Management of borderline personality disorder y community mental health services - NICE Pathways
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Management of borderline personality disorder by community mental health services NICE Pathways bring together everything NICE says on a topic in an interactive flowchart. NICE Pathways are interactive and designed to be used online. They are updated regularly as new NICE guidance is published. To view the latest version of this NICE Pathway see: http://pathways.nice.org.uk/pathways/personality-disorders NICE Pathway last updated: 10 August 2018 This document contains a single flowchart and uses numbering to link the boxes to the associated recommendations. Personality disorders Page 1 of 14 © NICE 2019. All rights reserved. Subject to Notice of rights.
Management of borderline personality disorder b
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© NICE 2019. All rights reserved. Subject to Notice of rights.Management of borderline personality disorder b
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1 Management of people with borderline personality disorder by
community mental health services
No additional information
2 Providing information about treatment
Before offering any treatment for a person with borderline personality disorder or for a comorbid
condition:
provide written material about the treatment being considered
consider offering alternative means of presenting the information, such as video or DVD, for
people who have reading difficulties
give them the opportunity to discuss this information including the evidence for the
effectiveness and potential harm of the treatment so that they can make an informed
choice.
NICE has written information for the public on borderline personality disorder.
3 Managing crises
Principles for managing crises
Consult the crisis plan and:
maintain a calm and non-threatening attitude
try to understand the crisis from the person's point of view
explore the person's reasons for distress
use empathic open questioning, including validating statements, to identify the onset and
the course of the current problems
seek to stimulate reflection about solutions
avoid minimising the person's stated reasons for the crisis
wait for full clarification of the problems before offering solutions
explore other options before considering admission to a crisis unit or inpatient admission
offer appropriate follow-up within a timeframe agreed with the person.
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Drug treatment during crises
Short-term drug treatments may be considered for people with borderline personality disorder
during a crisis.
Before starting short-term drug treatments:
ensure that there is consensus among prescribers and other involved professionals about
the drug used and that the primary prescriber is identified
establish likely risks of prescribing, including alcohol and illicit drug use
take account of the psychological role of prescribing (both for the individual and for the
prescriber) and the impact that prescribing decisions may have on the therapeutic
relationship and the overall care plan, including long-term treatment strategies
ensure that a drug is not used in place of other more appropriate interventions
use a single drug
avoid polypharmacy whenever possible.
When prescribing:
choose a drug (such as a sedative antihistamine1) that has a low side-effect profile, low
addictive properties, minimum potential for misuse and relative safety in overdose
use the minimum effective dose
prescribe fewer tablets more frequently if there is a significant risk of overdose
agree with the person the target symptoms, monitoring arrangements and anticipated
duration of treatment
agree a plan for adherence
discontinue the drug after a trial period if the target symptoms do not improve
consider alternative treatments, including psychological treatments, if target symptoms or
level of risk do not improve
arrange an appointment to review the overall care plan, including pharmacological and
other treatments, after the crisis has subsided.
Follow-up after a crisis
After a crisis has resolved or subsided, ensure that crisis plans, and if necessary the overall
care plan, are updated as soon as possible to reflect current concerns and identify which
treatment strategies have proved helpful. This should be done in conjunction with the person
with borderline personality disorder and their family or carers if possible, and should include:
a review of the crisis and its antecedents, taking into account environmental, personal and
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© NICE 2019. All rights reserved. Subject to Notice of rights.1 Sedative antihistamines are not licensed for this indication and informed consent should be obtained and documented. Personality disorders Page 5 of 14 © NICE 2019. All rights reserved. Subject to Notice of rights.
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relationship factors
a review of drug treatment, including benefits, side effects, any safety concerns and role in
the overall treatment strategy
a plan to stop drug treatment begun during a crisis, usually within 1 week
a review of psychological treatments, including their role in the overall treatment strategy
and their possible role in precipitating the crisis.
If drug treatment started during a crisis cannot be stopped within 1 week, review regularly to
monitor effectiveness, side effects, misuse and dependency. Agree frequency of the review with
the person and record it in the overall care plan.
4 Psychological treatment
When considering a psychological treatment, take into account:
the choice and preference of the service user
the degree of impairment and severity of the disorder
the person's willingness to engage with therapy and their motivation to change
the person's ability to remain within the boundaries of a therapeutic relationship
the availability of personal and professional support.
