Implementing NICE guidance

1. Borderline personality disorder Implementing NICE guidance 2009 NICE clinical guideline 78

2. What this presentation covers • Background • Scope • Key priorities for implementation • Costs • Discussion • Find out more

3. Prevalence and risks • Borderline personality disorder is present in just under 1% of the population. • Women present to services more often than men. • Borderline personality disorder rates are estimated to be 23% among male remand prisoners, 14% among sentenced male prisoners and 20% among female prisoners in England and Wales. • 60 -70% of people with borderline personality disorder attempt suicide. • Up to 10% of people with borderline personality disorder will commit suicide.

4. Characteristics • Borderline personality disorder can be seriously disabling and often takes a huge toll on the individual • It is characterised by a pattern of instability of interpersonal relationships, self-image and affects, and by marked impulsivity • A common factor is a history of traumatic events during childhood and adolescence • People with borderline personality disorder are amongst the most likely to use mental health services

5. Scope of guidance • Adults diagnosed with borderline personality disorder ; young people with borderline symptoms and people with learning disabilities and borderline personality disorder • NHS services providing treatment • Interface with other services • Effective clinical management

6. Key areas for implementation • Access to services • Autonomy and choice • Developing an optimistic and trusting relationship • Managing endings and transitions • Assessment • Care planning in community mental health teams • The role of psychological treatment • The role of drug treatment • The role of specialist personality disorder services within trusts

7. 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

8. Work in partnership with people with borderline personality disorder to develop their autonomy and promote choice by: ensuring they remain actively involved in finding solutions to their problems, including during crises encouraging them to consider the different treatment options and life choices available to them, and the consequences of the choices they make. Autonomy and choice

9. Explore treatment options in an atmosphere of hope and optimism, explaining that recovery is possible and attainable Build a trusting relationship, work in an open, engaging and non-judgemental manner, and be consistent and reliable Bear in mind when providing services that many people will have experienced rejection, abuse and trauma, and will have encountered stigma often associated with self-harm and borderline personality disorder Developing an optimistic and trusting relationship

10. The ending of treatments or services, and transition between services can evoke strong emotions and reactions Anticipate, discuss, structure and phase changes carefully beforehand Build collaboration with other care providers into the care plan during endings and transitions – include access to services in times of crisis Ensure and agree support during referral periods to other services Managing endings and supporting transitions

11. Community mental health services should be responsible for the routine assessment, treatment and management of people with borderline personality disorder Assessment

12. Develop comprehensive multidisciplinary care plans in collaboration with the service user Identify the responsibilities of health and social care professionals Manageable treatment aims and specific steps Long-term treatment strategy underpinned by realistic goals linked to short-term treatment aims Crisis plan for when self-management strategies are insufficient Share care plan with GP and service user Care planning

13. Service characteristics Explicit and integrated theoretical approach – shared with service user Structured care in accordance with guideline Provision for therapist supervision Consider twice-weekly sessions according to need and context Do not use brief psychotherapeutic interventions of less than 3 months’ duration The role of psychological treatment

14. Drug treatment should not be used specifically for borderline personality disorder or for the individual symptoms or behaviour associated with the disorder The role of drug treatment

15. Assessment and treatment services Consultation and advice to primary and secondary care services Diagnostic services when general psychiatric services are in doubt about the diagnosis and/or management Facilitate information sharing among different services and collaborate with all relevant agencies within the local community Provide and/or advise on social and psychological interventions, and advise on the safe use of drug treatment in crises and for co-morbidities and insomnia The role of specialist personality disorder services

16. Develop protocols to govern arrangements for the transition of young people from CAMHS to adult services Establish and maintain clear lines of communication between primary and secondary care Support, lead and participate in the local and national development of treatments Oversee the implementation of this guideline Develop and provide training programmes on diagnosis and management Monitor the provision of services for minority ethnic groups to ensure equality of service delivery. The role of specialist personality disorder services

17. Costs • Training healthcare professionals in recognition, diagnosis and treatment • Establishing multidisciplinary teams • Cross-organisation communication • Consultation and treatment with a learning disabilities specialist • An increase in the use of services because of greater awareness/diagnoses • Provision of patient literature and video materials for treatment options

18. Discussion • What services currently exist in this area? • What provision do we have for people from minority ethnic groups or whose first language is not English? • How effective is communication between services? • How do we manage people with learning disabilities? • How do we build openness and optimism? • How do current local prescribing practices compare with the recommendations?

19. Find out more • Visit www.nice.org.uk/CG78 for: • Other guideline formats • Costing report • Audit support