8 Personality Disorders as a Psychiatric Emergency

A personality disorder is defined in psychiatric terms as a long-term pervasive pattern of maladaptive behaviors that have reached a degree of severity that they interfere with normal functioning. In contrast to, for example, an acute depressive episode where a patient has a discrete period of mood symptoms, patients with either a full-blown personality disorder or maladaptive personality traits have sometimes life-long patterns of thought and behavior that interfere with their ability to work and form relationships. While patients with paranoid, schizotypal, avoidant, obsessional, or schizoid traits may present to the ED for various reasons, borderline, narcissistic, and antisocial patients are by far the most frequent source of ED presentations and also cause the most distress for providers and families. It is usually not possible to diagnose someone with a personality disorder based on one brief encounter in the ED, but recognizing patterns of behavior and gathering longitudinal history can be helpful in informing disposition and treatment.

Ms. A is a 26-year-old single woman who is a graduate student. She was brought by an ambulance to the emergency room by a therapist at her school’s student mental health service after she told the social worker she wanted to kill herself. She showed the social worker a bottle of clonazepam and asked if there were enough pills to kill herself. The meeting with the therapist had occurred because the patient’s roommate brought her to the student mental health service after she told the roommate she was planning on killing herself.

The patient reported compliance with her medications of lamotrigine, escitalopram, and aripiprazole. She reports that she started feeling “bad” in the last week when her “only friend” told her he was taking a job in another state and her roommate told her she planned to move to a different apartment when the lease was up. The patient says of the experience, “Everyone is leaving me, I don’t want to live anymore.” She expressed surprise that she had been brought to the hospital and asked to be discharged as she was “feeling better.” When asked what she thought would happen when she showed her therapist a bottle of medication and asked if it was enough to kill her, she reluctantly agreed that the therapist had done the right thing. She explained that she had immediately felt better when “my therapist saved me,” and now no longer felt suicidal and wanted to leave. She denied any substance use, which was corroborated by her roommate. There was no evidence of psychosis or mania on exam. She had not engaged in any superficial self-injury in several years.

Ms. A has been hospitalized several times for suicide attempts including overdosing on several SSRI pills and one episode of stabbing herself. She has been on various medications and has largely been compliant with them, although has been limited in what she can take because of severe “side effects.” She has never been psychotic or manic, according to information provided by her psychiatrist. She has been in dialectical behavioral therapy in the past and found it very helpful; however, her current insurance plan mandates she be treated in the student health clinic, which does not provide that service.

None.

Ms. A was eager to share that she grew up as the only child of two parents. Her father died when she was young and her mother remarried. She experienced sexual abuse by her step-father for several years as a teenager. She graduated from college and was now in graduate school. She was not married and not currently in any romantic relationships, although she could not describe the nature of the relationship between her and the “friend” who was moving to a different state.

Urine toxicology was negative for THC, cocaine, PCP, barbiturate, benzodiazepines, opiates, and methadone. Blood alcohol level was zero. Other laboratory studies were unremarkable.

The patient had been functioning well up until this acute stressor, which seemed to be precipitated by her intense fear of abandonment by her friend. She did not have any acute symptoms apart from this episode, but she did have a significant history of prior suicide attempts. A case could be made for either admission or discharge.

Her outpatient treaters were not comfortable taking her back for treatment unless she was observed further and a safety plan was made. Ms. A remained unwilling to engage in any constructive planning, becoming more irritable and refusing to engage at all. She was admitted to ED observation for crisis stabilization, as the psychiatrist was concerned that an inpatient admission would be counterproductive but was also concerned about the lack of supports. Unfortunately, she became angry and hostile when told she would be staying in the hospital for the night and demanded to leave. She started throwing food at staff and other patients, threatening to throw chairs. She could not be verbally redirected but did accept sedating medication to take by mouth. She slept for the night.

The following morning she apologized for her behavior and was able to talk about her feelings of emptiness when she learned that her friend and roommate was “leaving” her. She was able to engage in a reasonable discussion about safety planning, including allowing her therapist to hold on to her clonazepam and meeting more frequently with her therapist. Her outpatient treaters were in agreement with this plan and made an appointment for her to be seen immediately upon release from the ED.

