A personality disorder is defined as “an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment” (11, p 629). Personality disorders or traits often coexist with axis I disorders, making treatment for the axis I disorder complicated (12,13,14). The Diagnostic and Statistical Manual of Mental Disorders classifies the axis II personality disorders into clusters A, B, and C (Table 24.1).

Understanding the patient’s perspective and unique way of interacting with the world will help the emergency clinician regardless of the patient’s presenting complaint. Table 24.2 briefly outlines reasons patients might present and recommends some ways to approach patients of each cluster or diagnostic group except borderline personality disorder (BPD), which is the major focus of this chapter.

Patients with BPD can present unique and troubling issues for PES clinicians because they may be (too) frequent PES users and because they often engender negative reactions from clinicians they encounter (21). Patients with BPD may then be considered a special PES population. Not only do they arrive in the PES in a dysregulated state (22), but often the negative reactions in the PES clinicians may culminate in the clinicians becoming emotionally dysregulated as well (23,24). The mixture of the clinician’s dysregulated affect and
the patient’s dysregulated affect potentiates the bias and stigma that is often attached to the diagnosis, which makes the process of objectively evaluating the patient’s safety complex.

We will suggest ways to approach the BPD patient to reduce some of the complexity and perhaps damp down some of the dysregulated feelings and cognitions that seem to be everywhere in a PES when a BPD patient appears. Although the evaluation of suicide is discussed elsewhere in this book, we will use the suicidal BPD patient as our model because this is such a common presentation. Chaos in the PES can be reduced by remembering two principles: (a) The PES clinician’s role with regard to the BPD patient is a limited one and is delineated by issues of safety and whether or not to hospitalize, and (b) the techniques of dialectical behavior therapy (DBT [24]), even in the PES, can reduce some interpersonal chaos and staff countertransference (23,25). DBT techniques not only may lead to a better evaluation of dangerousness, but also may help patients move forward in considering new ways to improve their well-being. Thus, much of the discussion that follows focuses on the use of a cognitive behavioral method, predominantly DBT, to manage the confounding attributes of the emotion dysregulation or affective instability of BPD.

Dialectical behavior therapy was developed by Marsha Linehan (24). It is currently a best practice, evidence-based method of treatment for persons with chronic suicidality and BPD (26). DBT considers the etiology of BPD as a combination of a predisposed biologic vulnerability (emotional sensitivity) and a mismatched environment (an environment that is unable to validate or empathize with the person’s [increased] emotional sensitivity [24]). The sensitivity includes rapid, intense acceleration of affect with slow return to baseline. The trigger for the intense emotion may not appear obviously provocative. The sensitivity threshold (the threshold to react emotionally in a

manner others see as dysregulated) decreases with each episode of emotional dysregulation, which results in the patient experiencing pain in situations in which someone without this decreased threshold might not. The emotional intensity interferes with the individual’s ability to process information rationally and leaves the patient increasingly incapacitated in his or her sense of self and relationships. Impulsive acts occur as an attempt to solve problems and regulate the affect, but such acts often make the problem worse (24). The DBT approach can help PES clinicians confronted with the dysregulation of a patient presenting with suicidality as a result of personality traits or disorders.