Online NewsLetter

New Treatment Strategies For Borderline Disorders

Ten years ago, patients with Borderline Personality Disorders were liberally hospitalized during suicidal crises, self mutilation or other pathologic behavior such as excessive drinking or drug use. These patients were kept on an inpatient service for weeks or months while staff grappled with mood shifts, impaired object relations and impulsivity.

These luxuries are no longer possible in an age of managed care. Sheppard Pratt has embarked on a treatment program which combines short-term inpatient stay with various forms of day care and residential placement. Significantly, all these interventions occur on one hospital campus, facilitating rapid transfers in times of acute stress. The move to a conjoint inpatient/outpatient care model has not been an easy one. It has required staff to be more flexible and perhaps take more chances in the service of reducing overall hospital costs. As such, staff have required more support as they have wrestled with keeping a potentially self-injuring patient in a conventional quarterway or halfway house with minimal security. The following case vignette, adapted from a previously published composite case report (1) illustrates some of the principles of treatment in an era of short-term hospital stays and a shift to outpatient maintenance.

A 36-year-old woman was transferred to Sheppard Pratt from another hospital. She had a history of many psychiatric inpatient stays, presented with mood lability, a history of dissociative episodes, binge alcohol use and self-injury by cutting and burning with cigarettes. As the patient is not acutely suicidal, stay on the Sheppard Pratt inpatient service is initially denied, but a physician reviewer called upon to assess the case agrees to a seven-day stay within the quarterway house built on the grounds of the hospital. There are no locked doors and the patient must abide by a contract for safety, agreeing to notify her case manager if she has difficulty in this regard; thus there are none of the privilege levels associated with a typical psychiatric unit. The patient moves in, but in short order burns herself in response to a phone call from her husband and is ultimately fully hospitalized for 48 hours. After giving notice, returning home and overdosing, she is again hospitalized. Transfer to the quarterway house is again contemplated, but staff are worried. A graduated transfer is arranged whereby the patient is allowed to visit the quarterway house each day while residing on the inpatient unit. Pharmacologic stabilization is attempted at the same time that the physicians involved in her care negotiate continued full and partial hospitalization with managed care providers.

A positive event now occurs. The patient befriends another patient who ultimately helps her resist an episode of self-mutilation as it comes time for discharge. Discharge is delayed for a week as attempts are made to have the patient attend AA, seek marital therapy with her husband and arrange for her own outpatient treatment. The patient does quite well at home but deteriorates after an argument with her spouse and is briefly hospitalized at the quarterway house. Initially resentful of this, she quickly perceives the experience as one of feeling at home. Next, plans are formulated for a supervised apartment program as an alternative to full discharge home. Options for both full and partial hospitalization are maintained with the recognition that the patient's illness is a volatile one.

The case remains incomplete and is presented to show the complexities of current treatment in today's medical marketplace. To treat a patient with this degree of illness requires a full set of resources in the community; in lieu of such resources, the "holding environment" (2) for care must still reside somewhere if the patient is to survive. At Sheppard Pratt, we have spread the "holding environment" over a greater area, utilizing partial care units or day care units which are in some geographic proximity to the main buildings of the hospital. Actually, the quarterway house, usually a "step-down" facility for inpatients, is increasingly being utilized as the first place certain patients come in lieu of full hospitalization which would other-wise be severely curtailed or even prohibited by managed care reviewers. Ten years ago, hospitalization covered only full inpatient stays. Now, in a reversal, partial hospitalization is more financially acceptable to insurers.

But the risks of partial care for disturbed individuals are significant. Limit setting and controls are less available in a quarterway or halfway house, and case managers carry great responsibility which is not shared by other staff. Instead, patients themselves come to serve as monitors for each other, something which can both foster a therapeutic milieu and detract from individual attention. Medical directors of partial care facilities must devote more time to the careful review of cases. Decisions to shift the patient from partial to full care, or the reverse, offer a fertile ground for the borderline personality disorder's tendency to split staff and is something which must be recognized. On the positive side, it becomes readily apparent to patients that they must take more responsibility for themselves in collaboration with the treatment team, rather than sinking into a regression and becoming dependent on the hospital. Such "shared" responsibility is not very different from the approach championed by Moses Sheppard, the founder of this hospital, who felt that in an environment of high expectations and humane treatment, a patient could rally in the direction of healthy functioning (3). Whether this all works in the long run remains unknown, but it is an adaptive start to the formidable constraints imposed by managed care in the treatment of these more chronic disorders.

Miles Quaytman, M.D.

REFERENCES

1. Quaytman M, Sharfstein SS: Treatment for severe borderline personality disorder in 1987 and 1997. Am J Psychiatry 1997;154: 1139-1144

2. Quaytman M: Developing a holding environment during the treatment of the borderline patient. Psychiatr Annals 1987; 17: 344-351

3. Forbush B: Moses Sheppard. Philadelphia, JB Lippincott, 1968



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Last modified: Tuesday, April 15, 2014

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