Skip Navigation
PrintDownload PDFGet Adobe ReaderDownload to WordDownload as HTMLDownload as XMLCitation Manager
Save to Favorites
Guideline Summary
Guideline Title
Borderline personality disorder: treatment and management.
Bibliographic Source(s)
National Collaborating Centre for Mental Health. Borderline personality disorder: treatment and management. London (UK): National Institute for Health and Clinical Excellence (NICE); 2009 Jan. 41 p. (Clinical guideline; no. 78). 
Guideline Status

This is the current release of the guideline.

Scope

Disease/Condition(s)

Borderline personality disorder

Note: The guideline also covers the treatment and management of people diagnosed with emotionally unstable personality disorder based on International Classification of Diseases, 10th Revision (ICD-10) criteria. This guideline does not cover the separate management of comorbid conditions.

Guideline Category
Counseling
Evaluation
Management
Risk Assessment
Treatment
Clinical Specialty
Family Practice
Internal Medicine
Pediatrics
Psychiatry
Psychology
Intended Users
Advanced Practice Nurses
Hospitals
Nurses
Patients
Physician Assistants
Physicians
Psychologists/Non-physician Behavioral Health Clinicians
Public Health Departments
Social Workers
Guideline Objective(s)
  • To make recommendations for the treatment and management of borderline personality disorder in adults and young people
  • To assist clinicians, people with borderline personality disorder, and their families/carers by identifying the merits of particular treatment approaches where the evidence from research and clinical experience exists
  • Specifically, the guideline aims to:
    • Evaluate the role of specific psychosocial interventions in the treatment of borderline personality disorder
    • Evaluate the role of specific pharmacological interventions in the treatment of borderline personality disorder
    • Integrate the above to provide best-practice advice on the care of individuals with a diagnosis of borderline personality disorder
    • Promote the implementation of best clinical practice through the development of recommendations tailored to the requirements of the National Health Service in England and Wales
Target Population

Adults and young people (under the age of 18) who meet criteria for the diagnosis of borderline personality disorder in primary, secondary, and tertiary care

Interventions and Practices Considered
  1. Referral to community mental health services
  2. Patient education (providing written materials about the disease and drugs being considered)
  3. Assessment of psychosocial and occupational functioning, coping strategies, comorbid mental disorders, need for psychological treatment
  4. Care planning including identifying short- and long-term goals, developing a crisis plan, using the Care Program Approach (CPA)
  5. Risk assessment including identifying risks to self and others
  6. Psychological treatment
  7. Drug treatment (e.g., sedatives)
  8. Management of comorbidities
  9. Management of crises
  10. Psychiatric unit admission of patients who pose significant risk to self or others that cannot be managed within other services
Major Outcomes Considered
  • Clinical effectiveness
    • Anger
    • Anxiety
    • Depression
    • Impulsiveness
    • Mental distress
    • Self-harm and suicide-related measures
    • Hospital admission and emergency department visits
    • Social and general functioning
    • Employment-related outcomes
  • Quality of life
  • Cost-effectiveness

Methodology

Methods Used to Collect/Select the Evidence
Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases
Searches of Unpublished Data
Description of Methods Used to Collect/Select the Evidence

Note from the National Guideline Clearinghouse (NGC): This guideline was developed by the National Collaborating Centre for Mental Health (NCCMH) on behalf of the National Institute for Health and Clinical Excellence (NICE). See the "Availability of Companion Documents" field for the full version of this guidance.

Systematic Clinical Literature Review

The aim of the clinical literature review was to systematically identify and synthesise relevant evidence from the literature in order to answer the specific clinical questions developed by the Guideline Development Group (GDG).

Methodology

A stepwise, hierarchical approach was taken to locating and presenting evidence to the GDG. The NCCMH developed this process based on methods set out in The Guidelines Manual (NICE, 2006; see the "Availability of Companion Documents" field) and after considering recommendations from a range of other sources. These included:

  • Clinical Policy and Practice Program of the New South Wales Department of Health (Australia)
  • Clinical Evidence Online
  • The Cochrane Collaboration
  • New Zealand Guidelines Group
  • National Health Service (NHS) Centre for Reviews and Dissemination
  • Oxford Centre for Evidence-Based Medicine
  • Scottish Intercollegiate Guidelines Network (SIGN)
  • United States Agency for Healthcare Research and Quality
  • Oxford Systematic Review Development Programme
  • Grading of Recommendations: Assessment, Development, and Evaluation (GRADE) Working Group

The Review Process

Searches

The standard mental health related bibliographic databases were searched including EMBASE, MEDLINE, PsycINFO, and Central, together with the grey literature database Healthcare Management Information Consortium (HMIC). Search filters developed by the review team consisted of a combination of subject heading and free-text phrases. Specific filters were developed for the guideline topic and, where necessary, for individual clinical questions. The topic-specific filters were combined with appropriate research design filters developed for systematic reviews, randomised controlled trials (RCTs) and other appropriate research designs (refer to Appendix 7 in the full version of the original guideline document [see the "Availability of Companion Documents" field]).

The review team also scanned the reference lists of included studies and existing systematic reviews for additional references, together with evidence submitted by stakeholders. Unpublished evidence was also sought. In addition, the tables of contents of appropriate journals were checked regularly for relevant studies. Searches for evidence were re-run every 6 months during the guideline development process with the final search undertaken between 6 and 8 weeks before submission of the consultation drafts. After this point, studies were included only if they were judged by the GDG to be exceptional (for example, the evidence was likely to change a recommendation).

The Search Process for Questions Concerning Interventions

For questions related to interventions, the initial evidence base was formed from well-conducted randomised controlled trials (RCTs) that addressed at least one of the clinical questions (the review process is illustrated in Flowchart 1 of the full version of the original guideline document [see the "Availability of Companion Documents" field]).

Although there are a number of difficulties with the use of RCTs in the evaluation of interventions in mental health, the RCT remains the most important method for establishing treatment efficacy. For other clinical questions, searches were for the appropriate study design.

Since it was known from a review of existing systematic reviews in this area that the evidence base for borderline personality disorder was relatively small, a search for all randomised controlled trials for this topic area was undertaken together regardless of intervention.

After the initial search results were scanned liberally to exclude irrelevant papers, the review team used a purpose-built study information database to manage both the included and the excluded studies (eligibility criteria were developed after consultation with the GDG). For questions without good-quality evidence (after the initial search), a decision was made by the GDG about whether to (a) repeat the search using subject-specific databases (e.g., CINAHL, AMED, SIGLE, or PILOTS), (b) conduct a new search for lower levels of evidence or (c) adopt a consensus process.

Study Selection

All primary-level studies included after the first scan of citations were acquired in full and re-evaluated for eligibility at the time they were being entered into the study information database. Appendix 8 in the full version of the original guideline document (see the "Availability of Companion Documents" field) lists the standard inclusion and exclusion criteria. More specific eligibility criteria were developed for each clinical question and are described in the relevant clinical evidence chapters (see the "Availability of Companion Documents" field).

