Implementing NICE guidance

2009

NICE clinical guideline 78

Borderline personality disorder

What this presentation covers

Background

Scope

Key priority areas for implementation

Costs

Discussion

Find out more

Characteristics

• Borderline personality disorder (BPD) 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 history of traumatic events during childhood and adolescence.

• People with BPD are among the most likely to use mental health services.

• BPD is particularly high in the prison population.

• Suicide is a particular risk in BPD.

Particular risks

Scope of guidance

• Adults diagnosed with BPD; young people with borderline symptoms and people with learning disabilities and BPD.

• NHS services providing treatment.

• Interface with other services.

• Effective clinical management.

Key priorities 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.

• Equal access to health and social care services regardless of diagnosis or a history of self-harm.

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 (community mental health teams, related community-based services, and tier 2/3 services in child and adolescent mental health services – CAMHS) should be responsible for the routine assessment, treatment and management of people with borderline personality disorder.

Assessment

Comprehensive multidisciplinary care plans developed 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 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 (for example, repeated self-harm, marked emotional instability, risk-taking behaviour and transient psychotic symptoms).

The role of drug treatment

• Assessment and treatment services.

• Consultation and advice to primary and secondary care services, and diagnostic services to assist general psychiatric services.

• Facilitate information sharing and collaboration, and ensure communication between primary and secondary care.

• Provide or advise on social, psychological and drug treatment, and on programmes on diagnosis and management.

• Oversee the transition of young people to adult services.

• Support, lead and participate in development of treatments.

• Oversee the implementation of this guideline.

• Monitor services for minority ethnic groups.

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 provisions 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?

• What are current local prescribing practices?

Find out more

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

•the guideline •the quick reference guide•‘Understanding NICE guidance’•costing report•audit support