A 26-year-old woman who is a recurrent presenter to the ED, represents with multiple superficial wrist slashes. She appears very angry and voices suicidal ideation. She demands to be seen by the psychiatry team.
Which ONE of the following is the MOST appropriate approach for this patient’s management in the ED?
Answer: B: BPD is a common emergency psychiatric presentation and has a load of about 15–25% in psychiatric inpatients. In primary care situations the prevalence is four times higher than in general population. BPD is the most common personality disorder and many sufferers don’t seek treatment. Current evidence doesn’t suggest a higher prevalence among either sex. Patients with BPD usually present for treatment after deliberate self-injury or suicidal attempts. These result in at least one ED visit every 2 years on average.
For the diagnosis of BPD, at least five of the nine criteria in the DSM-IV must be met. Recurrent suicidal threats or acts and self-injury with a combination of strong preoccupation with expected rejection and abandonment are the strongest indicators. These patients feel they need to be connected to someone who they believe really cares. This preoccupation sets unrealistic expectations and the need for continuous validation by others. The unrealistic expectations and perceived rejections or abandonments by others lead to breakdown of positive relationships.
The patient at one time perceives themselves as a ‘good person who has been mistreated by others’ (therefore anger predominates during such times) and at other times perceives themselves as a ‘bad person with a life not worth living’ (therefore self-injurious or suicidal behaviour predominates during such times). The completed suicide rate in BPD patients is 8–10%. For young women, this rate is considered very high. The self-injurious behaviour (cutting or self-poisoning) is a way of coping through their perceived sense of despair and their inability to gain control of this perceived despair. However, front-line emergency medicine staff see this more as a wilful and manipulative behaviour than signs of an illness. In reality the majority of these patients are low functioning individuals due to their illness.
BPD is considered to be heritable and the rates are similar to those reported with hypertension. Treatment mainly consists of therapies other than medications. Psychotherapy is a main form of treatment along with dialectical behaviour therapy and mentalization therapy.
Reference:
Borderline personality disorder (BPD) can present with other comorbid psychiatric conditions. All of the following are common presentations to the ED EXCEPT:
Answer: D: BPD is a very common presentation to the ED, with a high level of time and resource requirements in its management. These patients often have comorbid illnesses and therefore may present to the ED in a variety of presentations. Although a BPD patient occasionally presents with a psychotic illness (such as paranoid schizophrenia) other presentations are more common. Most patients with BPD (84.5%) meet criteria for diagnoses such as mood disorders, anxiety disorders and substance misuse. PTSD may be a comorbid illness in these patients. With respect to comorbid mental disorders, there are differences between female and male patients, with disorders associated with substance misuse being more common in men and eating disorders more common in women.
A 22-year-old man with bizarre thoughts of ‘aliens trying to contact from Mars’ is brought in by police to the ED during the night. He has been shouting and being violent in his house, running in and out during the day. The worried neighbours had called the police as they had feared his aggressive behaviour would lead to dangerous behaviour. When he arrives at the ED he is very agitated, looking suspicious and distressed. He keeps shouting and trying to leave the ED, needing the police to physically restrain him. His behaviour is disturbing others around him. The nursing staff urge you to ‘do something before he wrecks the place’. Police want to leave because they have more calls to attend to.
Regarding this patient’s management, all of the following statements are correct EXCEPT:
Answer: D: Rapid tranquilization (neurolepting) is an important aspect of emergency psychiatry. It has to be used appropriately. As this treatment is given without the patient’s consent it has to be appropriately supported clinically at that time and needs to be followed up with patient consent later. Rapid tranquilization must be done in a non-punitive manner with established norms of preserving patient respect and dignity. A written ED guideline should be followed.
Managing agitated patients is complex. Although verbal interventions, with logic and rational explanations, should be attempted first to obtain the patient’s cooperation, often such interventions fail in severely agitated patients such as the patient described in this scenario. A confident show of strength with several staff members and security staff may settle patients at times. Some patients may agree to take oral medications. However, once the decision has been made to use rapid tranquilization, the initiation of such treatment has to be rapid so as to help prevent potential risks to the patient and the staff. Current options in sedation include both antipsychotics (droperidol, olanzapine) and anxiolytics (benzodiazepines). Both traditional and novel antipsychotics are useful. Rapidly dissolving oral formulations are available for some of the newer antipsychotics (olanzapine). They may be as effective as parenteral formulations if patient cooperation can be obtained.
A young woman of Asian origin who is a refugee from a conflict area presents repeatedly to the ED. She is without family and lives in shared accommodation. She often presents at night and often via ambulance with severe abdominal pain. She seems to be in genuine pain and but calms down when a Buscopan® injection is given and some support is offered by the nurses. All investigations done so far to exclude a physical problem have turned out to be negative. Once the pain settles down she walks to her accommodation, which is only a few metres from the hospital. She has presented 17 times over the past 6 months.
Which ONE of the following is the MOST likely diagnosis in this patient?
Answer: C: PTSD is a long-lasting anxiety response following a traumatic or catastrophic event. Patients with this condition have poor sleep, hypervigilance and severe anxiety at night, which often leads them to seek help during this time. Patients from certain cultures may present with somatic problems when they are psychologically distressed.
Important symptoms of PTSD include:
An important management principle when dealing with a patient with PTSD is to ensure the safety of the patient and to validate the symptoms. Detailed questioning should be avoided as it may trigger severe symptoms.
A 17-year-old girl is taken to the ED by worried parents. She has never been obese, but in the past six months she has become determined to reduce her weight. Her weight was 59.1 kg. With a height of 1.7 m, her body mass index (BMI) was 21. She has been extensively dieting and doing exercise. She had lost 14.3 kg and stopped menstruating four months ago. Her current BMI is 15. Her parents found her fainted in the bathroom, which led to her coming to the ED.
She denies having problems and is annoyed that her parents, friends, and teachers are concerned. In the ED assessment, which ONE of the following is LEAST important in determining disposition of this patient?
Answer: D: Anorexia nervosa is an eating disorder that usually begins in adolescence but can occur in adulthood. Two types have been described:
Features of anorexia nervosa include:
Medical complications that should be assessed in the ED include (these can be used as physiological indications for hospital admission):
Deaths secondary to medical complications mainly result from cardiac arrhythmias. Early interventions to restore weight can reduce the risk of arrhythmias.
Another very important complication in adolescents is loss of brain white and grey matter during severe weight loss. Although white matter restores with proper weight restoration, grey matter loss persists and results in permanent cognitive impairment. Death from suicide is higher than the general population in these patients and therefore assessment regarding suicidal risk is important where appropriate.
Treatment in anorexia nervosa is focused on prompt weight restoration while attending to medical complications and psychological issues. Better outcomes have been observed when patients are treated in specialized eating disorder units than in general medical units.
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