Studies were critically appraised for methodological quality (see Appendix 9 and Appendix 16 in the full version of the original guideline document [see the "Availability of Companion Documents" field]). The eligibility of each study was confirmed by at least one member of the appropriate topic group. For some clinical questions, it was necessary to prioritise the evidence with respect to the UK context (that is, external validity). To make this process explicit, the topic groups took into account the following factors when assessing the evidence:

  • Participant factors (for example, comorbid diagnoses, and setting)
  • Provider factors (for example, model fidelity, the conditions under which the intervention was performed and the availability of experienced staff to undertake the procedure)
  • Cultural factors (for example, differences in standard care and differences in the welfare system)

It was the responsibility of each topic group to decide which prioritisation factors were relevant to each clinical question in light of the UK context and then decide how they should modify their recommendations.

Unpublished Evidence

The GDG used a number of criteria when deciding whether or not to accept unpublished data. First, the evidence must have been accompanied by a trial report containing sufficient detail to properly assess the quality of the data. Second, the evidence must have been submitted with the understanding that data from the study and a summary of the study's characteristics would be published in the full guideline. Therefore, the GDG did not accept evidence submitted as commercial in confidence. However, the GDG recognised that unpublished evidence submitted by investigators might later be retracted by those investigators if the inclusion of such data would jeopardise publication of their research.

Health Economics Review Strategies

Search Strategy

For the systematic review of economic evidence the standard mental-health-related bibliographic databases (EMBASE, MEDLINE, CINAHL and PsycINFO) were searched. For these databases, a health economics search filter adapted from the Centre for Reviews and Dissemination at the University of York was used in combination with the general strategy for borderline personality disorder. Additional searches were performed in specific health economics databases (National Health Service Economic Evaluation Database [NHS EED], Office of Health Economics, Health Economics Evaluation Database [OHE HEED]), as well as in the Health Technology Assessment [HTA] database. For the HTA and NHS EED databases, the general strategy for borderline personality disorder was used. OHE HEED was searched using a shorter, database-specific strategy. Initial searches were performed in January 2007. The searches were updated regularly, with the final search performed in May 2008. Details on the search strategies adopted for the systematic review of economic evidence are provided in Appendix 12 of the full version of the original guideline document (see the "Availability of Companion Documents" field).

In parallel to searches of electronic databases, reference lists of eligible studies and relevant reviews were searched by hand. Studies included in the clinical evidence review were also screened for economic evidence.

The systematic search of the literature resulted in 3,656 references in total. Publications that were clearly not relevant to the topic (that is, did not provide any information on the economics of borderline personality disorder) were excluded first. The abstracts of all potentially relevant publications (58 papers) were then assessed against a set of inclusion criteria by the health economist. Full texts of the studies potentially meeting the inclusion criteria (including those for which eligibility was not clear from the abstract) were obtained. At this stage, 30 studies had been selected. Studies that did not meet the inclusion criteria, were duplicates, were secondary publications of one study, or had been updated in more recent publications were subsequently excluded. Finally, 18 studies that provided information on the economics of borderline disorder were selected. Of these, 10 were cost-of-illness studies or studies that reported data on healthcare resource use associated with borderline personality disorder in general, and 8 studies were economic evaluations of specific interventions for people with borderline personality disorder covered in this guideline. All economic evaluations eligible for inclusion in the systematic review of economic literature were critically appraised according to the checklists used by the British Medical Journal to assist referees in appraising full and partial economic analyses (see Appendix 13 in the full version of the original guideline document [see the "Availability of Companion Documents" field]).

Inclusion/Exclusion Criteria

The following inclusion/exclusion criteria were applied to select studies identified by the economic searches for further analysis:

  • No restriction was placed on language or publication status of the papers
  • Studies published from 1996 onwards were included. This date restriction was imposed in order to obtain data relevant to current healthcare settings and costs
  • Only studies from Organisation for Economic Co-operation and Development countries were included, as the aim of the review was to identify economic information transferable to the UK context
  • Selection criteria based on types of clinical conditions and patients were identical to the clinical literature review; the intention was to include studies that provided data exclusively on people with borderline personality disorder; however, when no studies answering a specific economic question met this criterion, the criterion was relaxed and economic studies considering a wider study population relevant to people with borderline personality disorder were included in the review, following GDG's consensus.
  • Studies were included provided that sufficient details regarding methods and results were available to enable the methodological quality of the study to be assessed, and provided that the study's data and results were extractable; poster presentations or abstracts were excluded from review
  •  Full economic evaluations that compared two or more relevant options and considered both costs and consequences (that is, cost-consequence analyses, cost-effectiveness analyses, cost–utility analyses or cost– benefit analyses) as well as partial economic evaluations (that is, costing analyses) were included in the systematic review
  • Economic studies that omitted intervention costs from analysis were excluded from review, as their results were considered potentially misleading.
Number of Source Documents

Clinical Effectiveness: Not stated

Cost-Effectiveness: Eighteen studies that provided information on the economics of borderline disorder were selected.

Methods Used to Assess the Quality and Strength of the Evidence
Expert Consensus
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

The quality of the evidence was based on the quality assessment components (study design, limitations to study quality, consistency, directness and any other considerations) and graded using the following definitions:

  • High - Further research is very unlikely to change the confidence in the estimate of the effect.
  • Moderate - Further research is likely to have an important impact on the confidence in the estimate of the effect and may change the estimate.
  • Low - Further research is very likely to have an important impact on the confidence in the estimate of the effect and is likely to change the estimate.
  • Very low - Any estimate of effect is very uncertain.
Methods Used to Analyze the Evidence
Meta-Analysis
Review of Published Meta-Analyses
Systematic Review with Evidence Tables
Description of the Methods Used to Analyze the Evidence

Note from the National Guideline Clearinghouse (NGC): This guideline was developed by the National Collaborating Centre for Mental Health (NCCMH) on behalf of the National Institute for Health and Clinical Excellence (NICE). See the "Availability of Companion Documents" field for the full version of this guidance.

Clinical Effectiveness

Data Extraction

Outcome data were extracted from all eligible studies, which met the quality criteria, using a standardised form (see Appendix 8 in the full version of the original guideline document [see the "Availability of Companion Documents" field]). Study characteristics were also extracted into an Access database. Full study characteristics are in Appendix 16 of the full version of the original guideline document with summary tables in the evidence chapters.

