Personality disorders (borderline and antisocial) NICE

39 Pages·2014·0.31 MB·English

by  Anna Wasielewska

DRAFT

Personality disorders (borderline and
antisocial)
NICE quality standard
Draft for consultation
November 2014
Introduction
This quality standard covers treating and managing borderline and antisocial
personality disorders. For borderline personality disorder, this quality standard
applies to adults and young people under 18 years. For antisocial personality
disorder, this quality standard applies only to adults aged 18 years and over. NICE
quality standard 59 covers antisocial behaviour and conduct disorder in children and
young people under 18 years. For more information see the topic overview.
Why this quality standard is needed
Personality disorder is an enduring pattern of inner experience and behaviour that
deviates markedly from the expectations of the person’s culture. It is pervasive and
inflexible, has an onset in adolescence or early adulthood, is stable over time, and
leads to distress or impairment (this is the DSM–IV classification which was used in
the development of the NICE guidelines on antisocial personality disorder (CG77)
and borderline personality disorder (CG78)).
Borderline personality disorder is characterised by significant instability of
interpersonal relationships, self-image and mood, and impulsive behaviour. There is
a pattern of sometimes rapid fluctuation from periods of confidence to despair, with
fear of abandonment, rejection, and a strong tendency towards suicidal thinking and
self-harm. Borderline personality disorder is often comorbid with depression, anxiety,
eating disorders, post-traumatic stress disorder, alcohol and drug misuse, and
bipolar disorder (the symptoms of which are often confused with borderline
personality disorder).
Quality standard for personality disorders (borderline and antisocial) DRAFT (November 2014) 1 of 39
DRAFT
Borderline personality disorder is present in just under 1% of the population. It most
commonly presents in early adulthood, with women presenting to services more
often than men. It is usually not diagnosed formally before the age of 18 years, but
the features of the disorder can be identified earlier.
Most people with borderline personality disorder show symptoms in late adolescence
or early adult life, although some may not come to the attention of mental health
services until much later. With treatment or formal psychiatric assessment,
symptoms improve sufficiently for at least 50% of people not to meet the criteria for
borderline personality disorder 5–10 years after diagnosis.
Some traits of antisocial personality disorder include impulsivity, high negative
emotionality, low conscientiousness and associated behaviours, including
irresponsible and exploitative behaviour, recklessness and deceitfulness. As a result
of the disorder, people with antisocial personality disorder often experience unstable
interpersonal relationships and may show disregard for the consequences of their
behaviour and the feelings of others. Further traits of the disorder may result in a
failure to learn from experience and egocentricity. Antisocial personality disorder is
often comorbid with depression, anxiety, and alcohol and drug misuse.
The prevalence of antisocial personality disorder in the general population is 3% in
men and 1% in women. The prevalence among people in prison is around 47%, with
serious crimes being less common than a history of aggression, unemployment and
promiscuity.
The course of antisocial personality disorder is variable and although recovery is
achievable over time, some people may continue to experience social and
interpersonal difficulties.
Most people with antisocial personality disorder receive most of their care outside
the health service. They may be supported by educational, social care and housing
services and, as result of offending, by the criminal justice system.
Although borderline and antisocial personality disorders are associated with
significant morbidity and increased mortality, the care provided to people with
personality disorders is often fragmented. Borderline and antisocial personality
Quality standard for personality disorders (borderline and antisocial) DRAFT (November 2014) 2 of 39
DRAFT
disorder are frequently misdiagnosed because of comorbid conditions and people
with personality disorders are often prescribed medication or therapies unsuitable for
them. Moreover, they are sometimes excluded from health or social care services
because of their diagnosis. This may be because staff lack the confidence and skills
to work with this group of people and because their challenging behaviours may
result in negative attitudes amongst some staff. Some topic experts and people with
personality disorder feel that there is stigma attached to borderline and antisocial
personality disorders, even in mental health services.
In 2011, the government published its mental health strategy, No health without
mental health, which set out long-term ambitions for transforming mental healthcare
and the way people with mental health problems are supported in society as a
whole. The strategy was built around 6 objectives:
 more people will have good mental health
 more people with mental health problems will recover
 more people with mental health problems will have good physical health
 more people will have a positive experience of care and support
 fewer people will suffer avoidable harm
 fewer people will experience stigma and discrimination.
The quality standard is expected to contribute to improvements in the following
outcomes:
 quality of life for people with serious mental illness
 service user experience of health/care services
 excess under 75 mortality rate in adults with serious mental illness
 employment of people with mental illness
 experience of integrated care.
How this quality standard supports delivery of outcome
frameworks
NICE quality standards are a concise set of prioritised statements designed to drive
measurable quality improvements within a particular area of health or care. They are
derived from high-quality guidance, such as that from NICE or other sources
Quality standard for personality disorders (borderline and antisocial) DRAFT (November 2014) 3 of 39
DRAFT
accredited by NICE. This quality standard, in conjunction with the guidance on which
it is based, should contribute to the improvements outlined in the following 3
outcomes frameworks published by the Department of Health:
 Adult Social Care Outcomes Framework 2014–15
 NHS Outcomes Framework 2014–15
 Improving outcomes and supporting transparency: a public health outcomes
framework for England 2013–2016, Parts 1A, 1B and 2
Tables 1–3 show the outcomes, overarching indicators and improvement areas from
the frameworks that the quality standard could contribute to achieving.
Table 1 Adult Social Care Outcomes Framework 2014–15
Domain Overarching and outcome measures
1 Enhancing quality of life for Overarching measure
people with care and support 1A Social care-related quality of life*
needs
Outcome measures
People manage their own support as much as they wish,
so that they are in control of what, how and when
support is delivered to match their needs.
1B Proportion of people who use services who have control
over their daily life
Carers can balance their caring roles and maintain their
desired quality of life.
1D Carer-reported quality of life
People are able to find employment when they want,
maintain a family and social life and contribute to
community life and avoid loneliness or isolation.
1F Proportion of adults in contact with secondary mental
health services in paid employment**
1H Proportion of adults in contact with secondary mental
health services living independently, with or without support*
1I Proportion of people who use services and their carers
who reported that they had as much social contact as they
would like*
2 Delaying and reducing the Overarching measure
need for care and support 2A Permanent admissions to residential and nursing care
homes, per 100,000 population
Quality standard for personality disorders (borderline and antisocial) DRAFT (November 2014) 4 of 39
DRAFT
3 Ensuring that people have Overarching measure
a positive experience of care People who use social care and their carers are satisfied
and support with the experience of care and support services.
3A Overall satisfaction of people who use services with their
care and support.
3B Overall satisfaction of carers with social services
3E Improving people’s experience of integrated care**
Outcome measures
Carers feel that they are respected as equal partners
throughout the care process.
3C The proportion of carers who report that they have been
included or consulted in discussion about the person they
care for
People know what choices are available to them locally,
what they are entitled to, and who to contact when they
need help.
3D Proportion of people who use services and carers who
find it easy to find information about services
People, including those involved in making decisions on
social care, respect the dignity of the individual and
ensure support is sensitive to the circumstances of
each individual.
4 Safeguarding adults whose Overarching measure
circumstances make them 4A. The proportion of people who use services who feel
vulnerable and protecting safe**
them from avoidable harm
Outcome measures
Everyone enjoys physical safety and feels secure.
People are free from physical and emotional abuse,
harassment, neglect and self-harm.
People are protected as far as possible from avoidable
harm, disease and injuries.
People are supported to plan ahead and have the
freedom to manage risks the way they wish.
4B Proportion of people who use services who say that
those services have made them feel safe and secure
Aligning across the health and care system
* Indicator complementary
** Indicator shared

