Affective and Personality
Disorders in the ED
Joann McIlwrick, MD, FRCPC, MSc
Clinical 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:



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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)
cluster B
(bad)
cluster C
(sad)
odd or eccentric group
dramatic, emotional,
erratic group
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
– instability of everything
 Histrionic - excessive emotionality and attentionseeking behavior.
 Borderline
 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-harm
2. Sequelae of reckless behaviour
Psychological
1.
2.
3.
4.
“Depression” (mood instability)
Suicidal ideation
Intense anger, agitation in the community
Stress-related “psychosis”
Social
1.
2.
3.
4.
5.
Therapist is unavailable
Caregiver is unavailable
Housing crisis
Financial crisis (day before AISH cheque)
Seeking admission
A pervasive pattern of instability of interpersonal relationships, selfimage, 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.
2.
3.
4.
5.
6.
7.
8.
9.
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
WHAT IS
THIS?
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
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 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.
 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 ED
1.
2.
3.
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
1.
2.
3.
4.
4.
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.
 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.
2.
3.
4.
Previous violence
Threats of violence
Psychiatric diagnoses, including PD
Intoxication
WHAT IS THE APPROACH TO
THE ASPD/NARCISSIST IN
THE ED?
1.
2.
3.
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
1.
2.
3.
4.
4.
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.

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 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:
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 ED
1.
2.
3.
4.
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.
“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, selfloathing; 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 depression
1.
2.
3.
4.
5.
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
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 agestratified 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
 Gp
needs:
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
Psychological
Social
1.
2.
3.
4.
1.
2.
3.
4.
1.
2.
Serious suicide attempt.
New onset mood disorder
Physical co-morbidities
Substance use co-morbidities
Psychotic features
Post-partum
Suicidality
Homicidality
No supports in the community
No gp for follow-up
HOW DOES MANIA PRESENT
TO THE ED?
DIG FAST:
Distractibility
Indiscretion (DSM-IV's "excessive involvement in
pleasurable activities")
Grandiosity
Flight of ideas
Activity increase
Sleep 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



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Reckless
Deterioration
Psychotic (grandiose)
Hypomania – admission not always needed
COMMENTS AND QUESTIONS