Management of Borderline Personality Disorder in an Obstetric Unit

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Providing care to individuals with borderline personality disorder (BPD) within inpatient medical settings can bring unique challenges for patients and medical teams. Individuals with BPD are more likely to have limited medical literacy, engage in challenging behavior and verbal altercations with their medical team, and be psychiatrically misdiagnosed.

They also often are considered high-risk patients in hospital settings due to the increased possibility of intentional or unintentional self-harm behaviors. These include overdoses, impulsive verbal arguments, unprotected sexual activity, poor medication and treatment adherence, nonsuicidal self-injurious behaviors, and suicide attempts.

These factors can be barriers for patients with BPD when they undergo admission, as medical units are less equipped to adequately address primarily psychiatric symptoms. This can then affect the care of other hospitalized patients as well as staff morale.

Consultation-liaison (C-L) psychiatry assumes the pivotal role in correctly discerning the presence of BPD, facilitating effective communication between patients and medical teams, and providing effective treatments as well as behavioral management during these patients’ admissions.

There are unique considerations during an obstetric hospitalization. Clinicians need to incorporate pregnancy and lactation safety data in their treatment recommendations and to be mindful of attachment and infant safety. 

BPD can impact parenting behaviors and influence infant attachment in mother-baby dyads where the mother is diagnosed with BPD.¹ Women with BPD are at elevated risk for comorbid psychiatric disorders, including mood and anxiety disorders, eating disorders, substance abuse histories, and trauma/stressor-related disorders.²

Navigating disposition planning can be a challenge, as postpartum patients are expected to be hospitalized for a brief time. This requires rapid evaluation and treatment planning to support a safe discharge home for mother and baby. For those requiring inpatient psychiatric admission, it may be challenging to find a unit willing to admit a pregnant or breastfeeding patient.

Case Example, Part 1

A woman aged 28 years with a self-reported history of bipolar I disorder is admitted to the antepartum obstetric unit at 32 weeks’ gestational age following a presentation to the emergency department for vaginal bleeding. The patient is initially admitted overnight with the expectation that she will be discharged after 24 hours of observation.

She has had limited prenatal care but has presented to the hospital multiple times during the pregnancy. She is a survivor of intimate partner violence involving the baby’s father. On the morning of her discharge, she tells the team that she is suicidal. The medical team places a consult to C-L psychiatry. 

During the initial evaluation, the patient reports low mood, emotional lability, and sleep maintenance insomnia. Her affect is labile during the interview. She has had 5 psychiatric hospitalizations beginning when she was 15 and reported that the most recent was the result of a “manic” episode when she 23.

Closer assessment of the reported symptoms is inconsistent with true mania (ie, although the patient has a history of goal-directed and risky behaviors, the reports were typical behaviors for her, did not occur in the setting of a mood disturbance, and did not represent a change in her baseline functioning).

She has never had a period of decreased need for sleep, excluding several incidents in her early 20s when she was using cocaine with friends. The patient clarified that the hospitalizations typically occurred in the setting of conflict with her parents, suicidal ideation, or a suicide attempt.

She has been prescribed several antidepressant medications since she was 13 but is not currently taking any out of concern for her baby’s well-being. She has limited coping skills. Following the initial evaluation and a chart review, the C-L consultant concluded that the patient does not meet diagnostic criteria for bipolar disorder; however, the consultant determines that her symptoms are consistent with BPD.

Differential Diagnosis of BPD With Peripartum Patients 

BPD describes a pervasive pattern of interpersonal volatility, affective instability, impulsivity, and insecure sense of self. There are no biological markers of the disorder, nor is there clear evidence of a true gender difference in prevalence.

There do seem to be gender differences in how BPD traits are displayed. BPD traits typically are observed between adolescence and early adulthood. The prevalence of BPD is approximately 1% for the general population and between 12% and 22% for clinical populations.³

BPD and Trauma

Patients with BPD are more likely to endorse a trauma history, especially prior experiences of repeated child abuse and neglect and instances of sexual trauma.⁴ Trauma is a known contributor to emotional lability, dissociative symptoms, and interpersonal difficulties. Patients with a trauma history and BPD traits are at higher risk for developing comorbid posttraumatic stress disorder.⁴

During the peripartum period, there are many opportunities for patients with a trauma history to experience retraumatization. Many aspects of routine care and pregnancy include sensitive exams (eg, cervical checks), physical discomfort (eg, hyperemesis, pelvic floor changes), and personal questions (eg, sexual history, birth preparation).

