ebook img

Borderline personality disorder PDF

495 Pages·2009·2.94 MB·English
by  
Save to my drive
Quick download
Download
Most books are stored in the elastic cloud where traffic is expensive. For this reason, we have a limit on daily download.

Preview Borderline personality disorder

Borderline personality disorder (BPD) Borderline Personality Disorder: treatment and management NICE Clinical Guideline 78 National Collaborating Centre for Mental Health Commissioned by the National Institute for Health and Clinical Excellence Borderline personality disorder: full guideline (January 2009) Page 1 of 495 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 Research Assistant, The National Collaborating Centre for Mental Health (2008) 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 Consultant Nurse, Gwent Healthcare NHS Trust (2007) Ms Elizabeth Costigan Project Manager, The National Collaborating Centre for Mental Health (2007) 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/carer interests Dr Rex Haigh Consultant Psychiatrist, Berkshire Healthcare NHS Foundation Trust Ms Sarah Hopkins Borderline personality disorder: full guideline (January 2009) Page 2 of 495 Project Manager, The National Collaborating Centre for Mental Health (2007- 2008) Mrs Farheen Jeeva Health Economist, The National Collaborating Centre for Mental Health (2008) Mr Dennis Lines Representing service user and family/carer interests Dr Ifigeneia Mavranezouli Senior Health Economist, The National Collaborating Centre for Mental Health (2008) 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 Research Assistant, The National Collaborating Centre for Mental Health (2007) Ms Sarah Stockton Informations 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 Borderline personality disorder: full guideline (January 2009) Page 3 of 495 Dr Angela Wolff Representing service user and family/carer interests Mr Loukas Xaplanteris Health Economist, The National Collaborating Centre for Mental Health (2007) Borderline personality disorder: full guideline (January 2009) Page 4 of 495 Table of content Guideline Development Group members ..................................................................... 2 1 Preface ........................................................................................................................ 9 1.1 National guideline ................................................................................................ 9 1.2 The national borderline personality disorder guideline ........................................ 12 2 Borderline personality disorder ............................................................................ 15 2.1 The disorder ....................................................................................................... 15 2.2 Diagnosis ........................................................................................................... 17 2.3 Epidemiology ...................................................................................................... 21 2.4 Aetiology ............................................................................................................ 22 2.5 Treatment and management ............................................................................... 26 2.6 Multi-agency perspective.................................................................................... 35 2.7 Young people ...................................................................................................... 37 2.8 The experience of service users and families/carers .............................................. 37 2.9 Economic impact ................................................................................................ 37 3 Methods used to develop this guideline .............................................................. 41 3.1 Overview............................................................................................................ 41 3.2 The Scope ........................................................................................................... 41 3.3 The Guideline Development Group ..................................................................... 42 3.4 Clinical questions ............................................................................................... 44 3.5 Systematic clinical literature review ................................................................... 45 3.6 Health economics review strategies ..................................................................... 60 3.7 Stakeholder contributions ................................................................................... 63 3.8 Validation of this guideline ................................................................................. 63 4 Experience of care ................................................................................................... 64 4.1 Introduction ....................................................................................................... 64 4.2 Personal accounts ............................................................................................... 64 4.3 Review of the qualitative literature ..................................................................... 90 4.4 Family/Carer experience .................................................................................. 103 4.5 Summary of themes .......................................................................................... 107 4.6 Clinical practice recommendations.................................................................... 110 5 Psychological therapies, therapeutic communities, arts therapies, and complementary therapies in the management of borderline personality disorder 112 Borderline personality disorder: full guideline (January 2009) Page 5 of 495 5.1 Introduction ..................................................................................................... 112 5.2 Psychological therapies ..................................................................................... 112 5.3 Complex interventions.......................................... Error! Bookmark not defined. 5.4 Individual psychological therapies .................................................................... 