For a given outcome (continuous and dichotomous), where more than 50% of the number randomised to any group were not accounted for by trial authors, the data were excluded from the review because of the risk of bias. However, where possible, dichotomous efficacy outcomes were calculated on an intention-to-treat basis (that is, a 'once-randomised-always-analyse' basis). This assumes that those participants who ceased to engage in the study — from whatever group — had an unfavourable outcome. This meant that the 50% rule was not applied to dichotomous outcomes where there was good evidence that those participants who ceased to engage in the study were likely to have an unfavourable outcome (in this case, early withdrawals were included in both the numerator and denominator). Adverse effects were entered into Review Manager as reported by the study authors because it was usually not possible to determine whether early withdrawals had an unfavourable outcome. For the outcome 'leaving the study early for any reason', the denominator was the number randomised.

Consultation was used to overcome difficulties with coding. Data from studies included in existing systematic reviews were extracted independently by one reviewer and cross-checked with the existing data set. Where possible, two independent reviewers extracted data from new studies. Where double data extraction was not possible, data extracted by one reviewer was checked by the second reviewer. Disagreements were resolved with discussion. Where consensus could not be reached, a third reviewer resolved the disagreement. Masked assessment (that is, blind to the journal from which the article comes, the authors, the institution and the magnitude of the effect) was not used since it is unclear that doing so reduces bias.

Synthesising the Evidence

Where possible, meta-analysis was used to synthesise the evidence using Review Manager 4.2.8 (Cochrane Collaboration, 2005). If necessary, reanalyses of the data or sub-analyses were used to answer clinical questions not addressed in the original studies or reviews.

Dichotomous outcomes were analysed as relative risks (RR) with the associated 95% confidence interval (CI). A relative risk (also called a risk ratio) is the ratio of the treatment event rate to the control event rate.  An RR of 1 indicates no difference between treatment and control.

Continuous outcomes were analysed as weighted mean differences (WMD), or as a standardised mean difference (SMD) when different measures were used in different studies to estimate the same underlying effect. If provided, intention-to-treat data, using a method such as 'last observation carried forward', were preferred over data from completers.

To check for consistency between studies, both the I2 test of heterogeneity and a visual inspection of the forest plots were used. The I2 statistic describes the proportion of total variation in study estimates that is due to heterogeneity.

To explore the possibility that the results entered into each meta-analysis suffered from publication bias, data from included studies were entered, where there were sufficient data, into a funnel plot. Asymmetry of the plot was taken to indicate possible publication bias and investigated further. An estimate of the proportion of eligible data that were missing (because some studies did not include all relevant outcomes) was calculated for each analysis.

Presenting the Data to the Guideline Development Group (GDG)

Summary characteristics tables and, where appropriate, forest plots generated with Review Manager were presented to the GDG in order to prepare an evidence profile for each review and to develop recommendations.

Evidence Profile Tables

An evidence profile table was used to summarise both the quality of the evidence and the results of the evidence synthesis (see Table 3 in the full version of the original guideline document [see the "Availability of Companion Documents" field] for an example of an evidence profile table). Each table included details about the quality assessment of each outcome: quality of the included studies based on the Scottish Intercollegiate Guideline Network (SIGN) grade (see Appendix 9 in the full version of the original guideline document for checklist), number of studies, and limitations, information about the consistency of the evidence, directness of the evidence (that is, how closely the outcome measures, interventions and participants match those of interest) and any other considerations (for example, effect sizes with wide confidence intervals would be described as imprecise data). Each evidence profile also included a summary of the findings: number of patients included in each group, an estimate of the magnitude of the effect, quality of the evidence, and the importance of the evidence.

Refer to Section 3.5 in the full version of the original guideline document (see the "Availability of Companion Documents" field) for more information on data extraction and synthesizing evidence.

Cost-Effectiveness

Data Extraction

Data were extracted by the health economist using a standard economic data extraction form (see Appendix 14 in the full version of the original guideline document [see the "Availability of Companion Documents" field]).

Presentation of Economic Evidence

The economic evidence identified by the health economics systematic review is summarised in the respective chapters of the full version of the original guideline, following presentation of the clinical evidence. The characteristics and results of all economic studies included in the review are provided in the form of evidence tables in Appendix 15 of the full version of the original guideline document (see the "Availability of Companion Documents" field).

Methods Used to Formulate the Recommendations
Expert Consensus
Informal Consensus
Description of Methods Used to Formulate the Recommendations

Note from the National Guideline Clearinghouse (NGC): This guideline was developed by the National Collaborating Centre for Mental Health (NCCMH) on behalf of the National Institute for Health and Clinical Excellence (NICE). See the "Availability of Companion Documents" field for the full version of this guidance.

The Guideline Development Group (GDG)

The GDG was made up of professionals in psychiatry, clinical psychology, nursing, and general practice; academic experts in psychiatry and psychology; two former service users and a carer. The guideline development process was supported by staff from the NCCMH, who undertook the clinical and health economics literature searches, reviewed and presented the evidence to the GDG, managed the process, and contributed to drafting the guideline.

Guideline Development Group Meetings

Seventeen GDG meetings were held between January 2007 and September 2008. During each day-long GDG meeting, in a plenary session, clinical questions and clinical and economic evidence were reviewed and assessed, and recommendations formulated.

Topic Groups

The GDG divided its workload along clinically relevant lines to simplify the guideline development process, and GDG members formed smaller topic groups to undertake guideline work in that area of clinical practice. Topic group 1 covered questions relating to pharmacological interventions. Topic group 2 covered psychological therapies (with a sub-group covering therapeutic communities), topic Group 3 covered services, topic group 4 covered young people, and topic group 5 covered service user and family/carer issues. These groups were designed to manage the appraisal of the evidence more efficiently prior to presenting it to the GDG as a whole. Each topic group was chaired by a GDG member with expert knowledge of the topic area (one of the healthcare professionals or service users as appropriate). Topic groups refined the clinical questions, refined the clinical definitions of treatment interventions, reviewed and prepared the evidence with NCCMH staff before presenting it to the GDG as a whole, and also helped the GDG to identify further expertise in the topic. Topic group leaders reported the status of the group's work as part of the standing agenda. They also introduced and led the GDG discussion of the evidence review for that topic and assisted the GDG Chair in drafting the section of the guideline relevant to the work of each topic group.

Clinical Questions

Clinical questions were used to guide the identification and interrogation of the evidence base relevant to the topic of the guideline. Before the first GDG meeting, draft questions were prepared by NCCMH staff based on the scope. They were then discussed by the GDG at their first two meetings and a final list drawn up. Where appropriate, the questions were refined once the evidence had been searched and, where necessary, sub-questions were generated. The final list of clinical questions can be found in Appendix 6 of the full version of the original guideline document (see the "Availability of Companion Documents" field).

Forming the Clinical Summaries and Recommendations

Once the evidence profile tables relating to a particular clinical question were completed, summary tables incorporating important information from the evidence profile and an assessment of the clinical significance of the evidence were produced. Finally, the systematic reviewer along with the topic group lead produced a clinical summary.

Once the evidence profile tables and clinical summaries were finalised and agreed by the GDG, the associated recommendations were produced, taking into account the trade-off between the benefits and risks as well as other important factors. These included economic considerations, values of the development group and society, and the group's awareness of practical issues.

