Katharine J. Nelson

Managing Borderline Personality Disorder on General Psychiatric Units

Patients with Borderline Personality Disorder (BPD) are at high risk of suicide and are frequently hospitalized in the acute setting of emotional crisis, non-suicidal self-injury, and suicidal behaviors. Historically, patients with BPD have borne tremendous stigma and have tended to overwhelm providers and care systems. The reconceptualization of the pathophysiology and development of BPD in the context of a rapidly changing health care environment warrants examination of relevant psychotherapeutic and treatment principles. Through a case discussion, this article highlights several factors relevant to acute inpatient hospitalization of patients with BPD in an academic training environment in an effort to identify both the challenges and helpful treatment philosophies and practices to advance patient care and promote recovery.

A 44-Year-Old Woman with Intrusive Thoughts

A 44-year-old unmarried woman with a diagnosis of schizoaffective disorder, post-traumatic stress disorder, and more than 20 previous hospitalizations presented to the emergency department with a complaint of “losing it.” She reported 2 weeks of progressively worsening “voices.” On further questioning, the patient described these voices as her own thoughts intrusively indicating the occurrence of terrible circumstances (loss of her house and the ending of the relationship with her boyfriend). She had insight into the fact that these events were not actually occurring, but she could only briefly reassure herself before these thoughts would again interject and lead to significant worry and distress. She had no previous history of auditory hallucinations. She presented to the behavioral emergency center; inpatient admission was recommended due to the significant impact these symptoms were having on her functioning. Although she was not behaving in a disorganized manner, her distress was so intense she was not able to care for herself. Due to residual symptoms, 1 month before admission, her outpatient psychiatrist had increased her clozapine dose from 125 mg to 150 mg. Clozapine was noted as the most effective therapeutic intervention in the treatment of her symptoms compared with treatment with other neuroleptics. Her previous antipsychotic medication trials included: ziprasidone; paliperidone; risperidone; quetiapine; and aripiprazole. She had not been hospitalized for 2 years prior to this admission, despite many prior frequent hospitalizations. At the time of admission, she had been on clozapine for 30 months. She was also taking lisinopril, levothyroxine, insulin, hydroxyzine, and metformin. The patient described a history of schizoaffective disorder starting at age 19 years during her freshman year of college. In addition to a history of multiple hospital admissions, she reported difficulty functioning effectively in the occupational setting, having received Social Security Disability Insurance for 22 years. However, she reported being an active volunteer at a nursing home within walking distance of the townhouse shared with her boyfriend and owned by her mother. During the hospitalization, she continued to report symptoms of intrusive, egodystonic thoughts. She described these thoughts as “uncontrollable,” as if her “head was in overdrive.” Her thoughts centered on fears that her boyfriend was going to end their relationship, and the hospital was going to take away her townhouse. She acknowledged these events were not realitybased, but continued to perseverate on these worries. To relieve her anxiety, she would repeat aloud or in writing that these circumstances “were not true.” She would also call her mother many times a day for reassurance, or ask staff to confirm that these negative events were not going to happen. A 44-Year-Old Woman with Intrusive Thoughts

Schizophrenia and Psychotic Spectrum Disorders

Although it has been known for several decades that genetic factors play a major role in the etiology of schizophrenia, it has been only recently that the field has had the tools to probe the genetic architecture of the syndrome. As these tools have been applied to increasingly large samples of cases and controls to reveal DNA variations that occur more frequently among those with schizophrenia, one overriding conclusion has been reached: there is a humbling degree of complexity in the genetic foundations of schizophrenia. Risk for the disorder is now understood to be conferred by thousands of common single nucleotide variants, each of very small effect, as well as by thousands of larger mutations, each quite rare and of putatively larger effect (Purcell et al., 2014; Schizophrenia Working Group of the Psychiatric Genomics, 2014). This degree of genetic complexity is perhaps not surprising in view of the substantial heterogeneity in symptomology, course, treatment response, and other Publisher: Oxford University Press Print Publication Date: Apr 2016 Print ISBN-13: 9780199378067 Published online: May 2016 DOI: 10.1093/med/ 9780199378067.001.0001

A 31-Year-Old Female with Suicidal Intent

31-year-old woman with a previous diagnosis of major depression and no previous suicide attempts or hospitalizations presented to her primary care clinic and reported planning on either jumping off a bridge or going to work and shooting herself in the head with her handgun. She was immediately referred to the Behavioral Emergency Center and recommended for inpatient admission. She worked as an imaging technician at a large hospital. She had no outpatient psychiatrist, but had been prescribed citalopram 40 mg by her primary care provider for treatment of mood symptoms, in addition to an oral contraceptive, asthma, and allergy medications. She described a history of mood problems starting at an early age related to a history of physical and emotional abuse perpetrated by her mother, and sexual abuse by her uncle. This abuse had been reported to the authorities and parental custody was re-assigned to the patient’s father. She reported that her long-term