Mr. P is a 37-year-old man recently divorced and employed as a massage therapist. He recently moved from the suburbs to the city following his divorce. He was brought to the hospital by ambulance after his ex-wife called 911 from outside of the city. According to EMS, the patient had texted a photograph of a bloody knife to his ex-wife and then was not answering the telephone when she called him. She was concerned and called an ambulance. On exam, Mr. P appears incredulous that he is in the emergency room and says, “all of a sudden, emergency crews showed up in my apartment and the police said they would handcuff me if I didn’t come with them.” He was angry about being in the emergency room, repeatedly demanding that he be allowed to leave before an evaluation could be done. After accepting an explanation about the emergency nature of his evaluation and that he would not be permitted to elope from the emergency room, Mr. P calmed down and was able to engage in an interview. He continued to insist that he had no complaints and had no idea why he was in the emergency room. When the evaluator shared with him the history provided by EMS, Mr. P admitted that he had texted such a picture to his ex-wife. He went on to explain that he had felt very upset by the divorce, even though he initiated it. He had noticed on social media earlier that day that she was tagged in a photo with a different man. He was at home cutting a beet root to roast for dinner when he noticed the way it looked like blood on his knife. He thought it looked “cool” so he took a picture and texted it to his ex-wife. When evaluator confronted him about not returning any phone calls from his ex-wife, he said he was “tired.” He remained “confused,” stating, “I just don’t understand what all the fuss is about.” He expressed anger at his ex-wife for “doing this to me.” He denied suicidal or homicidal thoughts, denied symptoms of depression other than difficulty sleeping since moving into the city alone. He did admit to feeling “lonely” at times, as much of his social network was in his old town. He had been in psychotherapy before, but since moving to the city, he has not been in psychotherapy. He denied any drug or alcohol use.

Mr. P has never been hospitalized for psychiatric reasons. He has engaged in superficial self-injury in the past, most recently 6 months ago in the context of his divorce. He has never made a suicide attempt and stated he has never been violent or arrested. He was in psychotherapy for many years but not currently. He reports a long history of disrupted relationships where after an initial intense period of involvement, the relationship falls apart in a dramatic way.

Divorced, no children, employed as a massage therapist. Mr. P does not drink alcohol, use drugs, or smoke cigarettes currently but admits to past episodes of alcohol and cocaine use in the context of romantic relationships where his girlfriend regularly used those drugs.

Urine toxicology negative for THC, amphetamines, benzodiazepines, opiates, and methadone. Blood alcohol level 0.

While it is possible that the patient does in fact harbor some suicidal thoughts or violent ideation towards his wife, and a period of divorce can be a risky time, particularly in a patient with a history of self-harm, there does not seem at this time to be any evidence apart from the texted “bloody knife” photo that the patient is experiencing any acute symptoms. It would be difficult to justify an involuntary psychiatric admission based on one photo, and the patient does not exhibit symptoms of an acute mood or psychotic disorder that would require inpatient treatment.

Multiple attempts were made to confront Mr. P with the nature of his behavior and its connection with 911 being activated. He maintained that he did not understand “the fuss.” He did admit that when he saw the picture of his ex-wife and another man, he felt “a little” suicidal for a moment, but had no intent or plan to act on that thought. He expressed pride that he had not resorted to cutting himself, as he had done in the past. He adamantly denied any suicidal ideation over the past months. When he was presented with an empathic understanding of his predicament regarding the intense feelings of anger at his ex-wife, his own loneliness in a new city, and perhaps his desire to hurt her in some way, he was able to acknowledge that his behavior was aggressive and expressed embarrassment at his behavior. After a careful consideration of his risk assessment, he was discharged with referral to a psychotherapist to help him with improved coping skills.