Method Used to Answer a Clinical Question in the Absence of Appropriately Designed, High-Quality Research

In the absence of level I evidence (or a level that is appropriate to the question), or where the GDG were of the opinion (on the basis of previous searches or their knowledge of the literature) that there were unlikely to be such evidence, either an informal or formal consensus process was adopted. This process focused on those questions that the GDG considered a priority.

Informal Consensus

The starting point for the process of informal consensus was that a member of the topic group identified, with help from the systematic reviewer, a narrative review that most directly addressed the clinical question. Where this was not possible, a brief review of the recent literature was initiated.

This existing narrative review or new review was used as a basis for beginning an iterative process to identify lower levels of evidence relevant to the clinical question and to lead to written statements for the guideline. The process involved a number of steps:

  1. A description of what is known about the issues concerning the clinical question was written by one of the topic group members
  2. Evidence from the existing review or new review was then presented in narrative form to the GDG and further comments were sought about the evidence and its perceived relevance to the clinical question
  3. Based on the feedback from the GDG, additional information was sought and added to the information collected. This may include studies that did not directly address the clinical question but were thought to contain relevant data
  4. If, during the course of preparing the report, a significant body of primary-level studies (of appropriate design to answer the question) were identified, a full systematic review was done
  5. At this time, subject possibly to further reviews of the evidence, a series of statements that directly addressed the clinical question were developed
  6. Following this, on occasions and as deemed appropriate by the development group, the report was then sent to appointed experts outside of the GDG for peer review and comment. The information from this process was then fed back to the GDG for further discussion of the statements
  7. Recommendations were then developed
  8. After this final stage of comment, the statements and recommendations were again reviewed and agreed upon by the GDG
Rating Scheme for the Strength of the Recommendations

Not applicable

Cost Analysis

Health Economics Evidence on Brief Psychological Interventions

The systematic search of economic literature identified two studies that assessed the cost-effectiveness of brief psychological interventions for borderline personality disorder. One study assessed the cost effectiveness of manually-assisted cognitive therapy (MACT) versus treatment as usual (TAU) in a sample of 397 people with recurrent deliberate self-harm participating in a UK-based randomised controlled trial (RCT). Outcomes were expressed as the proportion of people with a repeat self-harm episode and as number of quality adjusted life years (QALYs).

Results were presented in the form of incremental cost effectiveness ratios (ICERs), which express the difference in total cost divided by the difference in the measure of effectiveness between interventions examined. The authors conducted univariate sensitivity analysis on a number of cost parameters, to investigate the robustness of the results under use of different values and assumptions. In addition, they used bootstrapping techniques to generate distributions of costs and clinical outcomes for the two interventions. Results of probabilistic analysis were presented in the form of cost effectiveness acceptability curves (CEACs), which demonstrate the probability of each treatment option being cost-effective at different levels decision-makers might be willing to pay per unit of effectiveness (that is, at different potential cost effectiveness thresholds set by decision-makers).

MACT was found to be slightly less costly than TAU (13,450 pounds sterling versus 14,288 pounds sterling, respectively, in 1999/2000 prices), but this difference was non-significant.

MACT was more effective than TAU in terms of proportion of people with a repeat self-harm episode (39% in the MACT group versus 46% in the TAU group); again, this finding was not statistically significant. According to these results, MACT was less costly and more effective than TAU; this means that MACT was dominant over TAU, and therefore more cost-effective.

Refer to Section 5.3.4 of the full version of the original guideline document (see the "Availability of Companion Documents" field) for additional information on cost analyses.

Method of Guideline Validation
External Peer Review
Internal Peer Review
Description of Method of Guideline Validation

The guideline was validated through two consultations.

  1. The first draft of the guideline (The full guideline, National Institute for Clinical Excellence [NICE] guideline and Quick Reference Guide) were consulted with Stakeholders and comments were considered by the Guideline Development Group (GDG)
  2. The final consultation draft of the full guideline, the NICE guideline and the Information for the Public were submitted to stakeholders for final comments.

The final draft was submitted to the Guideline Review Panel for review prior to publication.

Recommendations

Major Recommendations

Note from the National Guideline Clearinghouse (NGC): This guideline was developed by the National Collaborating Centre for Mental Health (NCCMH) on behalf of the National Institute for Health and Clinical Excellence (NICE). See the "Availability of Companion Documents" field for the full version of this guidance.

General Principles for Working with People with Borderline Personality Disorder

Access to Services

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.

Young people with a diagnosis of borderline personality disorder, or symptoms and behaviour that suggest it, should have access to the full range of treatments and services recommended in this guideline, but within child and adolescent mental health services (CAMHS).

Ensure that people with borderline personality disorder from black and minority ethnic groups have equal access to culturally appropriate services based on clinical need.

When language is a barrier to accessing or engaging with services for people with borderline personality disorder, provide them with:

  • Information in their preferred language and in an accessible format
  • Psychological or other interventions in their preferred language
  • Independent interpreters

Borderline Personality Disorder and Learning Disabilities

When a person with a mild learning disability presents with symptoms and behaviour that suggest borderline personality disorder, assessment and diagnosis should take place in consultation with a specialist in learning disabilities services.

When a person with a mild learning disability has a diagnosis of borderline personality disorder, they should have access to the same services as other people with borderline personality disorder.

When care planning for people with a mild learning disability and borderline personality disorder, follow the Care Programme Approach (CPA). Consider consulting a specialist in learning disabilities services when developing care plans and strategies for managing behaviour that challenges.

People with a moderate or severe learning disability should not normally be diagnosed with borderline personality disorder. If they show behaviour and symptoms that suggest borderline personality disorder, refer for assessment and treatment by a specialist in learning disabilities services.

Autonomy and Choice

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

Developing an Optimistic and Trusting Relationship

When working with people with borderline personality disorder:

  • 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 encountered stigma often associated with self-harm and borderline personality disorder

Involving Families or Carers

Ask directly whether the person with borderline personality disorder wants their family or carers to be involved in their care, and, subject to the person's consent and rights to confidentiality:

  • Encourage family or carers to be involved
  • Ensure that the involvement of families or carers does not lead to withdrawal of, or lack of access to, services
  • Inform families or carers about local support groups for families or carers, if these exist

CAMHS professionals working with young people with borderline personality disorder should:

  • Balance the developing autonomy and capacity of the young person with the responsibilities of parents or carers
  • Be familiar with the legal framework that applies to young people, including the Mental Capacity Act, the Children Acts and the Mental Health Act

Principles for Assessment

When assessing a person with borderline personality disorder:

  • Explain clearly the process of assessment
  • Use non-technical language whenever possible
  • Explain the diagnosis and the use and meaning of the term borderline personality disorder
  • Offer post-assessment support, particularly if sensitive issues, such as childhood trauma, have been discussed

