Patients with Borderline Personality Disorder in Emergency Departments

Borderline personality disorder (BPD) patients, when in crisis, are frequent visitors of emergency departments (EDs). When these patients exhibit symptoms such as aggressiveness, impulsivity, intense anxiety, severe depression, self-harm, and suicidal attempts or gestures, diagnosis, and treatment of the BPD becomes challenging for ED doctors. This review will, therefore, outline advice to physicians and health-care providers who face this challenging patient population in the EDs. Crisis intervention should be the first objective of clinicians when dealing with BPD in the emergency. For the patients with agitation, symptom-specific pharmacotherapy is usually recommended, while for non-agitated patients, short but intensive psychotherapy especially dialectical behavior therapy (DBT) has a positive effect. Although various psychotherapies, either alone or integrated, are preferred modes of treatment for this group of patients, the effects of psychotherapies on BPD outcomes are small to medium. Proper risk management along with developing a positive attitude and empathy toward these patients will help them in normalizing in an emergency setting after which treatment course can be decided.


MethoDology
Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology (1), a search for relevant published literature was done using PubMed. The key words and phrases used together with Boolean operators included: "borderline personality disorder in emergency department" (Mesh), "borderline personality disorder pharmacotherapy and psychotherapy" (Mesh), "dialectical behavior therapy, cognitive behavioral therapy in borderline personality disorder" (Mesh), borderline personality disorder and cluster B personality disorders (Mesh), "borderline personality disorder and impulsivity, aggression, suicidality" (Mesh). Other relevant studies were found by a review of the primary studies obtained in the search as well as reference tracing of selected articles.
The inclusion and exclusion criteria were: • Any articles that reported the patient of borderline personality disorder (BPD), crisis intervention in the Emergency departments (EDs) and beyond in terms of acute and long-term treatment plan. • Eligible studies were included if they were observational or interventional in which pharmacotherapy or psychotherapy were investigated as immediate or follow-up treatment. The above-outlined search strategy allowed for the retrieval a total of 396 articles following the removal of duplicates from various sources. The identified results were then reviewed by two independent researchers. From the 396 articles obtained, only 71 studies were relevant to the topic of review. Article relevance was found after looking at the title of the article and reading their abstracts. After a full-text review, 56 of the 71 relevant articles were found and used to extract qualitative data and summarize the findings from this literature review (Tables 1 and 2).

intRoDUCtion
The Diagnostic and Statistics Manual for Mental Disorders, fifth edition (2) classifies borderline line personality disorder (BPD) as a cluster B personality disorder and describes it as "a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity that begins by early adulthood and is present in a variety of contexts" (2). The Genesis of BPD is multifactorial, the biological inheritance, psychological, and social factors are the three major reasons for the development of BPD (3)(4)(5)(6)(7). Race, gender, and being socially disadvantageous influence the development of BPD (6)(7)(8)(9)(10)(11)(12)(13)(14). Functional impairment is the prime concern associated with the disease (15). BPD was once considered as an untreatable disease; however, the study by Gunderson and colleagues reported a remission rate of about 45% in 2 years and 85% in 10 years, indicating that correct diagnosis, proper, and timely management can allow the patient to live a normal life (15,16).
Borderline personality disorder is a frequent psychiatric condition encountered in both the hospital and in psychiatric emergencies (17). Approximately 9-27% of agitated emergency patients are diagnosed with the borderline disorder (3,18,19). Predominantly, BPD patients visit an ED in the state of crisis, which includes immediate episodes of self-harm, suicidal attempt, aggressiveness, impulsivity, intense anxiety, short-term hallucinations, and delusions (17,20). Such crises are usually short-lived, but severe in nature, and the intensity varies from person to person. Once the patient has reached the ED, the crisis state is either in the continuation or has subsided keeping the patient in a phase of strong emotional stress, which makes them non-cooperative. With such a heightened stress and difficult situation in the ED, identifying the disease, managing the patient, and defining the course of treatment becomes challenging not only for the attending psychiatrist but also for the accompanying staff. We review the difficulties faced by ED staff including physicians when diagnosing these patients, implementing a treatment regimen.

