Question 4

You are an intern working in an accident and emergency department. A 25 year-old woman, Kim,
is brought in by her boyfriend. Relevant information that you obtain from Kim includes:
 That she has had an “overdose” of 5 paracetamol tablets – total dose 2.5 g. She also
superficially cut her wrist five times with a kitchen knife. She states these were an effort
to both hurt and kill herself.
 She has been cutting her thighs, abdomen, and wrists since early puberty.
Before seeing Kim, you reviewed her emergency department file and note that she has had six
similar presentations to the accident and emergency department this year. She has been
reviewed by the Psychiatry team at each presentation, but the psychiatry notes are not available
to you.
 Kim is sitting in a hospital gown with her wrist bandaged; she appears calm and in good
spirits.
 Nursing staff are clearly ignoring this young woman.
Your tasks are to:
 Obtain further information helpful to making a risk assessment about the patient from the
examiner.
 Present the likely diagnosis, risk assessment and an initial management plan to the
examiner.

Provisional: Borderline personality disorder

Differential dx:
 Drug induced: Stimulant overdose or depressant withdrawal
 Organic causes: Delirium, Infection, Space occupying lesion, head trauma, electrolyte
abnormalities, hyperthyroidism
 Psychiatric causes
o Other personalities disorders
 Cluster B: Narcissistic, Histrionic, Antisocial personality disorders
o Psychotic disorder
 Schizophrenia
 Schizoaffective disorder
 Schizophreniform
 Drug induced psychosis
o Mood disorder:
 Bipolar affective disorder
 MDD with suicidal ideation

Approach:
 Ensure safety of self and staff. Verbal de-escalation or security if needed.
 Psychiatric history, MSE, risk assessment, physical examination with an open and non-
judgmental approach.
 Chaperone should be present during patient assessment.
 Confirm provisional diagnosis (collateral history, investigations to rule out organic causes)
 Management according to Biopsychosocial framework.
Clinical history (from patient and collateral from boyfriend)
 Patient details – age, what they do, where they live, partners and children
 Current suicidal attempt
o Details surrounding this; suicidal intent
o Medical issues:
 When ingested paracetamol tablets
 How many tablets
 Any other substances used during this overdose attempt
o History of suicide and self harm
 Risk assessment
o At risk mental state?
 Depresion, hopelessness, despair, feelings of worthlessness
 Severe anger, hostility
 Presence of psychotic symptoms (auditory hallucinations about death;
delusions of jealousy, and paranoia)
o Suicidal attempt
 Clear intention of high lethality
 Access to means and firearms (mandatory reporting
 Risk to self (financial, reputational, sexual and physical)
 Risk to others and children (mandatory reporting)
o Substance disorder
 Current misuse of alcohol and other drugs
o Collateral history from family, carers, and medical records
 Able to confirm patient’s story
 Reliability of patient’s account of events
o Strengths, supports, coping methods and connectedness
 Expressed communication
 Availability of support
 Willingness to get professional help
o Reliability, confidence and changeability of risk assessment and level
 DSM-5 criteria for BPD
o Pervasive pattern of impulsivity and unstable relationships, affects, self-image and
behaviour
o Features present by early adulthood and in multiple contexts
o At least 5 of the following (IMPULSIVE)
 Impulse: Impulsivity in at least two potentially harmful ways (spending,
sexual activity, substance use, binge eating etc)
 Moody: Unstable mood/affect
 Paranoid under stress: Transient, stress-related paranoid ideation or
dissociative symptoms
 Unstable self-image
 Labile intense interpersonal relationships
 Suicidal: Recurrent suicidal threats or attempts of self-mutilations
 Inappropriate anger: Difficulty controlling anger
 Vulnerable to abandonment: Frantic efforts to avoid real or imagined
abandonment
 Emptiness: Chronic feelings of emptiness
 Other features of BPD
o Splitting
 Tend to see the world in polarized, over-simplified, all or nothing terms
o Using self-harm as a method of help seeking (getting into hospital), attention from
others (be good or bad), or relieves pain (from overwhelming thoughts)
 Severity
o Significant distress or impairment in social, occupational or other important areas of
functioning
 Screen with McLean Screening Instrument for BPD (10 items) – self-reported measure
 Screen for co-morbid psychiatric symptoms
o Psychotic:
 Hallucinations (visual and auditory)
 Delusions (persecution, reference, passivity, broadcast)
o Mood:
 MDD: SIGECAPS
 Any previous episodes of Mania (DIGFAST > 1 week)
o Other Cluster B personality disorders