When providing psychological treatment:
ensure that the following service characteristics are in place, especially for people with
multiple comorbidities and/or severe impairment:
an explicit and integrated theoretical approach used by both treatment team and
therapist and shared with the service user
structured care in accordance with these recommendations
provision for therapist supervision.
consider twice-weekly psychotherapy sessions, although the frequency should be adapted
to the person's needs and context of living
do not use brief psychological interventions (of less than 3 months' duration) specifically for
borderline personality disorder or for the individual symptoms of the disorder outside a
service that has the characteristics outlined above.
For women with borderline personality disorder for whom reducing recurrent self-harm is a
priority, consider a comprehensive dialectical behaviour therapy programme.
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Use the CPA to clarify the roles of different services, professionals providing psychological
treatment and other healthcare professionals when providing psychological treatment as a
specific intervention in a person's overall treatment and care.
Monitor the effect of treatment on a broad range of outcomes, including personal functioning,
drug and alcohol use, self-harm, depression and the symptoms of borderline personality
disorder.
Quality standards
The following quality statement is relevant to this part of the interactive flowchart.
2. Psychological therapies – borderline personality disorder
5 Drug treatment
Do not use:
drug treatment 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)
antipsychotic drugs for the medium- and long-term treatment of borderline personality
disorder.
Consider drug treatment in the overall treatment of comorbid conditions.
Consider cautiously short-term use of sedative medication as part of the overall treatment plan
for people with borderline personality disorder in a crisis. Agree the duration of treatment with
them, but it should be no longer than 1 week.
Review the treatment of those who do not have a diagnosed comorbid mental or physical illness
and who are currently being prescribed drugs. Aim to reduce and stop unnecessary drug
treatment.
Quality standards
The following quality statement is relevant to this part of the interactive flowchart.
4. Pharmacological interventions
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6 Managing comorbidities
Before starting treatment for a comorbid condition in people with borderline personality disorder,
review:
the diagnosis of borderline personality disorder and that of the comorbid condition,
especially if either diagnosis has been made during a crisis or emergency presentation
the effectiveness and tolerability of previous and current treatments; discontinue ineffective
treatments.
When treating a comorbid condition in people with borderline personality disorder follow the
NICE guidance for the comorbid condition.
Depression, post-traumatic stress disorder, anxiety
Treat within a well-structured treatment programme for borderline personality disorder.
Major psychosis, dependence on alcohol or Class A drugs, severe eating disorder
Refer people to an appropriate service.
The care coordinator should keep in contact with people being treated for the comorbid
condition so that they can continue with treatment for borderline personality disorder when
appropriate.
For more information on comorbid mental disorders, see what NICE says on:
alcohol-use disorders
attention deficit hyperactivity disorder (ADHD)
depression
drug misuse
generalised anxiety disorder
obsessive-compulsive disorder and body dysmorphic disorder
post-traumatic stress disorder.
7 Managing insomnia
Provide people with borderline personality disorder who have sleep problems with general
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advice about sleep hygiene, including having a bedtime routine, avoiding caffeine, reducing
activities likely to defer sleep, and employing activities that may encourage sleep.
For the further short-term management of insomnia follow the recommendations in the NICE
technology appraisal guidance on the use of zaleplon, zolpidem and zopiclone for the short-
term management of insomnia (see below). However, be aware of the potential for misuse of
many of the drugs used for insomnia and consider other drugs such as sedative antihistamines.
Zolpidem and zopiclone
The following recommendations are from NICE technology appraisal guidance on the use of
zaleplon, zolpidem and zopiclone for the short-term management of insomnia.
When, after due consideration of the use of nonpharmacological measures, hypnotic drug
therapy is considered appropriate for the management of severe insomnia interfering with
normal daily life, it is recommended that hypnotics should be prescribed for short periods of time
only, in strict accordance with their licensed indications.
It is recommended that, because of the lack of compelling evidence to distinguish between
zolpidem, zopiclone or the shorter-acting benzodiazepine hypnotics, the drug with the lowest
purchase cost (taking into account daily required dose and product price per dose) should be
prescribed.
It is recommended that switching from one of these hypnotics to another should only occur if a
patient experiences adverse effects considered to be directly related to a specific agent. These
are the only circumstances in which the drugs with the higher acquisition costs are
recommended.
Patients who have not responded to one of these hypnotic drugs should not be prescribed any
of the others.
NICE has written information for the public on zolpidem and zopiclone.
8 Discharge to primary care
When discharging a person from secondary care to primary care, discuss the process with them
and, whenever possible, their family or carers beforehand. Agree a care plan that specifies the
steps they can take to try to manage their distress, how to cope with future crises and how to re-
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engage with community mental health services if needed. Inform the GP.