Managing Endings and Supporting Transitions

Anticipate that withdrawal and ending of treatments or services, and transition from one service to another, may evoke strong emotions and reactions in people with borderline personality disorder. Ensure that:

  • Such changes are discussed carefully beforehand with the person (and their family or carers if appropriate) and are structured and phased
  • The care plan supports effective collaboration with other care providers during endings and transitions, and includes the opportunity to access services in times of crisis
  • When referring a person for assessment in other services (including for psychological treatment), they are supported during the referral period and arrangements for support are agreed beforehand with them

CAMHS and adult healthcare professionals should work collaboratively to minimise any potential negative effect of transferring young people from CAMHS to adult services. They should:

  • Time the transfer to suit the young person, even if it takes place after they have reached the age of 18 years
  • Continue treatment in CAMHS beyond 18 years if there is a realistic possibility that this may avoid the need for referral to adult mental health services

Managing Self-Harm and Attempted Suicide

Follow the recommendations in 'Self-harm: the short-term physical and psychological management and secondary prevention of self-harm in primary and secondary care' to manage episodes of self-harm or attempted suicide.

Training, Supervision and Support

Mental health professionals working in secondary care services, including community-based services and teams, CAMHS, and inpatient services, should be trained to diagnose borderline personality disorder, assess risk and need, and provide treatment and management in accordance with this guideline. Training should also be provided for primary care healthcare professionals who have significant involvement in the assessment and early treatment of people with borderline personality disorder. Training should be provided by specialist personality disorder teams based in mental health trusts.

Mental health professionals working with people with borderline personality disorder should have routine access to supervision and staff support.

Recognition and Management in Primary Care

Recognition of Borderline Personality Disorder

If a person presents in primary care who has repeatedly self-harmed or shown persistent risk-taking behaviour or marked emotional instability, consider referring them to community mental health services for assessment for borderline personality disorder. If the person is younger than 18 years, refer them to CAMHS for assessment.

Crisis Management in Primary Care

When a person with an established diagnosis of borderline personality disorder presents to primary care in a crisis:

  • Assess the current level of risk to self or others
  • Ask about previous episodes and effective management strategies used in the past
  • Help to manage their anxiety by enhancing coping skills and helping them to focus on the current problems
  • Encourage them to identify manageable changes that will enable them to deal with the current problems
  • Offer a follow-up appointment at an agreed time.

Referral to Community Mental Health Services

Consider referring a person with diagnosed or suspected borderline personality disorder who is in crisis to a community mental health service when:

  • Their levels of distress and/or the risk to self or others are increasing
  • Their levels of distress and/or the risk to self or others have not subsided despite attempts to reduce anxiety and improve coping skills
  • They request further help from specialist services.

Assessment and Management by Community Mental Health Services

Assessment

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

When assessing a person with possible borderline personality disorder in community mental health services, fully assess:

  • Psychosocial and occupational functioning, coping strategies, strengths, and vulnerabilities
  • Comorbid mental disorders and social problems
  • The need for psychological treatment, social care and support, and occupational rehabilitation or development
  • The needs of any dependent children (See the May 2008 Social Care Institute for Excellence research briefing 'Experiences of children and young people caring for a parent with a mental health problem'. Available from www.scie.org.uk/publications/briefings/files/briefing24.pdf External Web Site Policy)

Care Planning

Teams working with people with borderline personality disorder should develop comprehensive multidisciplinary care plans in collaboration with the service user (and their family or carers, where agreed with the person). The care plan should:

  • Identify clearly the roles and responsibilities of all health and social care professionals involved
  • Identify manageable short-term treatment aims and specify steps that the person and others might take to achieve them
  • Identify long-term goals, including those relating to employment and occupation, that the person would like to achieve, which should underpin the overall long-term treatment strategy; these goals should be realistic and linked to the short-term treatment aims
  • Develop a crisis plan that identifies potential triggers that could lead to a crisis, specifies self-management strategies likely to be effective and establishes how to access services (including a list of support numbers for out-of-hours teams and crisis teams) when self-management strategies alone are not enough
  • Be shared with the general practitioner (GP) and the service user.

Teams should use the Care Programme Approach (CPA) when people with borderline personality disorder are routinely or frequently in contact with more than one secondary care service. It is particularly important if there are communication difficulties between the service user and healthcare professionals, or between healthcare professionals.

Risk Assessment and Management

Risk assessment in people with borderline personality disorder should:

  • Take place as part of a full assessment of the person's needs
  • Differentiate between long-term and more immediate risks
  • Identify the risks posed to self and others, including the welfare of any dependent children.

Agree explicitly the risks being assessed with the person with borderline personality disorder and develop collaboratively risk management plans that:

  • Address both the long-term and more immediate risks
  • Relate to the overall long-term treatment strategy
  • Take account of changes in personal relationships, including the therapeutic relationship.

When managing the risks posed by people with borderline personality disorder in a community mental health service, risks should be managed by the whole multidisciplinary team with good supervision arrangements, especially for less experienced team members. Be particularly cautious when:

  • Evaluating risk if the person is not well known to the team
  • There have been frequent suicidal crises.

Teams working with people with borderline personality disorder should review regularly the team members' tolerance and sensitivity to people who pose a risk to themselves and others. This should be reviewed annually (or more frequently if a team is regularly working with people with high levels of risk).

Psychological Treatment

When considering a psychological treatment for a person with borderline personality disorder, 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.

Before offering a psychological treatment for a person with borderline personality disorder or for a comorbid condition, provide the person with written material about the psychological treatment being considered. For people who have reading difficulties, alternative means of presenting the information should be considered, such as video or DVD. So that the person can make an informed choice, there should be an opportunity for them to discuss not only this information but also the evidence for the effectiveness of different types of psychological treatment for borderline personality disorder and any comorbid conditions.

When providing psychological treatment for people with borderline personality disorder, especially those with multiple comorbidities and/or severe impairment, the following service characteristics should be in place:

  • An explicit and integrated theoretical approach used by both the treatment team and the therapist, which is shared with the service user
  • Structured care in accordance with this guideline
  • Provision for therapist supervision.

Although the frequency of psychotherapy sessions should be adapted to the person's needs and context of living, twice-weekly sessions may be considered.

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.

When providing psychological treatment to people with borderline personality disorder as a specific intervention in their overall treatment and care, use the CPA to clarify the roles of different services, professionals providing psychological treatment and other healthcare professionals.

When providing psychological treatment to people with borderline personality disorder, 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.

The Role of Drug 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).

Antipsychotic drugs should not be used for the medium- and long-term treatment of borderline personality disorder.

Drug treatment may be considered in the overall treatment of comorbid conditions (see below under "The Management of Comorbidities").

