Borderline personality disorder, therapeutic privilege, integrated care: is it ethical to withhold a psychiatric diagnosis?

Once common, therapeutic privilege-the practice whereby a physician withholds diagnostic or prognostic information from a patient intending to protect the patient-is now generally seen as unethical. However, instances of therapeutic privilege are common in some areas of clinical psychiatry. We describe therapeutic privilege in the context of borderline personality disorder, discuss the implications of diagnostic non-disclosure on integrated care and offer recommendations to promote diagnostic disclosure for this patient population.

Neurocircuitry associated with symptom dimensions at baseline and with change in borderline personality disorder.

Borderline personality disorder (BPD) is a serious illness associated with chronic suffering and self-injurious behavior. Parsing the relationships between specific symptom domains and their underlying biological mechanisms may help us further understand the neural circuits implicated in these symptoms and how they might be amenable to change with treatment. This study examines the association between symptom dimensions (Affective Disturbance, Cognitive Disturbance, Disturbed Relationships, and Impulsivity) and amygdala resting-state functional connectivity (RSFC) in a sample of adults with BPD (n = 18). We also explored the relationships between change in symptom dimensions and change in amygdala RSFC in a subset of this sample (n = 13) following 8 weeks of quetiapine or placebo. At baseline, higher impulsivity was associated with increased positive RSFC between right amygdala and left hippocampus. There were no significant differences in neural change between treatment groups. Improvement in cognitive disturbance was associated with increased positive RSFC between left amygdala and temporal fusiform and parahippocampal gyri. Improvement in disturbed relationships was associated with increased negative RSFC between right amygdala and frontal pole. These results support that specific dimensions of BPD are associated with specific neural connectivity patterns at baseline and with change, which may represent neural treatment targets.

The Development and Implementation of a Patient Continuity Conference in a Psychiatry Residency Program.

OBJECTIVE: A resident-led patient continuity case conference was initiated with the goals of improving communication among providers and increasing cohesion among residents. METHODS: A monthly case conference focusing on patient continuity of care was held over the course of the academic year. Residents were surveyed for feedback about the role of the conference in both improving their competency in navigating transitions of care and building cohesion among residents. RESULTS: The conference improved resident knowledge of care transitions and communication during transitions in care in addition to increasing comfort, cohesion, and exchange of knowledge between residents. CONCLUSIONS: Implementing a resident-led patient continuity case conference can improve resident competency during care transitions while improving cohesion among residents.

Managing borderline personality disorder on general psychiatric units.

Patients with Borderline Personality Disorder (BPD) are at high risk of suicide and are frequently hospitalized in the acute setting of emotional crisis, non-suicidal self-injury, and suicidal behaviors. Historically, patients with BPD have borne tremendous stigma and have tended to overwhelm providers and care systems. The reconceptualization of the pathophysiology and development of BPD in the context of a rapidly changing health care environment warrants examination of relevant psychotherapeutic and treatment principles. Through a case discussion, this article highlights several factors relevant to acute inpatient hospitalization of patients with BPD in an academic training environment in an effort to identify both the challenges and helpful treatment philosophies and practices to advance patient care and promote recovery.