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Borderline personality disorder: treatment and management PDF

557 Pages·2009·1.73 MB·English
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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 (www.pix18.co.uk) developed by National Collaborating Centre for Mental Health Royal College of Psychiatrists’ Research and Training Unit 4th Floor, Standon House 21 Mansell Street London E1 8AA www.nccmh.org.uk commissioned by National Institute for Health and Clinical Excellence MidCity Place, 71 High Holborn London WCIV 6NA www.nice.org.uk published by The British Psychological Society St Andrews House 48 Princess Road East Leicester LE1 7DR www.bps.org.uk and The Royal College of Psychiatrists 17 Belgrave Square London SW1X 8PG www.rcpsych.ac.uk 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

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