Short-term use of sedative medication may be considered cautiously as part of the overall treatment plan for people with borderline personality disorder in a crisis. (Note: Sedative antihistamines are not licensed for this indication and informed consent should be obtained and documented.) The duration of treatment should be agreed with them, but should be no longer than 1 week (see section "The Management of Crises," below).

When considering drug treatment for any reason for a person with borderline personality disorder, provide the person with written material about the drug being considered. This should include evidence for the drug's effectiveness in the treatment of borderline personality disorder and for any comorbid condition, and potential harm. For people who have reading difficulties, alternative means of presenting the information should be considered, such as video or DVD. So that the person can make an informed choice, there should be an opportunity for the person to discuss the material.

Review the treatment of people with borderline personality disorder who do not have a diagnosed comorbid mental or physical illness and who are currently being prescribed drugs, with the aim of reducing and stopping unnecessary drug treatment.

The Management of 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.

Treat comorbid depression, post-traumatic stress disorder, or anxiety within a well-structured treatment programme for borderline personality disorder.

Refer people with borderline personality disorder who also have major psychosis, dependence on alcohol or Class A drugs, or a severe eating disorder 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.

When treating a comorbid condition in people with borderline personality disorder, follow the NICE clinical guideline for the comorbid condition.

The Management of Crises

The following principles and guidance on the management of crises apply to secondary care and specialist services for personality disorder. They may also be of use to GPs with a special interest in the management of borderline personality disorder within primary care.

Principles and General Management of Crises

When a person with borderline personality disorder presents during a crisis, 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
  • Refrain from offering solutions before receiving full clarification of the problems
  • Explore other options before considering admission to a crisis unit or inpatient admission
  • Offer appropriate follow-up within a time frame agreed with the person.

Drug Treatment During Crises

Short-term use of drug treatments may be helpful for people with borderline personality disorder during a crisis.

Before starting short-term drug treatments for people with borderline personality disorder during a crisis:

  • 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 short-term drug treatment for people with borderline personality disorder in a crisis:

  • Choose a drug (such as a sedative antihistamine) 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 with the person a plan for adherence
  • Discontinue a drug after a trial period if the target symptoms do not improve
  • Consider alternative treatments, including psychological treatments, if target symptoms do not improve or the level of risk does not diminish
  • 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 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, there should be a regular review of the drug to monitor effectiveness, side effects, misuse and dependency. The frequency of the review should be agreed with the person and recorded in the overall care plan.

The Management of Insomnia

Provide people with borderline personality disorder who have sleep problems with general advice about sleep hygiene, including having a bedtime routine, avoiding caffeine, reducing activities likely to defer sleep (such as watching violent or exciting television programmes or films), and employing activities that may encourage sleep.

For the further short-term management of insomnia follow the recommendations in 'Guidance on the use of zaleplon, zolpidem and zopiclone for the short-term management of insomnia'. However, be aware of the potential for misuse of many of the drugs used for insomnia and consider other drugs such as sedative antihistamines.

Discharge to Primary Care

When discharging a person with borderline personality disorder 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-engage with community mental health services if needed. Inform the GP.

Inpatient Services

Before considering admission to an acute psychiatric inpatient unit for a person with borderline personality disorder, first refer them to a crisis resolution and home treatment team or other locally available alternative to admission.

Only consider people with borderline personality disorder for admission to an acute psychiatric inpatient unit for:

  • The management of crises involving significant risk to self or others that cannot be managed within other services
  • Detention under the Mental Health Act (for any reason)

When considering inpatient care for a person with borderline personality disorder, actively involve them in the decision and:

  • Ensure the decision is based on an explicit, joint understanding of the potential benefits and likely harm that may result from admission
  • Agree the length and purpose of the admission in advance
  • Ensure that when, in extreme circumstances, compulsory treatment is used, management on a voluntary basis is resumed at the earliest opportunity.

Arrange a formal CPA review for people with borderline personality disorder who have been admitted twice or more in the previous 6 months.

National Health Service (NHS) trusts providing CAMHS should ensure that young people with severe borderline personality disorder have access to tier 4 specialist services if required, which may include:

  • Inpatient treatment tailored to the needs of young people with borderline personality disorder
  • Specialist outpatient programmes
  • Home treatment teams

Organisation and Planning of Services

The Role of Specialist Personality Disorder Services within Trusts

Mental health trusts should develop multidisciplinary specialist teams and/or services for people with personality disorders. These teams should have specific expertise in the diagnosis and management of borderline personality disorder and should:

  • Provide assessment and treatment services for people with borderline personality disorder who have particularly complex needs and/or high levels of risk
  • Provide consultation and advice to primary and secondary care services
  • Offer a diagnostic service when general psychiatric services are in doubt about the diagnosis and/or management of borderline personality disorder
  • Develop systems of communication and protocols for information sharing among different services, including those in forensic settings, and collaborate with all relevant agencies within the local community including health, mental health, and social services, the criminal justice system, CAMHS and relevant voluntary services
  • Be able to provide and/or advise on social and psychological interventions, including access to peer support, and advise on the safe use of drug treatment in crises and for comorbidities and insomnia
  • Work with CAMHS to develop local protocols to govern arrangements for the transition of young people from CAMHS to adult services
  • Ensure that clear lines of communication between primary and secondary care are established and maintained
  • Support, lead, and participate in the local and national development of treatments for people with borderline personality disorder, including multi-centre research
  • Oversee the implementation of this guideline
  • Develop and provide training programmes on the diagnosis and management of borderline personality disorder and the implementation of this guideline
  • Monitor the provision of services for minority ethnic groups to ensure equality of service delivery.

The size and time commitment of these teams will depend on local circumstances (for example, the size of trust, the population covered, and the estimated referral rate for people with borderline personality disorder).

Specialist teams should develop and provide training programmes that cover the diagnosis and management of borderline personality disorder and the implementation of this guideline for general mental health, social care, forensic and primary care providers, and other professionals who have contact with people with borderline personality disorder. The programmes should also address problems around stigma and discrimination as these apply to people with borderline personality disorder.

Specialist personality disorder services should involve people with personality disorders and families or carers in planning service developments, and in developing information about services. With appropriate training and support, people with personality disorders may also provide services, such as training for professionals, education for service users and families or carers, and facilitating peer support groups.

Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

Recommendations are based on clinical and cost effectiveness evidence. In the absence of level I evidence (or a level that is appropriate to the question), or where the Guideline Development Group (GDG) were of the opinion that there were unlikely to be such evidence, either an informal or formal consensus process was adopted.