Borderline personality disorder (BPD) is a pervasive pattern of instability of interpersonal relationships, self-image, affects, and behavior which begins before age 18, manifests in a variety of contexts, and results in significant impairment of functioning.¹ It is a serious psychiatric illness, characterized by instability in relationships, self-image, and emotions, often leading to impulsivity and self-damaging behavior. Common and important features are a severely impaired capacity for attachment, predictably maladaptive behavior in response to separation, and a lifetime suicide rate of 10%.² Given the brevity of assessment and acuity of presentation, it is much more common for the ED psychiatrist to see patients who display features or traits that are consistent with borderline pathology than to be able to actually diagnose someone with the disorder. It is also important to understand that patients in the throes of an acute mood or psychotic episode may display traits or symptoms that are not consistent with their lifetime personality structure, and clinicians risk overdiagnosing personality disorders in the acute setting. However, mindfulness to personality pathology and its powerful influence on behavior remains helpful in determining treatment and outcome.

Although there is limited data evaluating the BPD in the ED setting, given the rates just described, it is a common co-occurring condition in ED visits, particularly in patients who have repeat the ED visits.³ Individuals with BPD are high utilizers of medical care: while studies have demonstrated a prevalence of about 1–2% of the general population, BPD has a prevalence of 6% in primary care settings, 10% of psychiatric outpatients, and 20% of inpatients.^4,5,6 For the ED psychiatrist, evaluating and treating the patient with BPD carries its own set of challenges, particularly around risk assessment, management of countertransference (personal as well as institutional), and determination of appropriate disposition. Key to understanding BPD in the ED setting is that individuals with BPD tend to experience the world as chaotic, and thus experience emergencies. Furthermore, there is a high co-occurrence of substance abuse, eating disorders, re-traumatization, depression, chronic suicidality, and self-harm behaviors, all of which lead to ER visits. Recurrent suicidal or self-injurious behavior is one of the diagnostic criteria, so it should be not be a surprise that there have been estimates that 43–80% percent of those diagnosed with BPD engage in some type of self-mutilating behaviors (e.g., cutting, burning, skin picking, head banging).⁷ Typically such behaviors are primitive maneuvers to manage intense feelings rather than as suicide attempts.⁸ Although these behaviors are often to manage intense emotional states, rather than cause death, they can be potentially lethal. Frequent self-mutilators were found to be more likely to attempt suicide, and it is important to keep in mind the high rate of completed suicide attempts (10%), either through the fatal outcomes of misadventure or through intentional suicide. Because of these factors, the crises that bring a patient with BPD into the ED are often difficult to manage, and clinical and medicolegal complications may arise.⁹ However, the task of the emergency room psychiatrist remains the same: to determine whether hospitalization is required and what treatment (medication or otherwise) should be prescribed.

As discussed in the chapter 15 of this volume, “Psychodynamic Aspects of Emergency Psychiatry,” countertransference can be understood as the set of reactions and feelings that clinicians experience, whether consciously or unconsciously, in response to a patient’s presentation in the context of their own history and background. Countertransference is frequently thought of as something negative, but clinicians who are aware of their own reactions and triggers can use these feelings as another assessment tool.

Patients with BPD are often difficult to manage in the emergency setting. The hallmark symptoms of BPD, such as volatile emotions, dangerous behaviors, and a tendency to escalate, are often the exact factors which make staff wary.¹⁰ While these patients often make provocative statements that can ring false, not paying enough credence to the patient’s subjective sense of crisis (whether or not it seems realistic to the listener) can have poor outcomes. It is useful to keep in mind that the maladaptive behaviors that we see were developed in response to a particular environment, and patients with BPD can be hypersensitive to perceived rejection, criticism, or negativity. Anxiety around being poorly treated is a common trigger for acting out, and patients may appear labile, needy, and easily frustrated.¹¹