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Glossary
Anger control
usually offered to children who are aggressive at school, anger control includes a number of
cognitive and behavioural techniques similar to cognitive problem-solving skills training
Brief strategic family therapy
an intervention that is systemic in focus and is influenced by other approaches such as
structural/systemic family therapy. The main elements include engaging and supporting the
family, identifying maladaptive family interactions and seeking to promote new and more
adaptive family interactions
CAMHS
child and adolescent mental health service
Cognitive problem-solving skills training
an intervention that aims to reduce children's conduct problems by teaching them different
responses to interpersonal situations. Using cognitive and behavioural techniques with the child,
the training has a focus on thought processes.
The training includes:
teaching a step-by-step approach to solving interpersonal problems
structured tasks such as games and stories to aid the development of skills
combining a variety of approaches including modelling and practice, role-playing and
reinforcement
CPA
Care Programme Approach
Functional family therapy
family-based intervention that is behavioural in focus. The main elements include engagement
and motivation of the family in treatment, problem-solving and behaviour change through
parent-training and communication-training
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Multidimensional treatment foster care
using strategies from family therapy and behaviour therapy to intervene directly in systems and
processes related to antisocial behaviour (for example, parental discipline, family affective
relations, peer associations and school performances) for children or young people in foster
care and other out-of-home placements
Multisystemic therapy
using strategies from family therapy and behaviour therapy to intervene directly in systems and
processes related to antisocial behaviour (for example, parental discipline, family affective
relations, peer associations and school performances) for children or young people
Parent-training programme
an intervention that aims to teach the principles of child behaviour management, to increase
parental competence and confidence in raising children and to improve the parent/carer-child
relationship by using good communication and positive attention to aid the child's development
Self-talk
the internal conversation a person has with themselves in response to a situation. Using or
changing self-talk is a part of anger control training
Social problem-solving skills training
a specialist form of cognitive problem-solving training that aims to:
modify and expand the child's interpersonal appraisal processes through developing a more
sophisticated understanding of beliefs and desires in others
improve the child's capacity to regulate his or her own emotional responses
Sources
Borderline personality disorder: recognition and management (2009) NICE guideline CG78
Guidance on the use of zaleplon, zolpidem and zopiclone for the short-term management of
insomnia (2004) NICE technology appraisal guidance 77
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Your responsibility
Guidelines
The recommendations in this guideline represent the view of NICE, arrived at after careful
consideration of the evidence available. When exercising their judgement, professionals and
practitioners are expected to take this guideline fully into account, alongside the individual
needs, preferences and values of their patients or the people using their service. It is not
mandatory to apply the recommendations, and the guideline does not override the responsibility
to make decisions appropriate to the circumstances of the individual, in consultation with them
and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline
to be applied when individual professionals and people using services wish to use it. They
should do so in the context of local and national priorities for funding and developing services,
and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to
advance equality of opportunity and to reduce health inequalities. Nothing in this guideline
should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable
health and care system and should assess and reduce the environmental impact of
implementing NICE recommendations wherever possible.
Technology appraisals
The recommendations in this interactive flowchart represent the view of NICE, arrived at after
careful consideration of the evidence available. When exercising their judgement, health
professionals are expected to take these recommendations fully into account, alongside the
individual needs, preferences and values of their patients. The application of the
recommendations in this interactive flowchart is at the discretion of health professionals and
their individual patients and do not override the responsibility of healthcare professionals to
make decisions appropriate to the circumstances of the individual patient, in consultation with
the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable
the recommendations to be applied when individual health professionals and their patients wish
to use it, in accordance with the NHS Constitution. They should do so in light of their duties to
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have due regard to the need to eliminate unlawful discrimination, to advance equality of
opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable
health and care system and should assess and reduce the environmental impact of
implementing NICE recommendations wherever possible.
Medical technologies guidance, diagnostics guidance and interventional procedures
guidance
The recommendations in this interactive flowchart represent the view of NICE, arrived at after
careful consideration of the evidence available. When exercising their judgement, healthcare
professionals are expected to take these recommendations fully into account. However, the
interactive flowchart does not override the individual responsibility of healthcare professionals to
make decisions appropriate to the circumstances of the individual patient, in consultation with
the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in
their local context, in light of their duties to have due regard to the need to eliminate unlawful
discrimination, advance equality of opportunity, and foster good relations. Nothing in this
interactive flowchart should be interpreted in a way that would be inconsistent with compliance
with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable
health and care system and should assess and reduce the environmental impact of
implementing NICE recommendations wherever possible.
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