 Past psychiatric history

o Previous hospitalisations
o Previous treatments
o What happened then and why have things happened now
 Drug and alcohol history
o Smoking, alcohol, stimulants (cocaine, methamphetamines), opioids,
benzodiazepines, prescription medications
o Quantify how much and often
o Last use
 Past medical history, medications and allergies
 Family history of mental illness
 Developmental history
o Development as a child – trait anxiety/temperament
o Unstable parenting/single parent
 o Abuse/domestic violence or any other trauma
 Psychosocial
o Work, home life, finances, psychosocial stressors
o Document past relationships, coping mechanisms, past history of trauma
o Personality disorders often arise in the context of significant physical or psychosocial
trauma
 Collaborative history from paramedics, family, partner, GP

Examination
 Mental state examination (MSE) + physical examination (wound + excluding organic causes)
 Mental state examination
o Appearance – evidence of self-neglect and self-mutilating behaviour
o Behaviour – Eye contact, cooperative, psychomotor agitation or retardation
o Speech – Tone, rate, volume; might have outburst of anger
o Mood
o Affect – Labile; dysphoric, irritable, anxious
o Intact thought form
o Thought content: suicidal ideation, feelings of emptiness, paranoid ideation,
dissociative symptoms
o Insight: Limited or poor
o Intact judgement and cognition
 Physical examination
o Vitals: Hemodynamically stable given wrist cutting
o Constitutional symptoms for infections and malignancies
o Signs of hyperthyroidism and goitre
o Signs of overdose and drug intoxication

Investigation
 Diagnosis of BPD is mostly clinical; through multiple sychiatric interviews and mental state
examinations; other investigations are not necessary
 Other investigations to be performed:
o Bedside
 Urine drug screen
 ECG
o Laboratory
 Paracetamol levels
 Blood alcohol level
 FBC, TFT, EUC, glucose (if clinically indicated)
Management
 Ongoing risk assessment and management
 Consider voluntary vs involuntary treatment, hospital admission
o Safety in acute crisis – no weapons, risks, may require isolation
o Aiming for least restrictive and most effective care
o Indications for hospitalization (under Mental Health Act)
 Suicidal intent and lack of adequate safeguard
 Unable to take care of self
 Intent to harm others (e.g. partner)
 Psychotic symptoms
 MDT setting involving psychiatrist, medical team, psychologist, SW, GP
 Biopsychosocial approach
o Biological intervention
 Tetanus shot if unknown vaccination status
 Pharmacotherapy does not alter the nature or course of the disease
 Adjunct pharmacological therapies in acute setting, mainly for symptomatic
control:
 For affective dysregulation/aggression/interpersonal problems –
mood stabilizer or antipsychotic
 For co-occuring MDD, PTSD, anxiety – antidepressant (SSRI)
 Beware of risk of medicinal overdose
o Psychological intervention (mainstay of therapy)
 Dialectical behavioural therapy: Weekly, individual psychotherapy and
group skills training
 Like CBT but also teaches distraction techniques (positive coping
skills, resilience e.g. holding ice in hand or having an elastic band
around wrist to flick rather than cutting)
 Targeting patients between 15-25 years of age
 Program consists of 4 components:
o Interpersonal response patterns
o Emotional regulation
o Distress tolerance
o Mindfulness
 Aim to teach skills to cope with sudden, intense surges of emotion.
 Characteristics:
o Support-oriented
 Identify strengths + build on these; so person can
feel better about him/herself + their life
o Cognitive-based
 Identify thoughts, beliefs and assumptions that
make life harder
 E.g. I have to be perfect at everything, If I
get angry, I’m a terrible person, etc.
 + Helps people learn different ways of thinking that
will make life more bearable
 E.g. I don’t have to be perfect at things for
people to care about me; Everyone gets
angry, it’s a normal emotion, etc.
o Collaborative
 Requires constant attention to relationships
between clients and staff
 Encouraged to work out problems in their
relationships with their therapist
 Asks people to complete homework assignments,
role-play new ways of interacting with others,
practice skills such as soothing yourself when upset
  Crucial part of DBT; taught in weekly lectures,
reviewed in weekly homework groups and referred
to in nearly every group
  Individual therapist helps the person to learn, apply
and master the DBT skills

 Mentalisation-based therapy
 Focuses on patient’s understanding of their own intentions and
those of others.
 Aims to make the patient more in tune with their thoughts in order
to understand the impact of these thoughts on themselves and on
others.
 It is good for identifying maladaptive or inappropriate emotions
which can then be altered to facilitate better and closer
relationships.
 Interpersonal therapy
 Developing personal skills to help patient engage/interact with their
loved ones.
 Four key areas:
o Grief
o Interpersonal disputes
o Role transitions (developing coping strategies to deal with
change e.g. job loss, relationship changes).
o Interpersonal sensitivity (identifying areas that one can work
on to help build and maintain relationships).
o Social interventions
 Family therapy and educate family members on BPD
 Develop acute crisis plan involving family, partner, and carers with patient’s
consent
 First aid course for carers