It is common for staff members to feel as though they are being deliberately provoked, challenged, or manipulated by these patients. In the case of Mr. P, he minimized the circumstances leading to 911 being called and was initially demanding to leave, no doubt confusing and frustrating the interviewer. His behavior could raise the concern that he is engaging in intimidating behavior toward his ex-wife, in a more classically antisocial way. Ms. A endorsed highly variable emotions within the context of the interview, making it difficult to formulate her present state of mind. While such interactions can be provocative, there are some clear guidelines that can go a long way in managing the particular needs of these patients. For example, by establishing early on that staff is invested in helping, we can lessen anxiety. Encouraging the patient to identify and explore the precipitants that lead to crisis, interpreting their impulses as a reaction to overwhelming feelings that may no longer be present, and supporting the decision to visit the PED instead of acting on destructive impulses can shift the paradigm so that the individual is enabled to control his or her impulses. Having a frank discussion about what the patients need and want from the ED visit can lessen fears of abandonment. When needed, limits should be clear, reasonable, and enforceable. Clinicians should be mindful of their tone of voice, volume, and rate of speech, as individuals with BPD are often very perceptive of negative attitudes conveyed by nonverbal communication.¹² Refraining from engaging in power struggles and choosing to “agree” on less important issues allows the focus to remain on patient safety and collaboration.

Risk assessment in this population can be challenging, given the level of distress they often present, the seriousness of their comorbidities, and the lethality of the diagnosis. Furthermore, there is no consensus about indications for hospitalization of patients with BPD that are having a psychiatric emergency. The American Psychiatric Association 2001 Practice Guidelines indicate brief hospitalization when patients present an imminent danger to others, lose control of suicidal impulses or make a serious suicide attempt, have transient psychotic episodes, and have symptoms of sufficient severity to interfere with functioning.² Given the common presentation of patients with BPD, one reading of the guidelines could suggest that most presentations would lead to hospitalization. However, common practice over the years has suggested that patients with personality disorders regress on inpatient units, do not benefit from admission, and that hospitalization is counter therapeutic.^10,13,14

A key part of the borderline experience is that affective dysregulation is often time limited. There is recent work that shows that short-term hospitalization, such as a brief crisis center admission or extended ED observation, may be the best alternative to classic psychiatric inpatient hospitalization.¹⁵ Providing a “hold” can treat acute symptoms, which are often time limited; allow for management and mitigation of acute risk, including bridging to social supports and long-term treatment; and enable short therapeutic interventions, including validation of patients’ subjective distress, attention to situational stressors, and limit setting, which introduces the issue of accountability and diminishes the potential for destructive effects on others.

However, there are specific times when hospitalization is the appropriate treatment choice. Special consideration for admission should be made in the following circumstances: complete absence of outpatient support; after potentially lethal suicide attempts; and when a comorbid mood or psychotic disorder is driving the symptomatology and is currently untreated. Furthermore, given that the risk of completed suicide increases with number of prior attempts,¹⁶ admission should be seriously considered for an individual with a history of serious and potentially lethal suicide attempts who remains actively suicidal. In these cases, the presentation can be formulated as a failure of current treatment, and admission can provide time for a diagnosis of treatment failure and establishment of improved outpatient care.

For many years it seems to have been common practice for the diagnosis of BPD to be withheld from the patient. While this may have been initially a result of certain strictly analytic styles of treatment, it may also reflect a clinician’s discomfort with their own negative feelings about the patient’s behavior. In some patients where the diagnosis is clear and established, it can in fact be helpful for patients to be educated about the symptoms of the disorder and the hope for successful treatment if they are able to engage in therapy.¹⁰ It is important to assess how patients understand their own problems and can be helpful to provide feedback about their behavior. For example, Ms. A had been in a structured treatment for BPD before, and reminding her of her prior diagnosis could be helpful for her in understanding her own behavior in a crisis situation and prompt her to use more effective coping skills in the future. Mr. P was able to comprehend that his behavior might have been a way of managing his own difficult feelings about his divorce. The idea that other people struggle with such intolerable feelings and emotions can be helpful and normalizing to patients who have spent their lives feeling that they are tortured and no one understands them. Furthermore, reiterating that there is growing evidence that effective treatment is available¹¹ that can lead to symptom improvement, increased functioning, and remission can provide needed hope and motivation to engage in outpatient treatment.

