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Brief Report

A Call for Increased Psychiatric Training in Emergency Medicine: Physician Attitudes Toward Substance Use Disorders and Co-Occurring Borderline Personality Disorder

Giselle Appel, MSa,b,*; Sara R. Zaidi, MDb; Bernadine H. Han, MD, MSc; Joseph J. Avery, JD, MAd; and Jonathan D. Avery, MDa

Published: August 13, 2020

Substance use disorders (SUDs) and borderline personality disorder (BPD) remain two of the most highly stigmatized disorders within medicine and society.1–5 Extensive research demonstrates that this stigma is associated with poor provider experiences in clinical interactions, including low motivation, powerlessness, decreased empathy, and wrongful bias.6–14 SUDs and BPD also frequently co-occur, with a study15 reporting co-occurrence rates as high as 53.2%. In that same study, rates of lifetime SUDs with BPD ranged from 45.5% to 86.2%.15 The overlap and exacerbation of symptoms of one disorder by the other lead to incomplete or missed diagnoses and, subsequently, improper management strategies, which further contribute to provider frustration.5,16–21 Patients with these disorders often present to the emergency department (ED) with overdose, intoxication, trauma, or self-harm, making the ED a frequent setting for affectively intense encounters with such patients.16,22–28 The goal of the current study was to evaluate emergency medicine physician attitudes toward these patients.


The study used a cross-sectional survey design and was conducted between December 2019 and March 2020. The Weill Cornell Medicine Institutional Review Board approved the study. The respondents included residents and board-certified attending physicians in emergency medicine across hospitals in New York City. The questionnaire comprised the Medical Condition Regard Scales (MCRS).29 The MCRS is a valid and reliable 11-item instrument scored on a 6-point Likert scale, designed to assess the degree to which clinicians find individuals with a given medical condition to be enjoyable, treatable, and worthy of medical resources.29 Higher scores indicate greater enjoyment, perceived treatability, and belief in the utility of dedicating medical resources for treatment. The 4 diagnoses assessed in the questionnaire included BPD, SUDs, co-occurring BPD and SUDs, and depression. A between-subjects analysis of variance multivariate test and post hoc paired t tests (95% CI) were used to compare differences between groups. SurveyMonkey and SPSS v.26 (IBM, Armonk, New York) were used for survey response collection and analysis, respectively.


A total of 35 emergency medicine physicians completed the questionnaire. Results showed significant differences in attitudes across the conditions (Wilks Λ = 0.164, F3,32 = 54.35, P = .0005) (Figure 1). Multiple paired samples t tests indicated that attitudes toward depression (mean = 4.6727, SD = 0.7203) were significantly higher than attitudes toward BPD (mean = 3.3455, SD = 0.7082), SUD (mean = 3.7688, SD = 1.0667), and BPD/SUDs (mean = 2.9351, SD = 0.8760). The greatest difference was between attitudes toward depression versus co-occurring BPD/SUD (P < .001), followed by those toward BPD/SUDs versus SUD (P < .001). The difference in attitudes toward SUD and BPD was not significant (P = .09). Of respondents, 63.2% stated they did not feel adequately trained to treat patients with SUD or BPD. Lastly, respondents reported borderline or substance use disorders made up 8.75% of all patients seen within their past week.


Our results demonstrate worse attitudes toward patients with co-occurring BPD and SUD than toward patients with just 1 of these conditions or depression. Depression was most favorably regarded, despite both its high co-occurrence with BPD/SUDs and its role in triggering ED visits (eg, relapse, interpersonal problems, diffuse sense of self) in those with BPD or SUDs.3,4,17,18,30 Most notably, roughly two-thirds of physicians stated that their training was inadequate to treat these disorders, emphasizing the need to integrate best treatment practices for SUDs and co-occurring mental illness into residency curricula.

Such results are consistent with research2,31 suggesting physicians’ perceptions of their own treatment agency might influence their overall attitude toward a medical condition. Adequate treatment might be predicated on physicians’ ability to recognize and manage their own responses to complex and affect-laden patient presentations, such as guilt, hostility, helplessness, or rescue.6,11,19,26,30 Greater training in navigating the intense affects that these patients exhibit and evoke may alleviate burnout associated with repeated negative patient encounters and improve patient outcomes.

Published online: August 13, 2020.
Potential conflicts of interest: None.
Funding/support: Dr Avery was supported by the Department of Defense through external funding by the National Defense Science & Engineering Graduate Fellowship Program.
Role of the sponsor: The sponsor was responsible for review of the manuscript.


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aDepartment of Psychiatry, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, New York

bDepartment of Emergency Medicine, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, New York

cDepartment of Psychiatry, NYU School of Medicine, Bellevue Hospital, New York, New York

dDepartment of Psychology, Princeton University, Princeton, New Jersey

*Corresponding author: Giselle Appel, MS, Department of Psychiatry
Weill Cornell Medical College, NewYork-Presbyterian Hospital, 525 East 68th Street, Box 140, New York, New York 10065 (

Prim Care Companion CNS Disord 2020;22(4):20br02674

To cite: Appel G, Zaidi SR, Han BH, et al. A call for increased psychiatric training in emergency medicine: physician attitudes toward substance use disorders and co-occurring borderline personality disorder. Prim Care Companion CNS Disord. 2020;22(4):20br02674.

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