134 5.5 Brief psychological interventions ...................................................................... 125 5.6 Data by outcome ............................................................................................... 180 5.7 Combination therapy ........................................................................................ 152 5.8 Overall clinical summary ................................................................................. 204 5.9 Therapeutic Communities................................................................................. 180 5.10 Studies considered ............................................................................................ 183 5.11 Complementary therapies ................................................................................. 133 5.12 Arts therapies ................................................................................................... 112 5.13 Clinical practice recommendations.................................................................... 206 5.14 Research recommendations ............................................................................... 207 6 Pharmacological and other physical treatments in the management of borderline personality disorder................................................................................... 210 6.1 Introduction ..................................................................................................... 210 6.2 Anticonvulsants and lithium ............................................................................ 218 6.3 Antipsychotics .................................................................................................. 226 6.4 Antidepressants ................................................................................................ 238 6.5 Omega-3 fatty acids .......................................................................................... 244 6.6 Naloxone .......................................................................................................... 246 6.7 Effect of treatment on symptoms ....................................................................... 247 6.8 Effect of treatment on general functioning and other outcomes ......................... 259 6.9 Effect of treatment on acceptability/tolerability outcomes .................................. 262 6.10 Summary of clinical evidence review ................................................................ 268 6.11 Clinical practice recommendations.................................................................... 270 6.12 Research recommendation................................................................................. 270 7 Management of crises ........................................................................................... 271 7.1 Introduction ..................................................................................................... 271 7.2 Current practice ............................................................................................... 272 7.3 Reviewing the evidence base ............................................................................. 272 7.4 General management of crises ........................................................................... 272 7.5 Pharmacological management of crises ............................................................. 274 7.6 Follow-up after a crisis ......................................... Error! Bookmark not defined. 7.7 Management of insomnia ................................................................................. 277 Borderline personality disorder: full guideline (January 2009) Page 6 of 495 8 The configuration and organisation of services ................................................ 278 8.1 Introduction ..................................................................................................... 278 8.2 The role of specialist services ............................................................................. 280 8.3 Risk factors for sucide in people with borderline personality disorder ................ 283 8.4 The role of inpatient services ............................................................................. 290 8.5 Care pathway ................................................................................................... 294 8.6 Research recommendation................................................................................. 315 8.7 Special considerations for people with learning disabilities ................................ 315 8.8 Special considerations for people from black and ethnic minority groups ........... 317 9 Young people with borderline personality disorder ........................................ 320 9.1 Introduction ..................................................................................................... 320 9.2 Diagnosis ......................................................................................................... 322 9.3 Stability of the diagnosis of borderline personality disorder in young people...... 323 9.4 Suicide risk in young people with borderline personality disorder ..................... 331 9.5 Assessment ....................................................................................................... 335 9.6 Treatment......................................................................................................... 337 9.7 Service configuration ........................................................................................ 339 9.8 Suggested care pathway for young people with borderline personality disorder . 340 9.9 Overall clinical summary ................................................................................. 350 9.10 Clinical practice recommendations.................................................................... 350 10 Summary of recommendations ........................................................................... 352 11 Appendices ............................................................................................................ 353 12 References .................................................................. Error! Bookmark not defined. 13 Abbreviations ........................................................................................................ 