Psychiatric Emergencies: A Complex Case of Overdose and Assessment in the Emergency Department

  • Bruce Fage
  • Jodi LofchyEmail author


In this chapter, we explore the challenges associated with patients experiencing chronic or recurrent suicidal ideation. We discuss the case of Jennifer, a woman suffering from borderline personality disorder who presents to the emergency department in a time of interpersonal crisis. We review suicide risk assessments in this vulnerable population, highlight key risk factors, and provide an example of risk assessment documentation. We present therapeutic techniques for managing personal and countertransference reactions, drawing from techniques associated with Dialectical Behaviour Therapy. We explore the interface between medical and psychiatric issues in the emergency setting and review recommendations for dealing with these complex patients. Finally, we revisit our case and discuss a trauma-informed approach to managing agitation and distress.


Borderline personality disorder Suicide Risk assessment Emergency management 



Borderline personality disorder


Dialectical Behaviour Therapy


Emergency department

Project BETA

Best Practices in Evaluation and Treatment of Agitation


Disclosure Statement

“The authors have nothing to disclose.”


  1. 1.
    American Psychiatric Association. DSM 5. American Psychiatric Association. Washington, DC: 27 May 2013.Google Scholar
  2. 2.
    Leichsenring F, Leibing E, Kruse J, New AS, Leweke F. Borderline personality disorder. Lancet. 2011;377(9759):74–84.CrossRefPubMedGoogle Scholar
  3. 3.
    Hayashi N, Igarashi M, Imai A, Osawa Y, Utsumi K, Ishikawa Y, Tokunaga T, Ishimoto K, Harima H, Tatebayashi Y, Kumagai N. Psychiatric disorders and clinical correlates of suicidal patients admitted to a psychiatric hospital in Tokyo. BMC Psychiatry. 2010;10(1):1.CrossRefGoogle Scholar
  4. 4.
    Paris J. Chronic suicidality among patients with borderline personality disorder. Psychiatr Serv. 2002;53:738–42.CrossRefPubMedGoogle Scholar
  5. 5.
    Perlman CM, Neufeld EA, Martin L, Goy M, Hirdes JP. Suicide risk assessment inventory: a resource guide for Canadian health care organizations. Toronto, ON: Ontario Hospital Association and Canadian Patient Safety Institute; 2011. Accessed 25 Sep 2016.Google Scholar
  6. 6.
    Jacobs DG, Baldessarini RJ, Conwell Y, Fawcett JA, Horton L, Meltzer H, Pfeffer CR, Simon RI. Assessment and treatment of patients with suicidal behaviors. APA Pract Guidel. 2010:1–183Google Scholar
  7. 7.
    Cerel J, Currier GW, Conwell Y. Consumer and family experiences in the emergency department following a suicide attempt. J Psychiatr Pract. 2006;12(6):341–7.CrossRefPubMedGoogle Scholar
  8. 8.
    Oldham JM. Borderline personality disorder and suicidality. Am J Psychiatr. 2006;163:20–6.CrossRefPubMedGoogle Scholar
  9. 9.
    American Psychiatric Association. Practice guideline for the treatment of patients with borderline personality disorder. American Psychiatric Publ. 2001;158(10 Suppl):1–52.Google Scholar
  10. 10.
    Oumaya M, Friedman S, Pham A, Abou AT, Guelfi JD, Rouillon F. Borderline personality disorder, self-mutilation and suicide: literature review. L’Encephale. 2008;34(5):452–8.CrossRefPubMedGoogle Scholar
  11. 11.
    Zanarini MC, Laudate CS, Frankenburg FR, Wedig MM, Fitzmaurice G. Reasons for self-mutilation reported by borderline patients over 16 years of prospective follow-up. J Personal Disord. 2013;27(6).
  12. 12.
    Black DW, Blum N, Pfohl B, Hale N. Suicidal behavior in borderline personality disorder: prevalence, risk factors, prediction, and prevention. J Personal Disord. 2004;18(3):226.CrossRefGoogle Scholar
  13. 13.
    Zaheer J, Links PS, Liu E. Assessment and emergency management of suicidality in personality disorders. Psychiatr Clin N Am. 2008;31(3):527–43.CrossRefGoogle Scholar
  14. 14.
    Obegi JH, Rankin JM, Williams Jr JC, Ninivaggio G. How to write a suicide risk assessment that’s clinically sound and legally defensible. Curr Psychiatr Ther. 2015;14(3):50.Google Scholar
