Borderline personality disorder: treatment and management

557 Pages·2009·1.73 MB·English

by  National Collaborating Centre for Mental Health (UK)

Borderline
Personality
Disorder
THE NICE GUIDELINE ON TREATMENT AND MANAGEMENT
BORDERLINE
PERSONALITY
DISORDER:
TREATMENT AND
MANAGEMENT
National Clinical Practice Guideline Number 78
National Collaborating Centre for Mental Health
commissioned by the
National Institute for Health
& Clinical Excellence
published by
The British Psychological Society and The Royal College of
Psychiatrists
© The British Psychological Society
& The Royal College of Psychiatrists, 2009
The views presented in this book do not necessarily reflect those of the British
Psychological Society, and the publishers are not responsible for any error of
omission or fact. The British Psychological Society is a registered charity
(no. 229642).
All rights reserved. No part of this book may be reprinted or reproduced or
utilised in any form or by any electronic, mechanical, or other means, now
known or hereafter invented, including photocopying and recording, or in any
information storage or retrieval system, without permission in writing from
the publishers. Enquiries in this regard should be directed to the British
Psychological Society.
British Library Cataloguing-in-Publication Data
A catalogue record for this book is available from
the British Library.
ISBN: 978-1-85433-477-0
Printed in Great Britain by Stanley L. Hunt (Printers) Ltd.
Additional material: data CD-Rom created by Pixl8
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developed by National Collaborating Centre for Mental Health
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Contents
CONTENTS
GUIDELINE DEVELOPMENT GROUP MEMBERS 6
ACKNOWLEDGEMENTS 9
1. PREFACE 10
1.1 National guideline 10
1.2 The national borderline personality disorder guideline 13
2. BORDERLINE PERSONALITY DISORDER 15
2.1 The disorder 15
2.2 Diagnosis 17
2.3 Epidemiology 20
2.4 Aetiology 21
2.5 Treatment and management 25
2.6 Multi-agency perspective 32
2.7 Young people 34
2.8 The experience of service users, and families and carers 35
2.9 Economic impact 35
3. METHODS USED TO DEVELOP THIS GUIDELINE 38
3.1 Overview 38
3.2 The Scope 38
3.3 The Guideline Development Group 39
3.4 Clinical questions 41
3.5 Systematic clinical literature review 42
3.6 Health economics review strategies 55
3.7 Stakeholder contributions 58
3.8 Validation of this guideline 58
4. EXPERIENCE OF CARE 59
4.1 Introduction 59
4.2 Personal accounts 59
4.3 Review of the qualitative literature 81
4.4 Family and carer experience 93
4.5 Summary of themes 96
4.6 Clinical practice recommendations 99
3
Contents
5. PSYCHOLOGICAL AND PSYCHOSOCIAL TREATMENTS
IN THE MANAGEMENT OF BORDERLINE PERSONALITY
DISORDER 101
5.1 Introduction 101
5.2 Arts therapies 115
5.3 Brief psychological interventions 117
5.4 Complementary therapies 124
5.5 Individual psychological therapies 126
5.6 Combination therapy 144
5.7 Psychological therapy programmes 153
5.8 Therapeutic communities 175
5.9 Data by outcome 188
5.10 Overall clinical summary 204
5.11 Overall summary of economic evidence 206
5.12 Clinical practice recommendations 207
5.13 Research recommendations 208
6. PHARMACOLOGICAL AND OTHER PHYSICAL
TREATMENTS IN THE MANAGEMENT OF BORDERLINE
PERSONALITY DISORDER 211
6.1 Introduction 211
6.2 Anticonvulsants and lithium 218
6.3 Antipsychotics 230
6.4 Antidepressants 246
6.5 Omega-3 fatty acids 254
6.6 Naloxone 257
6.7 Effect of treatment on symptoms 260
6.8 Effect of treatment on general functioning and other outcomes 278
6.9 Effect of treatment on acceptability/tolerability outcomes 283
6.10 Summary of clinical evidence review 296
6.11 Health economic evidence 296
6.12 Clinical practice recommendations 297
6.13 Research recommendation 297
7. MANAGEMENT OF CRISES 298
7.1 Introduction 298
7.2 Current practice 298
7.3 Reviewing the evidence base 299
7.4 General management of crises 299
7.5 Pharmacological management of crises 301
7.6 Management of insomnia 303
4
Contents
8. THE CONFIGURATION AND ORGANISATION OF SERVICES 305
8.1 Introduction 305
8.2 The role of specialist services 306
8.3 Risk factors for suicide in people with borderline
personality disorder 310
8.4 The role of inpatient services 320
8.5 Care pathway 324
8.6 Research recommendation 342
8.7 Special considerations for people with learning disabilities 342
8.8 Special considerations for people from black and
minority ethnic groups 345
9. YOUNG PEOPLE WITH BORDERLINE PERSONALITY
DISORDER 346
9.1 Introduction 346
9.2 Diagnosis 348
9.3 Stability of the diagnosis of borderline personality
disorder in young people 349
9.4 Suicide risk in young people with borderline
personality disorder 358
9.5 Assessment 363
9.6 Treatment 365
9.7 Service configuration 366
9.8 Suggested care pathway for young people with
borderline personality disorder 366
9.9 Overall clinical summary 376
9.10 Clinical practice recommendations 377
10. SUMMARY OF RECOMMENDATIONS 378
11. APPENDICES 393
12. REFERENCES 519
13. ABBREVIATIONS 552
5
Guideline development group members
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 Health and
Social Care Foundation Trust
Professor Anthony Bateman
Consultant Psychiatrist, Barnet, Enfield, and Haringey Mental Health NHS Trust
Visiting Professor, University College London
Ms Linda Bayliss (2008)
Research Assistant, The National Collaborating Centre for Mental Health
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 Foundation Trust
Ms Rachel Burbeck
Systematic Reviewer, The National Collaborating Centre for Mental Health
Ms Jenifer Clarke-Moore (2006–2007)
Consultant Nurse, Gwent Healthcare NHS Trust
Ms Elizabeth Costigan (2007)
Project Manager, The National Collaborating Centre for Mental Health
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
6
Guideline development group members
Ms Sarah Hopkins (2007–2008)
Project Manager, The National Collaborating Centre for Mental Health
Mrs Farheen Jeeva (2007–2008)
Health Economist, The National Collaborating Centre for Mental Health
Ms Katherine Leggett (2008–2009)
Project Manager, The National Collaborating Centre for Mental Health
Mr Dennis Lines
Representing service user and family/carer interests
Dr Ifigeneia Mavranezouli (2008)
Senior Health Economist, The National Collaborating Centre for Mental Health
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 Health and Social Care
Foundation 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 (2006–2007)
Research Assistant, The National Collaborating Centre for Mental Health
Ms Sarah Stockton
Senior Information Scientist, The National Collaborating Centre for Mental
Health
Dr Michaela Swales
Consultant Clinical Psychologist, North Wales NHS Trust and Bangor University
7
Guideline development group members
Dr Clare Taylor
Editor, The National Collaborating Centre for Mental Health
Dr Angela Wolff
Representing service user and family/carer interests
Mr Loukas Xaplanteris (2006–2007)
Health Economist, The National Collaborating Centre for Mental Health
8
Acknowledgements
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 and Trafford Mental Health NHS Trust
Those who contributed personal accounts of their experiences of borderline personal-
ity disorder that have been included in this guideline.
9