A 24-year-old woman, with a history of trauma and BPD, presented to the Emergency Department reporting suicidal thoughts and a plan to kill herself by cutting her wrist following a breakup with her boyfriend. The patient had superficial horizontal cute on both forearms. She had been experiencing anxiety and depression symptoms in the weeks leading up to the ED visit. She reported experiencing chronic suicidality but did not have a plan until she had the breakup on the day of ED visit. Her sister, who was present at the Emergency Department described her as “dramatic” and mentioned that she tends to have emotional breakdowns and engage in cutting during periods of stress.

She was hospitalized 4 times in the past for suicidality. She has recently stopped taking antidepressants due to side effects. She had no significant medical history nor family history. Her immunizations were up to date. The patient has a history of childhood trauma which involved witnessing domestic violence. Her parents separated when she was a teenager. She had multiple relationships in the past, in which she struggled with abusive partners.

The physical examination revealed small wounds on both forearms but was otherwise normal with no signs of distress. The patient’s vital signs were normal: blood pressure 121/72 mm Hg, heart rate 98 beats/min, respiratory rate 24 breaths/min, oxygen saturation 99% on room air, and oral temperature 37.1 C. The diagnostic tests she received were a complete blood count, metabolic panel, pregnancy test, and urine drug screen. The results of her blood work were normal, and both the urine drug screen and pregnancy tests came back negative. She completed the Adverse Childhood Experience Questionnaire (ACEs) and scored 7. She completed the Colombia Suicide Severity Rating Scale (C-SSRS) and scored 19. In this case, the ED clinician did not utilize the McLean Screening Tool for BPD [10] since Amy has already been diagnosed with the disorder. The ED practitioner performed a mental status examination. The patient appearance was appropriate to age, she was agitated, sobbing, which made it harder for her to communicate. She expressed suicidal ideation with a plan to cut her wrist. She was not experiencing any auditory or visual hallucinations and did not exhibit delusional or paranoid thinking. She demonstrated appropriate insight and judgment.

While some hospitals offer emergency psychiatric care in the ED, these were not offered at this facility. Emergency practitioners, including physicians, nurse practitioners, and physician associates, may have to use their clinical judgment to determine the proper course of action and avoid unnecessary treatments that might negatively affect treatment outcomes. In this case, the ED practitioner conducted an interview and took a history as the patient struggled to communicate. Her sister offered collateral history. The practitioner opted to prescribe Olanzapine 10 mg oral tablet to alleviate agitation.

The patient was observed overnight and was reassessed in the morning. She was more communicative in the morning and reported feeling better. She denied having suicidal ideations or urges to self-harm. The patient reported that the superficial cuts she inflicted were not an attempt to end her life and explained that cutting makes her feel better and less stressed. She reported receiving dialectical behavior therapy (DBT) in the past but has not had any therapy sessions in the past 2 years. She is currently off medications because they caused her side effects. The patient agreed to enroll in an intensive outpatient program that provides DBT and other clinical services. A safe discharge plan was discussed with the patient and her sister, who agreed to stay with her for the next few days. She was discharged from the emergency department later that day. The patient agreed to enroll in an intensive outpatient program that provides DBT and other clinical services. A safe discharge plan was discussed with the patient and her sister, who agreed to stay with her for the next few days. She was discharged from the emergency department later that day.

Discussing BPD diagnosis, symptoms, and treatment may assist the patient to understand the disorder’s dynamics, and how it may affect their feeling and reaction to stressors. For those without a formal BPD diagnosis, it is vital to teach the patient and their loved ones about the condition and its treatment. Assure the patient that the prognosis for BPD is favorable and that the majority of people with BPD achieve remission, with some even making a full recovery [23] . In the case Vignette, Amy’s grasp of the nature of mood changes, emotions, and crises in the context of BPD helped to speed up stabilization, avoid hospitalization, and motivate her to resume therapy.

BPD patients are inclined to be sensitive and reserved. It is essential to make the patient perceive the provider’s presence and involvement in their treatment. Ask about their symptoms, stressors, and therapy. It is crucial to avoid overinvolvement and reactivity, which may result in unneeded treatments and suboptimal treatment outcomes [22] . The medical professionals who assisted Amy in this case utilized active listening, conducted a thorough assessment, and made her feel valued. Amy’s perception of being cared for made her more responsive to receiving medications, prevented any escalation during the visit, and inspired her to follow the recommended course of action following discharge.

Individuals with BPD are more likely to have longer and more frequent ED visits, despite the fact that ED visits might be brief. The establishment of a therapeutic relationship with BPD patients and their participation in the treatment plan may aid in the formulation of realistic expectations. Using an authentic style strengthens the therapeutic alliance and enhances the patient’s perception of the provider’s concern [2] . The formation of a therapeutic alliance and the discussion of realistic expectations facilitated Amy’s receptiveness to available treatment options, thereby averting unnecessary inpatient service utilization and emphasizing outpatient treatment instead.

Relationship instability is the leading cause of mental health crises among those with BPD. Understanding the circumstances preceding the crisis may assist the patient in regulating and organizing their emotions [2] [22] . Amy’s crisis originated from relationship difficulties that intensified following her breakup with her boyfriend. Facilitating the discussion and comprehending the impact of BPD on relationships may assist Amy in rectifying unhealthy relational patterns from her past, while participation in outpatient psychotherapy could alleviate relational difficulties and help in establishing healthy relationships.

Amy received Olanzapine 10 mg, which is a sedative antipsychotic medication that may help deescalate high levels of agitation and anxiety. Second generation antipsychotics are frequently prescribed to individuals with BPD who present with agitation and/or extreme anxiety to mitigate the risks associated with agitation and severe anxiety [24] . Antihistamines and other short-term sedatives are the initial treatment for a BPD crisis if the individual’s presentation is not associated with agitation. This approach has fewer adverse effects, a low potential for abuse, no overdose hazards, and a minimal likelihood of addiction [25] .

Treatment for BPD can include selective serotonin reuptake inhibitors (SSRIs) which are often used because they are seen as a safe alternative with few potential adverse effects [26] . Other drugs with a low risk of abuse, overdose, or dependency can be used. Serotonin norepinephrine reuptake inhibitors (SNRIs) and atypical antidepressants are regarded as safe maintenance treatment options for BPD. Mood stabilizers, a class of FDA-approved drugs for the treatment of Bipolar Disorder, can be used to address BPD’s mood instability and impulsivity on off label basis [24] . The use of Low dose Quetiapine has shown effectiveness in treating BPD symptoms [27] .

Despite conflicting data regarding the pharmacological management of Borderline Personality Disorder (BPD), a recent extensive comparative study determined that benzodiazepines were linked to the greatest risk of attempted or completed suicide compared to other medication classes used in individuals with BPD [28] .