Implementing NICE guidance

2009

NICE clinical guideline 78

Borderline personality disorder

What this presentation covers

Background

Scope

Key priorities for implementation

Costs

Discussion

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• Borderline personality disorder is present in just under 1% of the population.

• Women present to services more often than men.

• Borderline personality disorder rates are estimated to be 23% among male remand prisoners, 14% among sentenced male prisoners and 20% among female prisoners in England and Wales.

• 60 -70% of people with borderline personality disorder attempt suicide.

• Up to 10% of people with borderline personality disorder will commit suicide.

Prevalence and risks

Characteristics

• Borderline personality disorder can be seriously disabling and often takes a huge toll on the individual

• It is characterised by a pattern of instability of interpersonal relationships, self-image and affects, and by marked impulsivity

• A common factor is a history of traumatic events during childhood and adolescence

• People with borderline personality disorder are amongst the most likely to use mental health services

Scope of guidance

• Adults diagnosed with borderline personality disorder ; young people with borderline symptoms and people with learning disabilities and borderline personality disorder

• NHS services providing treatment

• Interface with other services

• Effective clinical management

Key areas for implementation

• Access to services

• Autonomy and choice

• Developing an optimistic and trusting relationship

• Managing endings and transitions

• Assessment

• Care planning in community mental health teams

• The role of psychological treatment

• The role of drug treatment

• The role of specialist personality disorder services within trusts

• People with borderline personality disorder should not be excluded from any health or social care service because of their diagnosis or because they have self-harmed

Access to services

Work in partnership with people with borderline personality disorder to develop their autonomy and promote choice by:

•ensuring they remain actively involved in finding solutions to their problems, including during crises

• encouraging them to consider the different treatment options and life choices available to them, and the consequences of the choices they make.

Autonomy and choice

• Explore treatment options in an atmosphere of hope and optimism, explaining that recovery is possible and attainable

• Build a trusting relationship, work in an open, engaging and non-judgemental manner, and be consistent and reliable

• Bear in mind when providing services that many people will have experienced rejection, abuse and trauma, and will have encountered stigma often associated with self-harm and borderline personality disorder

Developing an optimistic and trusting relationship

The ending of treatments or services, and transition between services can evoke strong emotions and reactions

•Anticipate, discuss, structure and phase changes carefully beforehand

•Build collaboration with other care providers into the care plan during endings and transitions – include access to services in times of crisis

•Ensure and agree support during referral periods to other services

Managing endings and supporting transitions

Community mental health services should be responsible for the routine assessment, treatment and management of people with borderline personality disorder

Assessment

Develop comprehensive multidisciplinary care plans in collaboration with the service user

•Identify the responsibilities of health and social care professionals

•Manageable treatment aims and specific steps

•Long-term treatment strategy underpinned by realistic goals linked to short-term treatment aims

•Crisis plan for when self-management strategies are insufficient

•Share care plan with GP and service user

Care planning

Service characteristics

• Explicit and integrated theoretical approach – shared with service user

• Structured care in accordance with guideline

• Provision for therapist supervision

• Consider twice-weekly sessions according to need and context

• Do not use brief psychotherapeutic interventions of less than 3 months’ duration

The role of psychological treatment

Drug treatment should not be used specifically for borderline personality disorder or for the individual symptoms or behaviour associated with the disorder

The role of drug treatment

• Assessment and treatment services

• Consultation and advice to primary and secondary care services

• Diagnostic services when general psychiatric services are in doubt about the diagnosis and/or management

• Facilitate information sharing among different services and collaborate with all relevant agencies within the local community

• Provide and/or advise on social and psychological interventions, and advise on the safe use of drug treatment in crises and for co-morbidities and insomnia

The role of specialist personality disorder services

•Develop protocols to govern arrangements for the transition ofyoung people from CAMHS to adult services

•Establish and maintain clear lines of communication between primary and secondary care

•Support, lead and participate in the local and national development of treatments

•Oversee the implementation of this guideline

•Develop and provide training programmes on diagnosis and management

•Monitor the provision of services for minority ethnic groups to ensure equality of service delivery.

The role of specialist personality disorder services

Costs

• Training healthcare professionals in recognition, diagnosis and treatment

• Establishing multidisciplinary teams

• Cross-organisation communication

• Consultation and treatment with a learning disabilities specialist

• An increase in the use of services because of greater awareness/diagnoses

• Provision of patient literature and video materials for treatment options

Discussion

• What services currently exist in this area?

• What provision do we have for people from minority ethnic groups or whose first language is not English?

• How effective is communication between services?

• How do we manage people with learning disabilities?

• How do we build openness and optimism?

• How do current local prescribing practices compare with the recommendations?

Find out more

Visit www.nice.org.uk/CG78 for:

•Other guideline formats•Costing report•Audit support