DiagnoStiC DiFFiCUlty
Accurate diagnosis of the disease is necessary for deciding the future treatment regimen. A patient qualifies as BPD if he or she meets the five criteria out of the nine mentioned in DSM-5 (2). These criteria are: (1) frantic efforts to avoid abandonment;    (2) a history of unstable and intense relationships with others; (3) identity disturbance; (4) impulsivity in at least two functional areas such as spending, sex, substance use, eating, or driving; (5) recurrent suicidal threats or behaviors as well as selfmutilation; (6) affective instability with marked reactivity of mood; (7) chronic feelings of emptiness; (8) inappropriate and intense anger or difficulty controlling anger; and (9) transient stress induced paranoid ideation or severe dissociative symptoms. This allows for significant variations in symptoms presentation from one BPD patient to another. Moreover, with overlapping clinical features with bipolar disease, pinpointing BPD becomes even more difficult (12). Although presenting symptoms of both the diseases are similar, their treatment course is completely different (21). The situation is further worsened when the patient in crisis displays a disruptive behavior and is non-cooperative. Thus, physicians are confronted with diagnostic dilemma and frustration. In such a situation, the crisis should be managed to make the patient more cooperative which, in turn, will aid an accurate identification of the disease and deciding the treatment course.

CRiSiS inteRvention in the eDs anD BeyonD
In a recent Cochrane review, Borschmann et al. defined crisis intervention as "an immediate response by one or more individuals to the acute distress experienced by another individual, which is designed to ensure safety and recovery and lasts not longer than 1 month" (22). Indeed, the priority of the ED physician who encounters a patient with BPD is to address any acute symptoms of distress and to calm the patient. However, the procedure for such crisis intervention is subjective.
In severely agitated patients, calming down them should be the prime focus. Managing agitation can be achieved by different methods such as administering non-specific sedating medication (benzodiazepines and/or antipsychotics), behavioral management, and psychological techniques such as de-escalation or physical restraint (23). Conventionally, benzodiazepines and antipsychotics are administered to control the agitated BPD patients. However, benzodiazepines use may lead to several side effects along with the strong sedation, hypotension, include respiratory depression, while typical antipsychotics cause dysphoria, acute dystonia, and akathisia. Recently, a few studies have reported that atypical antipsychotics such as Olanzapine, Ziprasidone, and Loxapine are more effective for treating acute crisis in BPD patients presenting to the ED (24)(25)(26)(27)(28)(29). Intramuscular administration of single dose of olanzapine resulted in fast reduction of agitation in BPD patients and was tolerated well, with only 16% of patients requiring a second dose (25). Roncero and colleagues have shown the effectiveness of lopaxine in managing agitation in the emergency. In their study, inhalation of a single dose of lopaxine (9.1 mg) was enough to calm the acutely agitated patients (29). Prescribing mood stabilizers for managing agitation in BPD patients is highly discouraged by many studies (27,30). In a report by Clivaz et al., administration of mood stabilizer topiramate augmented the incidences of panic attacks, thus worsening the situation (27). The authors recommended usage of atypical antipsychotics for managing the agitation in BPD patients (27).
In addition to agitation, the patient with BPD may present with a wide array of symptoms that indicate affective dysregulation. Such symptoms may include intense anger, mood liability, intense, depressive moods (31,32). Administering high doses of antidepressant such as fluoxetine, a selective serotonin reuptake Frontiers in Psychiatry | www.frontiersin.org August 2017 | Volume 8 | Article 136 Challenges of Borderline Personality Disorder inhibitor is recommended. However, if it fails, then antidepressants targeting multiple neurotransmitters such as venlafaxine or monoamine oxidase inhibitors should be given. Additionally, BPD patients may also present with the elevated level of anxiety, administration of Clonazepam has shown to be effective in reducing anxiety (31,32). However, Alprazolam, a drug belonging to the same class as clonazepam, has been reported to aggravate a hostile response.
In patients whose crisis state has subsided by arrival to the ED but who are experiencing severe emotional stress, such as suicidal attempters, psychotherapy is the preferred treatment option (32,33). In this situation, psychotherapy should be relatively intense for short duration and discontinued before dependence on the therapist develops. Intensive DBT consisting of individual therapy sessions with an emphasis on skills training provided in groups, mindfulness skills, and team consultation for 3 weeks, have been shown to be effective for patients with BPD in crisis, especially with suicidal attempts or gestures (34,35). Many studies nowadays suggest that after the crisis intervention, these patients should be continued on other form of psychotherapy such as; schematherapy (ST) and mentalization-based treatment (MBT). Because of the effectiveness and validation of MTB by numerous clinical studies, at present, it is widely suggested and included in treatment guidelines of BPD. Moreover, studies have found that intensive outpatient MBT effects are superior to conventional treatment (36,37). Similarly, ST is a psychotherapy model integrating cognitive, experiential, and behavioral interventions together, which is remarkably effective in decreasing severe symptoms of BPD (38).

