The risk-management issues that each psychiatrist encounters when treating suicidal patients are amplified in those with borderline personality disorder (BPD) for a number of reasons, including high suicide rates, heightened risk of boundary violations, and pathological anger of patients and their families.
This was the message presented to the 200 psychiatrists who attended the seminar "Patients With Suicidal Behaviors: Risks and Risk Management Strategies" in New York City in June. The seminar was organized by Professional Risk Management Services, the company that manages the APA-endorsed liability insurance program.
She appeared with Richard Hersh, M.D., assistant director of the program and an assistant professor of psychiatry at Columbia.
Although only a small minority of psychiatric patients are diagnosed with BPD, "a significant amount of the anxiety we experience from a risk-management standpoint is about this patient population," Hersh said.
Since as a group, people with BPD are known as "high utilizers" of mental health services, including pharmacotherapy and psychotherapy, psychiatrists are very likely to encounter patients with the illness, he said.
The boundaries that psychiatrists set routinely with patients may be experienced as "cruelly depriving" by some patients with BPD, according to Sciutto, "and clinicians may be tempted to modify these boundaries in order to fend off the patient’s aggression."
Yet psychiatrists must be able to tolerate anger, hatred, and contempt from their patients as part of their role, Sciutto emphasized, and "must adhere tightly to boundaries in patients who have difficulty managing boundaries themselves."
She advised clinicians to seek a professional consultation if they find themselves engaging in activities that would be considered unusual within the confines of treatment. A commercial transaction between doctor and patient is one such example.
Hersh and Sciutto also addressed the issue of sexual misconduct by citing an excerpt from the Clinical Handbook of Psychiatry and the Law, by Paul Appelbaum, M.D., and Thomas G. Gutheil, M.D.
According to the handbook, in one survey, "borderline patients accounted for more than 90 percent of the litigation cases of true sexual misconduct and. . .99 percent of the false accusations of sexual misconduct."
The one instance where it is acceptable to cross boundaries, Sciutto said, is when the patient is a danger to himself or herself and the clinician must go against the patient’s wishes in order to get the family involved in keeping the patient safe.
At times, it is not unusual for patients with BPD to express an intense and "contagious" rage toward their treaters, according to Sciutto and Hersh.
"The rage a patient may have had for a clinician may spread to family members who survive the patient after he or she commits suicide," said Hersh, which can then lead to a lawsuit in which the psychiatrist is named as the defendant.
Psychiatrists should be aware of their own negative reactions toward the patient, the speakers said. "Your initial reaction may be to avoid the anger by distancing yourself from the patient," noted Sciutto. "Instead, you have to get even more involved and make sure you keep the patient and his or her family engaged."
Many patients with BPD are also likely to experience feelings of abandonment when their psychiatrist goes on vacation or terminates treatment. "You will feel as if you are letting them down," said Sciutto. She advised attendees to "clearly define your role and work with the patient to set up the discharge plan."
When discharging patients from one setting and referring them elsewhere for continuing care, Sciutto said, the responsibility falls to the psychiatrist and his or her team to ensure that patients make it to the follow-up appointment. "How long are we responsible for these patients? As long as it takes for them to get the proper care," she emphasized.
Sciutto and Hersh also coached attendees on the basics of suicide assessment, which apply not just to patients with BPD but to all patients in psychiatric treatment.
"It’s important to assess patients for suicide risk during every mental status exam and at critical junctures in the treatment process," said Sciutto, such as when a patient’s spouse leaves him or her, when medications change, or when there is a change in physical health.
In addition to assessing patients for chronic risk factors such as hopelessness or previous suicide attempts, clinicians should pay attention to the lesser-known risk factors associated with imminent suicide risk: global insomnia, psychic anxiety, agitation, and depressive turmoil, for example.
Some of these symptoms can be treated with anxiolytic drugs, but with caution, Hersh noted, since the medications can be addictive and may lead to behavioral disinihibition.
The speakers also advised psychiatrists to document specific details involved in the suicide assessment and all other aspects of psychiatric treatment. Vague phrases such as "patient is less suicidal" are never a good thing to write in progress notes, Sciutto said.
Indeed, the psychiatrist’s written progress notes are the only real proof of the care provided to the patient.
"You can conduct all the right interventions, but if you didn’t write it down, you didn’t do it," Sciutto said.
Information about PRMS is available on the Web at www.prms.com or by phone at (800) 245-3333. ▪