462 Borderline personality disorder: full guideline (January 2009) Page 7 of 495 Acknowledgements The Borderline Personality Disorder Guideline Development Group and the National Collaborating Centre for Mental Health (NCCMH) review team would like to thank the following people: Those who acted as advisers on specialist topics or have contributed to the process by meeting with the Guideline Development Group: Dr Andrew Cotgrove, Cheshire and Wirral Partnership NHS Trust Professor Kate Davidson, University of Glasgow Ms Jane Dudley, South West London and St George’s Mental Health NHS Trust and The British Association of Art Therapy Professor Edzard Ernst, Peninsula Medical School Professor Roger Mulder, University of Otago Professor John Oldham, The Menninger Clinic Professor Kenneth Silk, University of Michigan Health System Professor Paul Soloff, University of Pittsburgh Dr Alison Wood, Bolton Salford & Trafford Mental Health NHS Trust Those who have experiences of borderline personality disorder who contributed testimonies that have been included in this guideline. Borderline personality disorder: full guideline (January 2009) Page 8 of 495 1 Preface This guideline has been developed to advise on the treatment and management of borderline personality disorder. The guideline recommendations have been developed by a multidisciplinary team of healthcare professionals, service users, a carer and guideline methodologists after careful consideration of the best available evidence. It is intended that the guideline will be useful to clinicians and service commissioners in providing and planning high-quality care for people with borderline personality disorder while also emphasising the importance of the experience of care for them and their familes/carers (see Appendix 1 for more details on the scope of the guideline). Although the evidence base is rapidly expanding, there are a number of major gaps, and future revisions of this guideline will incorporate new scientific evidence as it develops. The guideline makes a number of research recommendations specifically to address gaps in the evidence base. In the meantime, it is hoped that the guideline will 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. 1.1 National guideline 1.1.1 What are clinical practice guidelines? Clinical practice guidelines are ‘systematically developed statements that assist clinicians and patients in making decisions about appropriate treatment for specific conditions’ (Mann, 1996). They are derived from the best available research evidence, using predetermined and systematic methods to identify and evaluate the evidence relating to the specific condition in question. Where evidence is lacking, the guidelines incorporate statements and recommendations based upon the consensus statements developed by the Guideline Development Group (GDG). Clinical guidelines are intended to improve the process and outcomes of healthcare in a number of different ways. They can: • provide up-to-date evidence-based recommendations for the treatment and management of conditions and disorders by healthcare professionals • be used as the basis to set standards to assess the practice of healthcare professionals • form the basis for education and training of healthcare professionals Borderline personality disorder: full guideline (January 2009) Page 9 of 495 • assist service users and their families/carers in making informed decisions about their treatment and care • improve communication between healthcare professionals, service users and their families/carers • help identify priority areas for further research. 1.1.2 Uses and limitations of clinical guidelines Guidelines are not a substitute for professional knowledge and clinical judgement. They can be limited in their usefulness and applicability by a number of different factors: the availability of high-quality research evidence, the quality of the methodology used in the development of the guideline, the generalisability of research findings and the uniqueness of individuals with borderline personality disorder. Although the quality of research in this field is variable, the methodology used here reflects current international understanding on the appropriate practice for guideline development (AGREE: Appraisal of Guidelines for Research and Evaluation Instrument; www.agreecollaboration.org), ensuring the collection and selection of the best research evidence available and the systematic generation of treatment recommendations applicable to the majority of people with these disorders and situations. However, there will always be some people and situations for which clinical guideline recommendations are not readily applicable. This guideline does not, therefore, override the individual responsibility of healthcare professionals to make appropriate decisions in the circumstances of the individual, in consultation with the person with borderline personality disorder or their family/carer. In addition to the clinical evidence, cost-effectiveness information, where available, is taken into account in the generation of statements and recommendations of the clinical guidelines. While national guidelines are concerned with clinical and cost effectiveness, issues of affordability and implementation costs are to be determined by the National Health Service (NHS). In using guidelines, it is important to remember that the absence of empirical evidence for the effectiveness of a particular intervention is not the same as evidence for ineffectiveness. In addition, of particular relevance in mental health, evidence-based treatments are often delivered within the context of an overall treatment programme including a range of activities, the purpose of which may be to help engage the person and to provide an appropriate context for the delivery of specific interventions. It is important to maintain and enhance the service context in which these interventions are delivered; otherwise the specific benefits of effective interventions will be lost. Indeed, the importance of organising care in order to support and encourage a good Borderline personality disorder: full guideline (January 2009) Page 10 of 495

See more

The list of books you might like

Most books are stored in the elastic cloud where traffic is expensive. For this reason, we have a limit on daily download.