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Appropriate diagnosis and management of borderline personality disorder

Potential Harms

Not stated

Qualifying Statements

Qualifying Statements
  • This guidance represents the view of the National Institute for Health and Clinical Excellence (NICE), which was arrived at after careful consideration of the evidence available. Healthcare professionals are expected to take it fully into account when exercising their clinical judgement. However, the guidance 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 and informed by the summary of product characteristics of any drugs they are considering.
  • Implementation of this guidance is the responsibility of local commissioners and/or providers. Commissioners and providers are reminded that it is their responsibility to implement the guidance, in their local context, in light of their duties to avoid unlawful discrimination and to have regard to promoting equality of opportunity. Nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.
  • This guideline draws on the best available evidence. However, there are significant limitations to the evidence base, notably, few randomised controlled trials (RCTs) of interventions, which have few outcomes in common. Some of the limitations are addressed in the recommendations for further research (see section 4 in the original guideline document).
  • At the time of publication (January 2009), no drug has UK marketing authorisation for the treatment of borderline personality disorder, but this guideline contains recommendations about the use of drugs to manage crises, comorbid conditions, and insomnia. The guideline assumes that prescribers will use a drug's summary of product characteristics to inform their decisions for each person.

Implementation of the Guideline

Description of Implementation Strategy

The Healthcare Commission assesses how well National Health Service (NHS) organisations meet core and developmental standards set by the Department of Health in 'Standards for better health' (available from www.dh.gov.uk External Web Site Policy). Implementation of clinical guidelines forms part of the developmental standard D2. Core standard C5 says that NHS organisations should take into account national agreed guidance when planning and delivering care.

The National Institute for Health and Clinical Excellence (NICE) has developed tools to help organisations implement this guidance (listed below). These are available on the NICE website (http://guidance.nice.org.uk/CG78 External Web Site Policy; see also the "Availability of Companion Documents" field).

  • Slides highlighting key messages for local discussion.
  • Costing report to estimate the national savings and costs associated with implementation.
  • Audit support for monitoring local practice.

Key Priorities for Implementation

Access to Services

  • 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.

Autonomy and Choice

  • 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.

Developing an Optimistic and Trusting Relationship

  • When working with people with borderline personality disorder:
    • 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 encountered stigma often associated with self-harm and borderline personality disorder.

Managing Endings and Supporting Transitions

  • Anticipate that withdrawal and ending of treatments or services, and transition from one service to another, may evoke strong emotions and reactions in people with borderline personality disorder. Ensure that:
    • Such changes are discussed carefully beforehand with the person (and their family or carers if appropriate) and are structured and phased
    • The care plan supports effective collaboration with other care providers during endings and transitions, and includes the opportunity to access services in times of crisis
    • When referring a person for assessment in other services (including for psychological treatment), they are supported during the referral period and arrangements for support are agreed beforehand with them.

Assessment

  • 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.

Care Planning

  • Teams working with people with borderline personality disorder should develop comprehensive multidisciplinary care plans in collaboration with the service user (and their family or carers, where agreed with the person). The care plan should:
    • Identify clearly the roles and responsibilities of all health and social care professionals involved
    • Identify manageable short-term treatment aims and specify steps that the person and others might take to achieve them
    • Identify long-term goals, including those relating to employment and occupation, that the person would like to achieve, which should underpin the overall long-term treatment strategy; these goals should be realistic, and linked to the short-term treatment aims
    • Develop a crisis plan that identifies potential triggers that could lead to a crisis, specifies self-management strategies likely to be effective and establishes how to access services (including a list of support numbers for out-of-hours teams and crisis teams) when self-management strategies alone are not enough
    • Be shared with the General Practitioner (GP) and the service user.

The Role of Psychological Treatment

  • When providing psychological treatment for people with borderline personality disorder, especially those with multiple comorbidities and/or severe impairment, the following service characteristics should be in place:
    • An explicit and integrated theoretical approach used by both the treatment team and the therapist, which is shared with the service user
    • Structured care in accordance with this guideline
    • Provision for therapist supervision.

Although the frequency of psychotherapy sessions should be adapted to the person's needs and context of living, twice-weekly sessions may be considered.

  • Do not use brief psychotherapeutic 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 in the Psychological Treatment section of the Recommendations (see "Major Recommendations" field).

The Role of Drug 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 Specialist Personality Disorder Services within Trusts

  • Mental health trusts should develop multidisciplinary specialist teams and/or services for people with personality disorders. These teams should have specific expertise in the diagnosis and management of borderline personality disorder and should:
    • Provide assessment and treatment services for people with borderline personality disorder who have particularly complex needs and/or high levels of risk
    • Provide consultation and advice to primary and secondary care services
    • Offer a diagnostic service when general psychiatric services are in doubt about the diagnosis and/or management of borderline personality disorder
    • Develop systems of communication and protocols for information sharing among different services, including those in forensic settings, and collaborate with all relevant agencies within the local community including health, mental health and social services, the criminal justice system, child and adolescent mental health services (CAMHS) and relevant voluntary services
    • Be able to provide and/or advise on social and psychological interventions, including access to peer support, and advise on the safe use of drug treatment in crises and for comorbidities and insomnia
    • Work with CAMHS to develop local protocols to govern arrangements for the transition of young people from CAMHS to adult services
    • Ensure that clear lines of communication between primary and secondary care are established and maintained
    • Support, lead and participate in the local and national development of treatments for people with borderline personality disorder, including multicentre research
    • Oversee the implementation of this guideline
    • Develop and provide training programmes on the diagnosis and management of borderline personality disorder and the implementation of this guideline
    • Monitor the provision of services for minority ethnic groups to ensure equality of service delivery.

The size and time commitment of these teams will depend on local circumstances (for example, the size of trust, the population covered and the estimated referral rate for people with borderline personality disorder).

Implementation Tools
Audit Criteria/Indicators
Foreign Language Translations
Patient Resources
Quick Reference Guides/Physician Guides
Resources
Slide Presentation
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Getting Better
Living with Illness
IOM Domain
Effectiveness
Patient-centeredness

Identifying Information and Availability

Bibliographic Source(s)
National Collaborating Centre for Mental Health. Borderline personality disorder: treatment and management. London (UK): National Institute for Health and Clinical Excellence (NICE); 2009 Jan. 41 p. (Clinical guideline; no. 78). 
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2009 Jan
Guideline Developer(s)
National Collaborating Centre for Mental Health - National Government Agency [Non-U.S.]
Source(s) of Funding

National Institute for Health and Clinical Excellence (NICE)