Mr. N is a 58-year-old, divorced, homeless, unemployed white man who presents to the emergency room having called 911 on himself because, “I’m suicidal.” He is vague when describing how long he has been feeling suicidal, but eventually acknowledges to the doctor that he has been suicidal “for a really long time, Miss.” He is unable to explain why he sought emergency services in this very moment. He pan-endorses all symptoms of depression, although on exam he does not appear depressed. In fact, he has bright and reactive affect. He also reports drinking alcohol almost daily, at least a pint of vodka. He does not believe that his drinking is a problem, rather, his understanding is that the problems is, “my depression, Miss.” He has not sought outpatient treatment for his depression, despite several previous presentations to the ED that resulted in referrals to an outpatient clinic. He says that even though his drinking is not a “big problem,” he does plan to go to rehab because, “they can find me housing.” Following a gentle confrontation about the disconnect between his future-oriented statement about going to rehab and his statement that he is “suicidal,” he says to the doctor, “You are too young to be doing this, do you even know what you’re doing? Don’t you understand that if you discharge me, I’ll kill myself?” He then stormed out of the interview room. He was observed several minutes later reading the newspaper. He did not provide any phone numbers for collateral contact information. Staff overheard him talking on the phone about having been “kicked out” of his friend’s apartment earlier that day.

Mr. N has had many visits to the emergency room, typically when he is intoxicated and reporting suicidal thoughts. He usually retracts his suicidal statements after spending the night. He has a history of two suicide attempts in the past, both while intoxicated. The first was after his separation from his wife. He was found by a friend about to jump out of a high story window and was hospitalized psychiatrically. The second was one year ago when he lost his apartment. He took an overdose serious enough to require a medical admission followed by psychiatric admission.

Mr. N drinks alcohol almost daily. He has been to rehab once and remained sober for a few weeks after discharge. He has no history of withdrawal seizures or delirium treatments. He has never disclosed, but it is suspected that he lost his housing, job, and wife due to his ongoing alcohol use.

The patient has mild chronic elevation of his hepatic enzymes. He has never followed up with recommended ultrasound of his liver. He is mildly anemic.

Mr. N grew up in an intact household where he experienced physical and emotional abuse from his mother. He readily discloses this information and freely discusses how he feels he had a terrible mother. He graduated from college and worked for some time in a high-paying job in finance. He has no children and he has been divorced from his wife for 20 years. He lost his job about 10 years ago and lived off his savings until about one year ago when he ran out of money. He lost his apartment around that time and has been intermittently staying with friends and going to shelters. He has no contact with his ex-wife or any of his family members.

Blood alcohol level was not obtained until several hours after arrival, when it was zero. The patient refused to submit urine for a toxicology screen.

Although he was not grossly intoxicated when he came in and although his remarks about suicide were not consistent with the exam (i.e., he had bright affect and was future-oriented despite reporting depression and suicidal ideations), there is more than meets the eye with Mr. N. He likely did feign or exaggerate his symptoms in order to have a place to spend the night, and his repetitive use of the ED, ostensibly as a place to stay, could also seem antisocial in nature. However, a decision about his disposition and treatment is an exercise in countertransference management. The decision needs to be based on a strict consideration of his risk factors for dangerousness rather than the desire to be as far from him as possible, a sensation he likely induces in most people, as evidenced by his limited social supports. Ignoring the feelings of hatred he engenders, we see that he has multiple serious risk factors for suicide, including his age, gender, race, substance use, history of significant suicide attempts, and poor social supports. His suicide attempts in the past have occurred in the context of significant stressors like losing his primary relationship and his housing. Added to these static risk factors are his current intoxication (albeit mild) and the recent stressor of being kicked out of his friend’s home. He is at relatively high risk for suicide. While most of his risk factors are not changeable, his intoxication is changeable by being observed longer. It is also important to note that confronting the patient during the interview may have acutely injured him, in that he perceived that the clinician doubted him and therefore possibly thought negatively of him, which is intolerable to him. A need to “prove” to the clinician how serious he is may then acutely worsen his risk of self-harm.

Mr. N was placed on hold overnight to monitor for withdrawal and to monitor his behavior for any evidence of depressed mood. The following morning he retracted his suicidal statements and asked to be discharged. He said he planned to go to a different friend’s apartment in the morning. He was encouraged to go to detox and rehab, both of which he declined. He was offered a referral to outpatient substance abuse treatment but said he was not planning on going. He showed no signs of alcohol withdrawal at time of discharge.