RiSK ManageMent
Patients with BPD often present with any number of behaviors that are considered disruptive, such as self-harming injuries, violent behavior, impulsivity, or suicide. Such behavioral tendencies put the patient at significant risk to themselves and others if left unmanaged. Thus, the treatment of a patient with BPD should keep risk management in mind, especially as the patient nears the time of discharge. Efficient risk management in emergency settings is required for patients with BPD who exhibit self-injury, violent behavior, suicide, and impulsivity, all of which are considered displays of disruptive behavior (32). To achieve this understanding of the patient's problem is of prime importance. However, patients and clinicians often have different opinions about the patient's problem, in an emergency setting, due to the stress and chaos therein (39). Therefore, proper communication is necessary. Boggild et al. and Theinhaus et al. studied the factors responsible for disruptive behaviors in BPD patients. Both the groups found that patients with disruptive behaviors were significantly less likely to report the presence of primary support network, i.e., family members and had more work-related issues than a patient without disruptive behavior (39,40). In this condition, developing a good rapport by proper communication and discussing their problems and finding alternative solutions should be the attitude of an attending clinicians, social workers, or nurses. Moreover, partial hospitalization has shown to be effective in managing crisis in BPD (41,42). Nonetheless, the presence of general medical conditions as infectious diseases, psychosocial, and environmental problems such as housing problems, or chronic suicidal ideations are also associated with disruptive behaviors during hospitalization (39). Therefore, addressing the underlying causes of the patient's disturbance should be approached as plainly such as treating a patient's infectious disease: understand and address the reason for the suicide attempt and addressing them or finding a solution for temporary stay after discharging from the hospital, which provide comfort to the patients and helping to reduce their disruptive behavior.