A Psychiatry Resident’s Perspective of the “Virtual Preceptor” as an Electronic Medical Record Clinical Education Support Tool

To the Editor: Evolving standards and expectations for documentation activities and other applications of the electronic medical record (EMR) in clinical practice has opened new opportunities and new challenges. One of the challenges is the sense from clinicians that they are spendingmore time in front of the computer screen and less time directly interacting with their patients. Despite this, EMR use is accepted as inevitable and is now integrated into daily clinical practice. An opportunity in this new era, is the utilization of EMR “shortcuts” (pre-written and easily imported blocks of text), which have tremendous potential for increasing workflow productivity and mitigating provider burnout by increasing documentation efficiency. At the University of Minnesota Psychiatry Residency, we have developed the Mental Health EMR Tools (MHET) which is a large database of over 200 text-blocks that allows residents to easily access pre-vetted and curated information, available to them any time they are logged in to the EMR [1, 2]. This database is a continuously updated and refined body of information that is developed though a collaborative process between PGY3 and PGY4 residents, and clinic faculty supervisors. This resource is also shared with family medicine residents for use in their clinics. On an ongoing basis, residents are polled about needed edits and are provided learning opportunities to create new entries to the database. There is an annual “Virtual Preceptor Retreat” which is a half-day spent dedicated to reviewing the content of the database and updating the content to reflect changes in practice guidelines or standards of care. The database is directed by the lead faculty ambulatory supervisor at our program. An index allows for easy location of specific categories of information. Having this information readily available is useful during patient visits as well as in between visits and structured supervision. It is a place residents can look to guide them in clinical decision making without having to immediately ask an attending or turn to Google, promoting an appropriate balance of autonomy and supervision. This also allows for more efficient use of time, as there are many pre-populated instructional information sets that can be provided in patient instructions. There are currently seven categories of referenceable and/ or importable blocks of text:

The Development and Implementation of a Patient Continuity Conference in a Psychiatry Residency Program

ObjectiveA resident-led patient continuity case conference was initiated with the goals of improving communication among providers and increasing cohesion among residents.MethodsA monthly case conference focusing on patient continuity of care was held over the course of the academic year. Residents were surveyed for feedback about the role of the conference in both improving their competency in navigating transitions of care and building cohesion among residents.ResultsThe conference improved resident knowledge of care transitions and communication during transitions in care in addition to increasing comfort, cohesion, and exchange of knowledge between residents.ConclusionsImplementing a resident-led patient continuity case conference can improve resident competency during care transitions while improving cohesion among residents.

A 15-Year-Old Boy with Aggression and Paranoia

A 15-year-old boy with a history of epilepsy and two previous psychiatric hospitalizations presented to the emergency department by ambulance after his school psychologist expressed concern for the safety of his peers and family. He had been making threats toward his peers at school, saying that he would “blast their brains out,” and had told his school psychologist that he was going to kill his family in their sleep. In light of these threats, inpatient hospitalization was recommended. At age 11 years he was diagnosed as having epilepsy, with predominantly complex-partial seizures. After numerous trials of anticonvulsant medications, the patient seemed to have finally obtained seizure control with his current medication regimen of 1,500 mg/d of divalproex sodium, 250 mg/d of lamotrigine, and 900 mg/d of oxcarbazepine (as prescribed by his outpatient neurologist). His last documented seizure was 12 months prior to admission.

A 25-Year-Old Affirmed Male with Multiple Comorbid Conditions

der type 1, but had been “fi red” by his previous psychiatrist for missing too many appointments. He had most recently been prescribed lithium ER 1,200 mg, clonazepam 2 mg, ramelteon 8 mg, and long-acting formulation of carbamazepine 900 mg every night, as well as narcotic pain medication as needed to manage chronic pain. The patient had also been diagnosed with posttraumatic stress Both authors are with the University of Minnesota, Minneapolis, Department of Psychiatry. Katharine J. Nelson, MD, is Assistant Professor of Psychiatry; and Medical Director, Borderline Personality Disorder Program. S. Charles Schulz, MD, is Professor, Head, and Donald W. Hastings Endowed Chair. Address correspondence to: Katharine J. Nelson, MD, F282/2A West, 2450 Riverside Ave., Minneapolis, MN 55454. fax: 612-2739779; email: nels2286@umn.edu. Dr. Nelson has disclosed no relevant fi nancial relationships. Dr. Schulz has disclosed the following relevant fi nancial relationships: consulting fees, Eli Lilly; contracted research, AstraZeneca, Otsuka, and RBM. doi: 10.3928/00485713-20120124-04