Ms. D is a 34-year-old, married, employed, black woman who works as a freelance designer and has no past psychiatric history. She was brought by an ambulance after her fiancé called 911 when he walked in on her putting her head in the oven. He also discovered that she had purchased a firearm recently and was worried she would use it to kill herself. She actually has a husband (who she married for immigration purposes and does not have a relationship with now), a fiancée (with whom she has been “engaged” for the last five years; he financially supports her and she lives in his apartment, but they no longer in a romantic relationship), and a boyfriend (with whom she has a romantic relationship). She is indignant about being brought to the emergency room and explains that her fiancé has entirely “misunderstood” the situation. She explains that he has recently asked her to move out of his apartment and told her he would no longer be supporting her financially because he would like another woman to move into his apartment. She says, “Yeah, I’m not happy about the situation, but I’m happy for him for moving on. I’ve just been stressed out about where I will move to. Wouldn’t you feel this way?” She denied any symptoms of depression, including sleep and appetite disturbance, low mood, or suicidal thoughts. She adamantly denied she had made or was thinking of making a suicide attempt.

She is very resistant to anyone speaking to her fiancé, the person who activated EMS. She refuses to provide his collateral contact information, but he calls the emergency room himself to speak with the doctor. He explains that when he told her she would need to move out one month ago she laughed at him and said she would rather die than have to live in a less expensive part of town. Since then she has been increasingly withdrawn and irritable with him. He believes she has made a résumé to apply for jobs but has not been submitting résumés, fearing she will be rejected. What has concerned him recently is her secretiveness. He discovered her on the day of presentation with her head in the oven after he returned home from work a few hours earlier than usual—she was not expecting him to be home at that time. He is also puzzled about her recent purchase of a firearm as she has never expressed interest in owning or using a gun. He is extremely concerned about her safety. He has not observed any symptoms of depression apart from her irritability.

Ms. D has never seen a psychiatrist before and has never been psychiatrically hospitalized. She has seen a therapist in the past to help her with “relationship troubles.” She has no history of suicide attempts.

Ms. D does not drink alcohol or use drugs. This was corroborated by her fiancé.

None.

Ms. D refused to talk about her early developmental history (“that’s none of your business”) but did say she has no children and explained the relationship situation described previously. She graduated from college and initially worked at several large prestigious firms where she was “let go” after working a few months because, “they didn’t value me.” She currently works for herself with moderate success attracting clients to her design services.

Blood alcohol level was zero. Toxicology screen was negative.

Ms. D is an attractive, pleasant, agreeable, young woman dressed in stylish clothes and makeup. She is polite and deferential to the physician, if somewhat overly familiar. She frequently asks for validation that that physician would share her feelings if presented a similar situation. She is linear and logical in her thought process, adamantly denies that she is suicidal, and minimizes the circumstances that prompted EMS activation. She repeatedly says, “You have to get me out of here, doctor, I’m not like these other patients.”

Ms. D’s presentation is very concerning. She has taken steps to conceal her suicide attempt from her fiancé/roommate and had no reason to expect him home early. Furthermore, she has recently purchased a firearm, suggesting a plan to kill herself. It is notable that other than some social withdrawal, there are no symptoms of depression described either by the patient or the person she lives with. This is an important finding in a narcissistic patient. Often the suicidal thoughts are related to feeling rejected not because of struggles around abandonment as in a borderline patient, but because the rejection is a confirmation of a fear of worthlessness. In this case, there is also a potential of a loss in social status (moving to a less prestigious neighborhood, having to rely only on her more meager income). Although she lacks major historical risk factors for self-harm, such as history of self-harm and drug use, her recent stressor and recent efforts to conceal her suicide attempts make her at moderate to high-risk for suicide.

Ms. D was admitted to the hospital on an involuntary basis. She was enraged at the admission and difficult to treat throughout her stay.