For patients with a trauma history, these experiences can be more distressing. The underlying personality traits of BPD can lead to maladaptive behaviors employed to cope with the distress of these experiences.

Researchers are starting to recognize that childbirth itself can be a potential trauma for peripartum patients. Patients with BPD are at heightened risk for poor outcomes if they experience a loss of control during the delivery, require unanticipated or emergency intervention, experience medical complications affecting themselves or their newborn, or perceive their medical team to be uncaring or even actively harmful.

Medical professionals can help by maintaining a calm, firm communication style and speaking from an emotionally empathic position. A trauma-informed approach is critical in supporting these patients before, during, and immediately after their delivery, with clinicians prioritizing clear communication and informed consent early in the medical decision-making process.

BPD and Bipolar Disorder

BPD is associated with increased likelihood for a co-occurring bipolar I or II disorder. When both are present, it suggests worsened overall functioning, heightened risk of suicide, and higher psychiatric acuity.^5,6 The significant overlap in symptoms (eg, emotional lability, suicidal behavior, and impulsivity) can lead to the misdiagnosis of bipolar disorder in patients with BPD.⁷

It is critical to correctly identify when bipolar disorder is present, as the gold standard of treatment for bipolar disorder—psychopharmacological treatments with adjunctive psychotherapy—differs from BPD, where behavior management and coping skills take precedence over medication. Furthermore, patients with BPD are at heightened risk of polypharmacy, despite minimal evidence that medication is effective in treating BPD.⁸

In the perinatal period, it is recommended that clinicians thoroughly assess for individual and family history of bipolar disorder, as it is a known risk factor for the development of postpartum psychosis (PPP) following delivery.⁹ PPP is a medical emergency that can progress rapidly, develops most often within 10 days after delivery, and carries an acute risk of infanticide and suicide.¹⁰

One of the most used questionnaires to identify patients with bipolar disorder, the Mood Disorder Questionnaire, has been shown to have a high false-positive rate in the BPD population^.11 It is critical to correctly differentiate bipolar disorder from BPD within the peripartum population with thorough diagnostic interviewing to maximize treatment gains and mitigate risks from medication management.

A patient who presents with self-reported or even a historical diagnosis of bipolar disorder, as identified through a chart review, might be unnecessarily exposed to a mood stabilizer if this diagnosis is incorrectly assigned.

Case Example, Part 2

Upon further evaluation, it was determined that the patient’s acute risk of self-harm was high. She was placed on a safety watch, and a search for an available inpatient psychiatry bed was started. Over the next several days, her behavior on the unit escalated, with the patient engaging in threatening and violent behavior toward hospital staff. Some examples include: 

Requiring that she receive care from only a select group of staff. When other staff attempted to provide care, she began yelling at staff to leave and shouting expletives. She yelled racial insults at non-White staff. Typically, the charge nurse or unit manager moved staff around to give the patient her preferred staff member. The staff member on the receiving end of these interactions often was distressed afterward.

Telling staff that she would hurt them when they began assessments related to her housing or talking about her plans for the baby. She occasionally followed up these statements by throwing items in her room or shoving furniture in the room toward them.

Making suicidal statements daily. These typically resulted in immediate outreach to C-L psychiatry and significant distress for the staff, who felt ill equipped to manage suicidal patients.

C-L psychiatry made treatment recommendations with the goal of minimizing problematic behaviors, supporting staff, and increasing the patient’s engagement in her medical treatment. Although medication is not the first line of treatment for BPD traits, several short-acting medications are recommended to manage acute outbursts and agitation.

The bulk of the treatment for the patient included implementing a behavior plan, along with individual therapy sessions 4 to 5 times a week. This behavior plan was created to provide clear guidance to staff. The goals of therapy were to build rapport with the patient, provide emotional support, and teach appropriate coping and communication skills.

Clinical Implications

Patients with BPD are at a higher risk of medical hospitalization, during which they are more likely to engage in self-harming behaviors, require constant observation for safety, and attempt or complete suicide.^12,13 These behaviors are challenging to treat in the medical setting and can complicate or undermine medical care. For patients with BPD, symptoms are best managed with therapeutic intervention focused on teaching appropriate coping skills, along with effective behavior management techniques from those around them.

Treatment Recommendations

Excluding clinical presentations where there is a comorbid mood or anxiety disorder, long-term medication management is not recommended for these patients, as personality disorders are inherently pervasive and global.

