Borderline personality disorder

495 Pages·2009·2.94 MB·English

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