Case Conference
C-L Case Conference: Applying Good Psychiatric Management for Borderline Personality Disorder in Hospitalized Patients With Co-occurring Substance Use Disorders

https://doi.org/10.1016/j.jaclp.2022.08.003Get rights and content

We present a case illustrating common challenges in the hospital management and treatment of comorbid borderline personality disorder and substance use disorders. Experts in the field of personality disorders and substance use disorders discuss various topics and strategies for patient-centered management. Key learning points include evaluation and diagnosis of borderline personality disorder, good psychiatric management, withdrawal and pharmacologic management, harm reduction, team dynamics, and behavior planning all in the hospital setting. This paper provides actionable considerations with elements common to many clinical encounters that present challenges to the consultation-liaison psychiatrist in the general hospital setting.

Section snippets

Case Presentation (Barrington Hwang)

A 35-year-old man, Mr. BP, with severe alcohol use disorder complicated by recurrent pancreatitis and multiple recent medical hospitalizations was readmitted to the internal medicine service for abdominal pain in the setting of relapsed daily alcohol use, and psychiatry was consulted to assist in alcohol withdrawal management on the day of admission.

Stigma, mistrust, and caregiver burnout were apparent in his treatment team: “He knows what causes this, and he keeps drinking”; “He looks

Evaluation and Diagnosis of BPD in the Hospitalized Patient with Substance Use Disorder (Barrington Hwang)

BPD is overrepresented in clinical settings, reflecting 15%–28% of psychiatric inpatients and outpatients despite 2%–3% general population prevalence.1 Medical and psychiatric comorbidity is common, driving care-seeking and high medical service utilization.2 BPD symptoms may adversely impact care engagement, with inconsistent interpersonal relationships, identity disturbance, affective dysregulation, impulsivity, and hostility disrupting alliance-building and collaboration.3 These symptoms and

Applying GPM in the General Hospital Setting (Brandon Unruh)

Decades of BPD research have established an overall positive prognosis for affected individuals and identified multiple effective psychosocial interventions associated with accelerated symptom remission and functional improvement.18 These empirically supported BPD treatments include transference-focused psychotherapy, a twice-weekly individual therapy grounded in psychodynamic object relations theory and focused on exploring the patient's experience of the treatment relationship19; dialectical

Applying GPM Principles to Withdrawal Management, Harm Reduction, and Behavior Planning (Kristopher Kast)

In addition to BPD-related symptoms, unaddressed or undertreated withdrawal states may lead to treatment-interfering behaviors. The GPM principle of judicious psychotropic medication use supports targeted treatment of acute withdrawal—particularly from opioids, alcohol, sedative hypnotics, and nicotine—to reduce the patient's stress response and somatic symptom burden. These interventions allow alliance building, diagnostic assessment, and psychotherapeutic treatment of co-occurring BPD

Case Conclusion

When BPD co-occurs in patients presenting with SUD, the interpersonal, emotional, and behavioral challenges commonly associated with both conditions are best managed by a GPM-informed consultative approach involving diagnostic disclosure and psychoeducation, empathic exploration of emotional experiences driving maladaptive behaviors, realistic goal-setting, problem-solving around interpersonal stressors, and judicious pharmacology while emphasizing psychosocial interventions.

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    Disclosure: The authors disclosed no proprietary or commercial interest in any product mentioned or concept discussed in this article.

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