When most people think of someone with narcissistic personality disorder (NPD), they think of an arrogant, haughty person. This stereotype misses not only the true clinical picture of NPD, which can be quite diverse, but also the significant suffering people with NPD can experience. As the vignettes demonstrate, NPD presents significant diagnostic and management challenges in the emergency setting.

NPD describes a pervasive and debilitating pattern of interpersonal relationships, self-image, and affects marked by grandiosity, need for admiration, and lack of empathy. Narcissistic personality disorder affects anywhere from 1 to 6.2% of the population.¹⁷ It is associated with significant comorbidities, including substance abuse and depression.

The difficulty in understanding the pathology is that unlike the apparent uniformity of the diagnosis as presented in DSM-V, there are several different subtypes.^18,19,20 The criteria captured by DSM-V capture important aspects of the pathology but may not be helpful in capturing all or even most individuals who receive the diagnosis in clinical practice. The subtypes that seem to emerge are the grandiose, “overt,” subtype; the vulnerable, “covert,” subtype; and the healthier, “higher functioning” subtype.¹⁹ Although the complexities of diagnosis may be outside the scope of an emergency setting, it is important to consider NPD or narcissistic traits in not just patients that seem “narcissistic” in the colloquial sense. For instance, Ms. D was likeable, polite, and not obviously grandiose. She struggled with feeling “unvalued.” The physician’s experience of her was not entirely negative, although her interpersonally exploitative relationships might have roused feelings of anger.

Diagnosis of any personality disorder, including NPD, can be very difficult. There are no quick and reliable instruments.²¹ Furthermore, the emergency setting allows only for assessment in one point in time, while a diagnosis of personality disorder requires understanding a patient more longitudinally. The diagnostic criteria are specific that this must be a “pervasive pattern” that has been present since late adolescence/early adulthood. Crises and emergency situations lend themselves to bringing out pathological traits in a person who may be able to function at a higher level when not in crisis. While understanding the narcissistic character is important in understanding a patient in the emergency room, it is important not to assume the patient is always organized narcissistically unless there is a known pattern or history.

A narcissistic patient is particularly sensitive to appearing vulnerable or powerless, a common feeling among patients in the emergency department. When her fragile sense of self is threatened in this manner she can become provocative and devaluing, thereby jeopardizing the opportunity for complete assessment. As illustrated in the case of Ms. D, the personality pathology can complicate a thorough assessment in many ways. Ms. D may have both consciously and unconsciously distorted the history to make herself appear in the best light. Collateral information was crucial in this case, in finding information that made an accurate risk assessment possible. In the case of Mr. N, he may feel such humiliation about his homelessness and social situation that just saying he feels distressed about his circumstances may feel impossible. The vulnerability may feel intolerable to him. Instead, he engages in manipulative and provocative statements designed to get a night in the emergency room, a behavior consistent with the interpersonally exploitative style of NPD patients.

The interpersonal difficulties that NPD patients suffer from can generate difficult feelings (or countertransferences) in nurses, staff, and physicians in an emergency department. Feelings that clinicians may struggle with in the emergency setting when treating NPD patients include feeling used, feeling bored, and feelings of hatred, among many others. Some literature has described clinicians left feeling unreasonably idealized, devalued, or disregarded.^17,19 Often, the feelings evoked are intense and difficult, reflecting both the severity of the patient’s pathology and the intensity of the patient’s emotional experience in a time of crisis. Awareness of these feelings is the first step in managing a difficult encounter and ensuring the best possible assessment. Processing difficult feelings about a patient encounter with colleagues can alleviate their intensity and help provide the necessary perspective to provide the best patient care.²¹

Building a good therapeutic alliance can go a long way to help stabilize the patient and assess his functioning. Clear, respectful gestures enable the patient to maintain his positive sense of self. Whereas other patients might benefit from a more familiar tone, the NPD patient will often respond best with respectful formalities such as “sir” and “thank you for speaking with me.”

Much can be accomplished in terms of building rapport with an NPD patient by accepting and tolerating the patient’s negative affect (often manifesting as difficult behavior) without reacting in a retaliatory way.²² For instance, Mr. N’s devaluing statements toward the clinician including, “You are too young to be doing this,” and “Do you even know what you’re doing?” could create a temptation to act in a defensive or retaliatory manner. In remaining neutral and respectful, the clinician can avoid a power struggle and complete the evaluation.

