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
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 )
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).
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.
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.