The maladaptive behaviors seen in this population respond robustly to behavior-based psychotherapies (eg, dialectical behavior therapy). Goals of therapy should be triaged across 4 stages beginning with minimizing self-harming behaviors and increasing treatment adherence. Following clinical improvement, the plan concludes with a focus on creating a meaningful and rich life (Table).¹⁴

Table. The Four Stages of Therapy for Peripartum Patients With BPD¹⁴

For clinicians caring for hospitalized obstetric patients with BPD, it is most likely that these patients will require the immediate skill-building and distress tolerance components in the initial stage of treatment.

Treating clinicians should prioritize the following: First, psychiatry should take a proactive approach, ensuring that patients are seen near daily to minimize the potential for secondary gains from reactive psychiatry consults occurring after patients engage in problematic behavior. Second, psychiatry should model direct, clear, and consistent communication for both the team and the patient. Clinicians should ensure that patients understand what to expect from all team members (ie, say what you mean and do what you say).

Third, prioritize patient safety in session content by working on minimizing self-harm behaviors (eg, suicide attempts, aggression toward others) and increasing treatment adherence (eg, attending required appointments and tests).

Finally, the therapeutic relationship can be used to build a positive association with mental health treatment for the peripartum patient with BPD, increasing the likelihood of successful outpatient treatment upon eventual discharge. This is helpful in managing symptoms of BPD and supporting a secure infant attachment in the postpartum period.

Behavior Planning

As staff on medical units receive significantly less exposure to and training in psychiatric symptom management, C-L psychiatry is a critical resource for medical teams. Compared with other medical units, obstetric units see fewer acute psychiatric emergencies due to higher patient turnover, more “healthy” patients, and shorter admissions.

The presence of newborns on the unit also adds an additional team to coordinate with, along with the responsibility of ensuring a safe discharge for the birthing parent and the newborn. All these factors can lead to increased uncertainty about how to manage problematic behaviors in an obstetric unit in a way that is consistent and unbiased and supports patient autonomy.

Behavior planning is an effective tool for staff and providers of these patients and should be based on the principles of behaviorism. When creating a behavior plan, there are several components to consider.

First, the clinician should meet with unit leadership, nursing, and medical team decision makers to elicit goals of care, barriers to discharge, and interpersonal concerns and to create a unified treatment plan. Second, the clinician needs a good understanding of the function of the patient’s behavior.

In other words, why is the patient engaging in problematic behaviors—what are they hoping to gain or avoid? With this answer, the clinician can then guide staff in teaching more appropriate ways to support the patient in getting needs met.

Behavior plans should clearly label target behaviors using observable and specific language. For example, the target behavior “patient will not get mad at staff” is unclear and hard to measure or intervene upon. This target behavior can be more specific: “patient will not throw items at staff, use expletives or racially derogatory terms, or speak to staff at a loud volume.”

This target behavior could be further improved by making a language shift that explicitly communicates behavior expectations such as “the patient will speak at an appropriate volume using respectful, nonderogatory language.”

Consequences should be clearly communicated and consistently implemented across all staff and settings. Behaviorism divides consequences as either a reinforcer (outcome that makes a behavior more likely) or a punisher (outcome that makes a behavior less likely). When a behavior’s function is identified, the consequence should be readily identified.

For example, if the patient is engaging in verbally aggressive behavior to see a favorite staff member and have the team round on her at her preferred time, the consequence should directly address those variables. If looking to reinforce appropriate behaviors, allow the patient to do those things after she engages appropriately.

Notably, the most effective behavior planning prioritizes reinforcement and limits the use of punishment solely to behaviors that are harmful to the patient and/or others. Reinforcement is the most effective tool in teaching new, robust behavioral repertoires while supporting and respecting patient autonomy. 

The previously outlined target behavior could include a reinforcer of allowing the patient a choice of when she would like the team to round on her or extra time with a preferred staff member after a period without verbal aggression.

Finally, behavior plans work best when they focus on a single behavior or a small group of behaviors. Prioritize behaviors that support the patient’s self-identified treatment goals, promote patient health and well-being, minimize treatment nonadherence, and reduce harm to staff.

Dr Eastin is a clinical psychologist in C-L psychiatry who specializes in perinatal mental health and a clinical instructor in medical psychology (in psychiatry) at Columbia University Irving Medical Center, New York, New York. Dr King is a reproductive and C-L psychiatrist at Columbia University Irving Medical Center.

References

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