Guideline Committee

Guideline Development Group

Composition of Group That Authored the Guideline

Guideline Development Group Members: Professor Peter Tyrer (Chair, Guideline Development Group), Professor of Community Psychiatry, Imperial College London; Dr Tim Kendall (Facilitator, Guideline Development Group), Joint Director, The National Collaborating Centre for Mental Health, Deputy Director, Royal College of Psychiatrists’ Research and Training Unit, Consultant Psychiatrist and Medical Director, Sheffield Care Trust; Professor Anthony Bateman, Consultant Psychiatrist, Barnet, Enfield, and Haringey Mental Health NHS Trust and Visiting Professor, University College London; Ms Linda Bayliss (2008), Research Assistant, The National Collaborating Centre for Mental Health; Professor Nick Bouras, Professor Emeritus of Psychiatry, Health Service and Population Research Department, Institute of Psychiatry, King’s College London, Honorary Consultant Psychiatrist, South London and Maudsley NHS Trust; Ms Rachel Burbeck, Systematic Reviewer, The National Collaborating Centre for Mental Health; Ms Jenifer Clarke-Moore (2006–2007), Consultant Nurse, Gwent Healthcare NHS Trust; Ms Elizabeth Costigan (2006–2007), Project Manager, The National Collaborating Centre for Mental Health; Dr Mike Crawford, Reader in Mental Health Services Research, Imperial College London, Honorary Consultant Psychiatrist, Central & North West London NHS Foundation Trust; Ms Victoria Green, Representing service user and family or carer interests; Dr Rex Haigh, Consultant Psychiatrist, Berkshire Healthcare NHS Foundation Trust; Ms Sarah Hopkins (2007–2008), Project Manager, The National Collaborating Centre for Mental Health; Mrs Farheen Jeeva (2007–2008), Health Economist, The National Collaborating Centre for Mental Health; Mr Dennis Lines, Representing service user and family or carer interests; Dr Ifigeneia Mavranezouli (2008), Senior Health Economist, The National Collaborating Centre for Mental Health; Dr David Moore, General Practitioner, Nottinghamshire County Teaching Primary Care Trust; Dr Paul Moran, Clinical Senior Lecturer, Institute of Psychiatry, King’s College London, Honorary Consultant Psychiatrist, South London and Maudsley NHS Foundation Trust; Professor Glenys Parry, Professor of Applied Psychological Therapies, Centre for Psychological Services Research, University of Sheffield, Consultant Clinical Psychologist, Sheffield Care Trust; Mrs Carol Paton, Chief Pharmacist, Oxleas NHS Foundation Trust; Dr Mark Sampson, Clinical Psychologist, Manchester Mental Health and Social Care Trust; Ms Poonam Sood (2006–2007), Research Assistant, The National Collaborating Centre for Mental Health; Ms Sarah Stockton, Senior Information Scientist, The National Collaborating Centre for Mental Health; Dr Michaela Swales, Consultant Clinical Psychologist, North Wales NHS Trust and Bangor University; Dr Clare Taylor, Editor, The National Collaborating Centre for Mental Health; Dr Angela Wolff, Representing service user and family/carer interests; Mr Loukas Xaplanteris (2006–2007), Health Economist, The National Collaborating Centre for Mental Health

Financial Disclosures/Conflicts of Interest

To minimise and manage any potential conflicts of interest, and to avoid any public concern that commercial or other financial interests have affected the work of the Guideline Development Group (GDG) and influenced guidance, members of the GDG must declare as a matter of public record any interests held by themselves or their families which fall under specified categories. These categories include any relationships they have with the healthcare industries, professional organisations and organisations for people who misuse drugs and their families and carers.

Individuals invited to join the GDG were asked to declare their interests before being appointed. To allow the management of any potential conflicts of interest that might arise during the development of the guideline, GDG members were also asked to declare their interests at each GDG meeting throughout the guideline development process. The interests of all the members of the GDG are listed in Appendix 2 of the full version of the original guideline document (see the "Availability of Companion Documents" field), including interests declared prior to appointment and during the guideline development process.

Guideline Status

This is the current release of the guideline.

Guideline Availability

Electronic copies: Available in Portable Document Format (PDF) format from the National Institute for Health and Clinical Excellence (NICE) Web site External Web Site Policy.

Availability of Companion Documents

The following are available:

  • Borderline personality disorder: the NICE guideline on treatment and management. Full guideline. London (UK): National Institute for Health and Clinical Excellence (NICE); 2009. 557 p. (Clinical guideline; no. 78). Electronic copies: Available in Portable Document Format (PDF) from the National Institute for Health and Clinical Excellence (NICE) Web site External Web Site Policy.
  • Borderline personality disorder: treatment and management. Quick reference guide. London (UK): National Institute for Health and Clinical Excellence (NICE); 2009 Jan. 20 p. (Clinical guideline; no. 78). Electronic copies: Available in Portable Document Format (PDF) from the NICE Web site External Web Site Policy.
  • Borderline personality disorder. Audit support. Implementing NICE guidance. London (UK): National Institute for Health and Clinical Excellence (NICE); 2009. 15 p. (Clinical guideline; no. 78). Electronic copies: Available from the NICE Web site External Web Site Policy.
  • Borderline personality disorder. Costing report. Implementing NICE guidance. London (UK): National Institute for Health and Clinical Excellence (NICE); 2009 Jan. 28 p. (Clinical guideline; no. 78). Electronic copies: Available in Portable Document Format (PDF) from the NICE Web site External Web Site Policy.
  • Borderline personality disorder. Slide set. Implementing NICE guidance. London (UK): National Institute for Health and Clinical Excellence (NICE); 2009. 19 p. (Clinical guideline; no. 78). Electronic copies: Available from the NICE Web site External Web Site Policy.
  • The guidelines manual 2007. London (UK): National Institute for Health and Clinical Excellence (NICE); 2007 April. Electronic copies: Available in Portable Document Format (PDF) from the NICE Web site External Web Site Policy.
Patient Resources

The following is available:

  • Borderline personality disorder. Understanding NICE guidance - Information for people who use NHS services. London (UK): National Institute for Health and Clinical Excellence; 2009 Jan. 16 p. (Clinical guideline; no. 78). Electronic copies: Available in Portable Document Format (PDF) from the National Institute for Health and Clinical Excellence (NICE) Web site External Web Site Policy. Also available in Welsh from the NICE Web site External Web Site Policy

Please note: This patient information is intended to provide health professionals with information to share with their patients to help them better understand their health and their diagnosed disorders. By providing access to this patient information, it is not the intention of NGC to provide specific medical advice for particular patients. Rather we urge patients and their representatives to review this material and then to consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their personal medical questions. This patient information has been derived and prepared from a guideline for health care professionals included on NGC by the authors or publishers of that original guideline. The patient information is not reviewed by NGC to establish whether or not it accurately reflects the original guideline's content.

NGC Status

This summary was completed by ECRI Institute on February 25, 2010.

The National Institute for Health and Clinical Excellence (NICE) has granted the National Guideline Clearinghouse (NGC) permission to include summaries of their clinical guidelines with the intention of disseminating and facilitating the implementation of that guidance. NICE has not yet verified this content to confirm that it accurately reflects that original NICE guidance and therefore no guarantees are given by NICE in this regard. All NICE clinical guidelines are prepared in relation to the National Health Service in England and Wales. NICE has not been involved in the development or adaptation of NICE guidance for use in any other country. The full versions of all NICE guidance can be found at www.nice.org.uk External Web Site Policy.

Copyright Statement

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

Disclaimer

NGC Disclaimer

The National Guideline Clearinghouse™ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.

Read full disclaimer...