NICE Guidelines on Recognising and Managing Borderline Personality Disorder – 1.3 Assessment and management by community mental health services

The following guidance is based on the best available evidence. The full guideline gives details of the methods and evidence used to develop the guidance. People have the right to be involved in discussions and make informed decisions about their care, as described in your care. Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

1.3.1 Assessment

1.3.1.1

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.

1.3.1.2

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.(2)

1.3.2 Care planning

1.3.2.1

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 GP and the service user.

1.3.2.2

Teams should use the 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.

1.3.3 Risk assessment and management

1.3.3.1

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.

1.3.3.2

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.

1.3.3.3

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.

1.3.3.4Teams 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).

1.3.4 Psychological treatment

1.3.4.1

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.

1.3.4.2

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.

1.3.4.3

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.

1.3.4.4

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 in 1.3.4.3.

1.3.4.5

For women with borderline personality disorder for whom reducing recurrent self-harm is a priority, consider a comprehensive dialectical behaviour therapy programme.

1.3.4.6

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.

1.3.4.7

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.

1.3.5 The role of drug treatment

1.3.5.1

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).

1.3.5.2

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

1.3.5.3

Drug treatment may be considered in the overall treatment of comorbid conditions (see section 1.3.6).

1.3.5.4

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.(3) The duration of treatment should be agreed with them, but should be no longer than 1 week (see section 1.3.7).

1.3.5.5

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.

1.3.5.6

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.

1.3.6 The management of comorbidities

1.3.6.1

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.

1.3.6.2

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

1.3.6.3

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.

1.3.6.4

When treating a comorbid condition in people with borderline personality disorder, follow the NICE clinical guideline for the comorbid condition (see the NICE mental health and behavioural conditions topic page, or search the NICE find guidance page).

1.3.7 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

1.3.7.1

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.

1.3.7.2

Before starting short-term drug treatments for people with borderline personality disorder during a crisis (see recommendation 1.3.5.4):

  • 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.

1.3.7.3

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

  • choose a drug (such as a sedative antihistamine[3]) 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

1.3.7.4

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.

1.3.7.5

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.

1.3.8 The management of insomnia

1.3.8.1

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.

1.3.8.2

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‘ (NICE technology appraisal guidance 77). However, be aware of the potential for misuse of many of the drugs used for insomnia and consider other drugs such as sedative antihistamines.

1.3.9 Discharge to primary care

1.3.9.1

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.

[2See 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‘.

[3Sedative antihistamines are not licensed for this indication and informed consent should be obtained and documented.

© NICE (2009) Borderline personality disorder: recognition and management
Clinical guideline [CG78]. Available from https://www.nice.org.uk/guidance/cg78. All rights reserved. Subject to Notice of rights. NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication.

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