In addition, setting clear expectations for behavior and firm but respectful limit setting can also make the patient feel better and help him avoid sabotaging the evaluation. The limit setting is easier for the patient to accept when paired with identification and validation of his feelings. For instance, if Mr. N’s devaluing had continued, the clinician could have said, “It can be frustrating not to know someone’s credentials when your health is at stake, but if you can’t speak to me respectfully I will have to terminate the interview.”

The treatment of personality disorders, including NPD, is not done in the emergency room or even in the hospital. Treatment requires long-term psychotherapy.^18,22,23 Despite this, patients with personality disorders are frequent utilizers of emergency psychiatric services. There is limited research into the prevalence of personality pathology in emergency room contexts, but a Swiss study found that patients with a personality disorder were four times more likely than patients with mood, anxiety, substance use, or psychotic disorders to have recurrent visits to the psychiatric emergency room during the study period.²⁴ The reason for patients with personality disorders in particular using the emergency room more frequently are yet to be fully understood. It is likely that the often limited family and social supports, as well as comorbidities including mood disorders and substance use, lend themselves to frequent crises. Complicating the possibility of engaging in appropriate outpatient treatment are the interpersonal difficulties of personality disordered patients. For NPD patients in particular, engaging in an outpatient treatment that requires a commitment, respecting the boundaries of the therapist, and accepting set appointments can be difficult.^18,25

Whether or not narcissistic problems alone bring patients to an emergency room, narcissistic pathology is worth diagnosing and considering, as NPD patients are also likely to seek emergency treatment related to comorbid diagnoses. The narcissistic pathology could make the assessment and treatment of other co-occurring diagnoses challenging.

It is thought that because NPD is associated with ego-syntonic symptoms such as feelings of superiority rather than suicidality and self-injury, narcissistic individuals are less likely to seek treatment. Newer literature suggests that NPD patients, particularly more vulnerable subtypes, can be help seeking. Many of these patients are distressed and lonely with poor social functioning.²⁶

In addition to evaluating comorbid disorders, identifying and properly evaluating NPD patients in the emergency room is important for risk assessment. Having a personality disorder increases risk for suicide, particularly a Cluster B personality disorder.²⁷ For NPD patients in particular, the risk for suicide could be from poorly managed comorbid conditions (i.e., mood disorders, substance use) or part of the personality pathology itself. For instance, NPD patients may find that their focus on beauty, fame, and wealth have been disappointed when they reach midlife or older age. This could precipitate a crisis.^20,28 NPD, in particular, seems to pose a risk for suicide after being fired from a job, supporting the idea that diminished fame or perceived importance may lead to crisis.²⁹ Furthermore, suicide attempts in attempters diagnosed with NPD are characterized by higher lethality and are less impulsive.³⁰

A study that followed patients with personality disorders for 10 years found that of all the personality disorders that seemed to confer risk of one suicide attempt, only NPD predicted a number of suicide attempts beyond the initial attempt.³¹

Just as with any personality disorder, NPD patients can have comorbid mood and psychotic disorders. Importantly, suicide risk does not seem to necessarily correspond with the presence of or severity of mood symptoms.³⁰ As discussed previously, managing co-morbid illness can also be hindered by the presence of NPD, making it difficult to manage some of the modifiable risk factors.

In summary, although NPD and narcissistic traits are associated with ego-syntonic symptoms such as feelings of superiority rather than suicidality, the reality of NPD is a more complex clinical picture of often very vulnerable patients who are at risk for suicide. Often these patients make a careful evaluation and risk assessment challenging because of the difficult feelings they create in physicians, nurses, and staff. Maintaining a neutral and respectful attitude, obtaining collateral information, and carefully thinking through risk assessment are important aspects of emergency evaluation of NPD patients. Unlike a borderline patient, who wants the clinician to see how distressed he feels, a narcissistic patient may conceal difficult, embarrassing, or painful feelings. She is also more likely to have a lethal suicide attempt without obvious symptoms of depression.