erratic group

cluster C(sad)

anxious and fearful group

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-overview

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.

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

HOW WILL BORDERLINE PD PRESENT TO THE ED?

BPD in the ED

Biological 1. Sequelae of self-harm2. Sequelae of reckless behaviour

Psychological 1. “Depression” (mood instability)2. Suicidal ideation3. Intense anger, agitation in the community4. Stress-related “psychosis”

Social 1. Therapist is unavailable2. Caregiver is unavailable3. Housing crisis4. Financial crisis (day before AISH cheque)5. Seeking admission

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

WHAT IS THIS?

ParasuicidalityAn 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

What is the risk of death by suicide for this patient?

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 53:738–742, 2002

Can a patient with borderline personality disorder be certified under

the Alberta Mental Health Act?

Form 1 AMHA (all must be met)In my opinion the person examined isa. 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.

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".

WHAT WOULD THE APPROACH TO A BPD PATIENT IN THE ED BE?

Approach to BPD in the ED1. Medical clearance – untold parasuicidal or suicidal

gestures2. Mental state clearance – look for new features to this

presentation (is this “the same old same old”?)3. Supportive interventions

1. Ask the patient what would be helpful2. Nicorette, warm blanket, food3. Recognize and reinforce healthy choices4. Watch your own countertransference (helplessness; anger)

4. Take responsibility for the patient’s treatment, but not the patient’s behaviours.

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-overview

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-overview

HOW WILL ASPD/NARCISSISTIC PD PRESENT TO THE ED?

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

WHAT ARE THE FOUR MOST IMPORTANT RISK-FACTORS FOR VIOLENT BEHAVIOUR IN A PATIENT?

1. Previous violence2. Threats of violence3. Psychiatric diagnoses, including PD4. Intoxication

WHAT IS THE APPROACH TO THE ASPD/NARCISSIST IN THE ED?

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 interventions1. Ask the patient what would be helpful2. Nicorette, warm blanket, food3. Recognize and reinforce healthy choices4. Watch your own countertransference

4. Take responsibility for the patient’s treatment, but not the patient’s behaviours.

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-overview

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 don’t 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

Duty to warn and protectThe 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:

1. Is there a clear risk to an identifiable person or group of persons?

2. Is there a risk of serious bodily harm or death?3. Is the danger imminent?

(Smith v. Jones, 1999, scc.)

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_Papers/duty.asp

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?

Psychiatric Management of PD in the ED1. Document mental state findings2. Urgent medication recommendations3. Connection to outpatient services4. Admission to inpatient unit for

management of new-onset mental state changes

They will be back.

“Contracting for safety” Arose from poorly conducted study in 1973 Was NEVER meant to be used as proof of a patient’s

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 37:363–70, 2009

WHAT ARE THE DIAGNOSTIC FEATURES FOR MDE?

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

HOW WILL A DEPRESSIVE MOOD DISORDER PRESENT TO THE ED?

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

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

What are the common physical health findings associated with “depression”?

Physical findings in depression1. Head: CNS (stroke; epilepsy; tumour; MS)2. Neck: Thyroid and parathyroid3. Chest: Heart disease; lung disease (smokers)4. Abdomen: Diabetes5. Pelvis: Peri menstrual; peri-menopausal

New-onset depression after age 40 = physical health problem until proven otherwise

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 patient’s 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

WHAT IS THE ASSOCIATION BETWEEN ANTIDEPRESSANT USE AND SUICIDE?

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).

Should you prescribe antidepressant meds from the ED?

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

When should a depressed patient in the ED be admitted?

Consider admission if:

Bio 1. Serious suicide attempt.2. New onset mood disorder3. Physical co-morbidities4. Substance use co-morbidities

Psychological 1. Psychotic features2. Post-partum3. Suicidality4. Homicidality

Social 1. No supports in the community2. No gp for follow-up

HOW DOES MANIA PRESENT TO THE ED?

DIG FAST:

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

WHAT ARE THE OPTIONS FOR CHEMICAL RESTRAINT OF A MANIC PATIENT IN THE ED?

WHEN WOULD YOU ADMIT A MANIC PATIENT FROM THE ED?

Probably every time Reckless Deterioration Psychotic (grandiose)

Hypomania – admission not always needed

COMMENTS AND QUESTIONS