aPPRoaCh towaRD BPD PatientS
Numerous studies have opined that clinicians and medical staff project a negative attitude for patients with BPD, more so for patients with self-damage or suicidal attitude (43)(44)(45). The main reasons for negative attitude include the stigma toward BPD, patients are considered as manipulative, lack of optimism for recovery, work pressure, poor communication skills, and time restraints (43,46). Among the clinicians in psychiatric department, nurses exhibited negative approach as well as least compassion and hope for the recovery of these patients followed by psychiatrist and psychologist (44,45,47). Social workers showed the highest concern, compassion, and treatment optimism for BPD patients. Moreover, general hospital staff display a more adverse attitude toward BPD patients than the employees of psychiatric department (45).
The negative attitude toward BPD patient in crisis makes them more volatile, non-complaint, which makes the diagnosis and treatment difficult leading to problematic outcomes like unnecessary hospitalizations, improper safety assessments, unneeded use of medications, extreme use of physical restraints, and, ultimately, increased liability (44,45,47). Imparting proper education through training and workshops separately to different categories of employers in the ED and the general hospital has shown to be effective in building a positive attitude, compassion, and patience toward BPD patients (46,48,49). In the crisis, a BPD patient not only comes in contact with emergency medical staff but also with ambulatory staffs as they require ambulance service to arrive emergency (50). Therefore, training of ambulance staff is also required. Treolar et al. (51) assessed the effectiveness of cognitive behavioral treatment and psychoanalytics in changing the attitude toward BPD with self-harm attitude (46). Both treatments showed remarkable improvements in the attitude of clinicians and medical staffs and the effect of psychonalytics was long lasting.
Considering the above studies, applying psychonalytics to different categories of hospital employers starting from ambulance staff to psychiatric and general emergency staff and clinicians for educating them about BPD should be carried out for better management and recovery in these patients. Challenges of Borderline Personality Disorder be to decrease the severity in symptoms such as self-damage, suicidal attempts/gesture, impulsivity, aggressiveness, substance abuse, etc., which in turn will reduce the number of visits to the ED. The treatment for BPD usually lasts for months or years. Psychotherapy along with pharmacotherapy is the usual mode of treatment for BPD (32,52,53). Cognitive behavioral therapy (CBT) and dialectical behavior therapy (DBT) are two most extensively studied forms of psychotherapy in BPD patients. When considering treatment options, physicians should be aware that CBT is an effective and affordable addition to existing care. Davidson et al. assessed the effectiveness of addition of CBT to treatment-as-usual for 1-2 years and reported that adding CBT has only small effect as the number of hospitalization and emergency visits were comparable between both the groups (54). The same group also assessed the long-term effect of the CBT (2-6 years) over treatment-as-usual (55). They observed a decreased in a number of suicidal attempts only. Nevertheless, measures of depression, anxiety, general psychopathology, social functioning, quality of life, dysfunctional attitudes, emergency visits, and mean length of hospitalization were comparable between both the groups. The same group had also utilized a variation of CBT, manual assisted CBT, for treating BPD and concluded that it was unable to reduce the number of attempts for self-damage BPD and was not costeffective (56).
Linehan et al. conducted an RCT wherein they subjected the BPD with suicidal attempts to DBT for 2 years and observed that it was efficient in reducing the suicide attempt, length of hospitalization for suicide ideation, lowered the medical risk, and decreased psychiatric ED visits (57). Similarly, in adolescents, application of DBT for 52 weeks showed a robust long-term decrease in incidences of self-damage and a fast recovery in suicidal ideation, depression, and borderline symptoms (58,59). Application of Combined Individual and Group DBT, a variation of DBT, for 12 and 18 months, was found to be equivalent to DBT in reducing the number of suicide attempts, suicidal behavior, and number of emergency visits (60).
Mentalization-based therapy has become a promising psychodynamic approach and added into guidelines for the treatment BPD patients. Mentalizing is related to the capability of interpreting self and others in the form of emotions, feelings, desires, and values. Studies suggest that mentalization impairments are associated with BPD (41). MBT effectively reduces depressive symptoms, suicidal attempts, and self-harm, which also include increasing social functioning in BPD patients (61). As we described earlier in introduction, ST offers an effective help, shows a significant improvement of core symptoms of personality disorder. Reiss et al. summarized the results of three pilot studies investigating the effect of intensive inpatient ST program delivered in individual or group format. Results showed that inpatient ST can significantly reduce symptoms of severe BPD (38). Similarly, other studies have found a large treatment effect in reduction in severity of BPD, impulsivity, affective instability, and general psychopathology (62,63).
Lana et al. adopted an integrated approach to treat severe BPD patients, which uses multiple psychotherapies in one treatment session (64). It included skill training group based on DBT; relationship therapy supported by MBT; stress management group; and psychoeducational group; individual therapy once a week, support by psychodynamic psychotherapy or DBT depending on the clinician's approach; medication review; nursing consultation; and telephone consultation for 6 months. Patients with integrated treatment had a lower number of visits to ED and decreased the length of hospitalization during the treatment duration as well as beyond it indicating in efficiency in treating BPD.
A recent systematic review analyzed the competency of psychotherapies in scaling down the suicidal attempts and non-suicidal self-injury (NSSI) in borderline patients (65). It concluded that psychotherapy seems to be an effective treatment for suicidal attempts only. For NSSI cases, MBT was a better means of management. This raises a question of the applicability of psychotherapy in BPD patients with other severity symptoms. Hence, a better means of treatment with the broad application is needed. In recent years, functional neuroimaging research describes BPD patients with the dysfunctional frontolimbic network (66). Further, severe BPD patients have impairment in decision-making functionality (67). In view of the above findings, Cailhol et al. evaluated the advantages of intermittent application of high-frequency transcranial magnetic stimulation (TMS) application on the right cerebral cortex in treating BPD (68).
Transcranial magnetic stimulation remarkably reduced the anger and affective instability in BPD patients after 3 months indicating as a promising technique for managing and treating BPD. As this technique is safe with no side effects and is applied intermittently, its application in acute crisis interventions should also be examined.

ConClUSion
Borderline personality disorder patients in crisis are frequent visitors of EDs. Due to lack of knowledge on BPD and social stigma, emergency clinicians and staff develop a negative approach for these patients, which in turn have a negative impact on their treatment outcome. Clinicians and medical staffs should be properly educated about this disorder, which will aid in getting into a comfortable zone with these patients, develop compassion for them and ways for managing the crisis. There is lack of RCTs investigating the efficacy of crisis interventions for people with BPD. Although psychotherapies show a positive effect on reducing BPD-related symptoms, the effect is small. Therefore, we recommend conducting prospective high-quality clinical trials with balanced control groups. These trials should measure a wider range of primary and secondary outcomes of the treatment investigated. All this together will help the patient to get back to the pre-crisis phase and make them more receptive to the actual treatment process.
aUthoR ContRiBUtionS SA has provided this idea to write about this important topic, supervised this manuscript, edited its grammar, and added references, written conclusion. US has helped to write manuscript, especially the introduction section. IQ has helped tremendously in this paper, she has worked hard to write two important section of papers including literature search and assisting in finding hand-pick papers from the library. FJ has helped to write a section of crisis intervention, her clinical experience was utilized to finalized that section. SS has helped us to add all studies provided in the table. She also corrected grammar and syntax of the language. YO helped to fix reference, discussion section.