Affective and Personality Disorders in the ED

1. Affective and Personality Disorders in the ED Joann McIlwrick, MD, FRCPC, MSc Clinical Medical Director FMC Psychiatric Emergency Services

2. 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

3. What are the three major categories used to classify personality disorders?

4. MAD, BAD, SAD

5. 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

6. 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.

7. 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

8. How will Borderline PD present to the ED?

9. BPD in the ED

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

11. What is this?

12. 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

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

14. 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

15. Can a patient with borderline personality disorder be certified under the Alberta Mental Health Act?

16. 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.

17. 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".

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

19. Approach to BPD in the ED • Medical clearance– untold parasuicidal or suicidal gestures • Mental state clearance– look for new features to this presentation (is this “the same old same old”?) • Supportive interventions • Ask the patient what would be helpful • Nicorette, warm blanket, food • Recognize and reinforce healthy choices • Watch your own countertransference (helplessness; anger) • Take responsibility for the patient’s treatment, but not the patient’s behaviours.

20. 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

21. 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

22. How will aspd/Narcissistic pd present to the ED?

23. ASPD presents to the ED as:

24. What are the four most important risk-factors for violent behaviour in a patient?

25. Previous violence • Threats of violence • Psychiatric diagnoses, including PD • Intoxication

26. What is the approach to the ASPD/narcissist in the ED?

27. Medical clearance– untold parasuicidal or suicidal gestures; injuries from altercations • Mental state clearance– i.e. rule-out psychosis as the reason for grandiosity • Supportive interventions • Ask the patient what would be helpful • Nicorette, warm blanket, food • Recognize and reinforce healthy choices • Watch your own countertransference • Take responsibility for the patient’s treatment, but not the patient’s behaviours.

28. 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

29. 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

30. 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 groupof persons? • Is there a risk of serious bodily harm or death? • Is the danger imminent? • (Smith v. Jones, 1999, scc.)

31. 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

32. 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?

33. 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.

34. “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

35. What are the diagnostic features for MDE?

36. 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

37. How will a depressive mood disorder present to the ED?

38. 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

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

41. 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

42. 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

43. What is the association between antidepressant use and suicide?

44. The advisory committeeconsidered the results of comprehensive meta-analyses of anenormous data set: data on 99,839 participants who had enrolledin 372 randomized clinical trials of antidepressants conductedby 12 pharmaceutical companies during the past two decades. • There were 8 suicide deaths: in 5of 39,729 participants assigned to the investigational drug,2 of 27,164 assigned to placebo, and 1 of 10,489 assigned toan active comparator. In addition, 501 participants had suicidalfeelings or thoughts or nonfatal suicide attempts — 243while receiving an investigational drug, 194 while receivingplacebo, and 64 while receiving an active comparator. • No increasedrisk of suicidal behavior or ideation was perceptible when analyseswere 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).

45. Should you prescribe antidepressant meds from the ED?

46. 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

47. When should a depressed patient in the ED be admitted?

48. Consider admission if:

49. How does mania present to the ED?

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