Introduction: Borderline crisis is a common behavioral health presentation in the emergency department (ED)1. At times, hospitalization is counterproductive for patients with borderline personality disorder (BPD) presenting to the ED2. Psychiatrists in the ED must explore alternative safe dispositions by allying with outpatient support and community resources. Case Description: We present a case series of three patients with BPD presenting with borderline crisis in which the emergency psychiatry team coordinated with their outpatient support for a safe and timely disposition. Patient one is a 27-year-old non-binary adult who presented to the ED after a suicide attempt via cutting following an argument with their partner. In the ED, they demonstrated emotional volatility, behavioral dyscontrol and agitation. Despite initial behavioral dyscontrol and volatility, resolution of symptoms was seen upon connecting patient with their significant other. A safety plan was developed by contacting the outpatient provider and arranging close follow-up. Patient two is a 42-year-old female who presented after the crisis line called EMS due to suicidal ideation with plan of cutting and earlier non-suicidal self-injury via cutting. Destabilization occurred in the context of disappointment regarding scheduling mental health appointments. Although initially presenting in crisis, she was able to safety plan with her roommate. They agreed to connect with her social worker and psychiatrist for follow-up care. Patient three is a 25-year-old female living at a chemical dependence treatment center, who presented with passive suicidal ideation increased from chronic baseline suicidal ideation over frustration towards the treatment center’s restrictions. Her initial crisis resolved while she was in the ED, and she desired to return to treatment. Psychiatry was able to work with staff at her treatment facility who were actively involved in safety planning. Since psychiatry was able to partner with her treatment facility in facilitating a safe plan home, she was able to continue her chemical dependency treatment. Discussion: This case series highlights the need for emergency psychiatry to form an alliance with a patient’s community mental health support. In each case, the patient’s crisis began with mood dysregulation then progressed rapidly due to maladaptive coping. Hospitalization was not indicated in these cases. Inappropriate use of hospitalization for borderline crisis is not only inferior to other treatment options but can also reinforce maladaptive behavior3. In the ED, we halted the cycle of borderline crisis. Without involving outpatient support, patients would have inappropriately lengthened the disruptive cycle and stayed in the ED for longer periods of time. There are many iatrogenic consequences of having a patient with BPD in the ED including reinforcing inadequate solutions for short-term crisis, overreliance on medications as a fleeting solution, and exposure to countertransference1. In each case, we engaged the patient’s outpatient team to expedite a safe discharge from the ED and avoid further exposure to the iatrogenic harm that patients with BPD can face in the ED. Community mental health care is essential for allowing patients with BPD return to the community after borderline crisis.
Learning Objectives
Find ways to ally with community mental health resources from the ED.
Understand disposition options other than psychiatric hospitalization or ED boarding for patients presenting in borderline crisis.
Learn practical advice for partnering with community mental health supports as an emergency psychiatrist.