  15. 15.
    Bergmans Y, Brown AL, Carruthers AS. Advances in crisis management of the suicidal patient: perspectives from patients. Curr Psychiatry Rep. 2007;9(1):74–80.CrossRefPubMedGoogle Scholar
  16. 16.
    Owens PL, Mutter R, Stocks C. Mental health and substance abuse-related emergency department visits among adults, 2007. Healthcare cost and utilization project (HCUP) statistical brief #92, July 2010. Agency for Healthcare Research and Quality, Rockville, MD. Accessed 25 Sep 2016.
  17. 17.
    Lieb K, Zanarini MC, Schmahl C, Linehan MM, Bohus M. Borderline personality disorder. Lancet. 2004;364(9432):453–61.CrossRefGoogle Scholar
  18. 18.
    Linehan M. Cognitive-behavioral treatment of borderline personality disorder. New York: Guilford Press; 1993.Google Scholar
  19. 19.
    Markham D. Attitudes towards patients with a diagnosis of ‘borderline personality disorder’: social rejection and dangerousness. J Ment Health. 2003;12(6):595–612.CrossRefGoogle Scholar
  20. 20.
    McElroy AL, Sheppard G. The assessment and management of self-harming patients in an accident and emergency department: an action research project. J Clin Nurs. 1999;8(1):66–72.CrossRefPubMedGoogle Scholar
  21. 21.
    Lofchy J, Boyles P, Delwo J. Emergency psychiatry: clinical and training approaches. Can J Psychiatry. 2015;60(6):1–7.PubMedPubMedCentralGoogle Scholar
  22. 22.
    Lykouras L, Douzenis A. Do psychiatric departments in general hospitals have an impact on the physical health of mental patients? Curr Opin Psychiatry. 2008;21(4):398–402.CrossRefPubMedGoogle Scholar
  23. 23.
    Leucht S, Burkard T, Henderson J, Maj M, Sartorius N. Physical illness and schizophrenia: a review of the literature. Acta Psychiatr Scand. 2007;116(5):317–33.CrossRefPubMedGoogle Scholar
  24. 24.
    Zun LS. Evidence-based evaluation of psychiatric patients. J Emerg Med. 2005;28(1):35–9.CrossRefPubMedGoogle Scholar
  25. 25.
    Lukens TW, Wolf SJ, Edlow JA, Shahabuddin S, Allen MH, Currier GW, Jagoda AS. Clinical policy: critical issues in the diagnosis and management of the adult psychiatric patient in the emergency department. Ann Emerg Med. 2006;47(1):79–99.CrossRefPubMedGoogle Scholar
  26. 26.
    Holloman GH, Zeller SL. Overview of project BETA: best practices in evaluation and treatment of agitation. Western Journal of Emergency Medicine. 2012;13(1):1–2.CrossRefPubMedPubMedCentralGoogle Scholar
  27. 27.
    Allen MH, Forster P, Zealberg J, Currier G. Report and recommendations regarding psychiatric emergency and crisis services. A review and model program descriptions. APA Task Force on Psychiatric Emergency Services; 2002.Google Scholar
  28. 28.
    Moscovitch A, Chaimowitz GA, Patterson PG. Trainee safety in psychiatric units and facilities: the position of the Canadian Psychiatric Association. Can J Psychiatry/La Rev Can Psychiatr. 1990. Accessed 25 Sep 2016.
  29. 29.
    Harris M, Fallot RD. Trauma-informed inpatient services. New Dir Ment Health Serv. 2001;2001(89):33–46.CrossRefGoogle Scholar
  30. 30.
    Richmond JS, Berlin JS, Fishkind AB, Holloman GH, Zeller SL, Wilson MP, Rifai MA, Ng AT. Verbal de-escalation of the agitated patient: consensus statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup. West J Emerg Med. 2012;13(1):17–25.CrossRefPubMedPubMedCentralGoogle Scholar
  31. 31.
    Poole N. In: Greaves L, editor. Becoming trauma informed. Toronto, ON: Centre for Addiction and Mental Health; 2012.Google Scholar
  32. 32.
    Yeager K, Cutler D, Svendsen D, Sills GM, editors. Modern community mental health: an interdisciplinary approach. New York: Oxford University Press; 2013.Google Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of PsychiatryUniversity of TorontoTorontoCanada
  2. 2.Psychiatry Emergency Services, Department of PsychiatryUniversity Health Network, University of TorontoTorontoCanada

Personalised recommendations