Quality standard for personality disorders (borderline and antisocial) DRAFT (November 2014) 5 of 39
DRAFT
Table 2 NHS Outcomes Framework 2014–15
Domain Overarching indicators and improvement areas
1 Preventing people from Overarching indicator
dying prematurely 1a Potential Years of Life Lost (PYLL) from causes
considered amenable to healthcare
Reducing premature death in people with serious
mental illness
1.5 Excess under 75 mortality rate in adults with serious
mental illness*
2 Enhancing quality of life for Overarching indicator
people with long-term 2 Health-related quality of life for people with long-term
conditions conditions**
Improvement areas
Ensuring people feel supported to manage their
condition
2.1 Proportion of people feeling supported to manage their
condition**
Enhancing quality of life for people with mental illness
2.5 Employment of people with mental illness****

4 Ensuring that people have Overarching indicators
a positive experience of care 4a Patient experience of primary care
4b Patient experience of hospital care
Improvement areas
Improving people’s experience of outpatient care
4.1 Patient experience of outpatient services
Improving hospitals’ responsiveness to personal needs
4.2 Responsiveness to in-patients’ personal needs
Improving experience of healthcare for people with
mental illness
4.7 Patient experience of community mental health services
Improving people’s experience of accident and
emergency services
4.3 Patient experience of A&E services
Improving people’s experience of integrated care
4.9 People’s experience of integrated care**
Alignment across the health and social care system
* Indicator shared with Public Health Outcomes Framework (PHOF)
** Indicator complementary with Adult Social Care Outcomes Framework (ASCOF)
**** Indicator complementary with Adult Social Care Outcomes Framework and Public
Health Outcomes Framework

Quality standard for personality disorders (borderline and antisocial) DRAFT (November 2014) 6 of 39
DRAFT
Table 3 Public health outcomes framework for England, 2013–2016
Domain Objectives and indicators
1 Wider determinants of Objective
health Improvements against wider factors that affect health and
wellbeing and health inequalities
Indicators
1.06ii - % of adults in contact with secondary mental health
services who live in stable and appropriate accommodation
1.07 - People in prison who have a mental illness or a
significant mental illness
1.08iii – Gap in the employment rate for those in contact
with secondary mental health services and the overall
employment rate
1.13i - % of offenders who re-offend from a rolling 12 month
cohort
1.13ii - Average no. of re-offences committed per offender
from a rolling 12 month cohort
2 Health improvement Objective
People are helped to live healthy lifestyles, make healthy
choices and reduce health inequalities
2.15i Successful completion of drug treatment – opiate
users
2.15ii Successful completion of drug treatment – non-opiate
users
2.18 Alcohol related admissions to hospital
4 Healthcare public health and Objective
preventing premature mortality Reduced numbers of people living with preventable ill
health and people dying prematurely, while reducing the
gap between communities
Indicators
4.09 Excess under 75 mortality in adults with serious
mental illness
4.10 Suicide rate

Patient experience and safety issues
Ensuring that care is safe and that people have a positive experience of care is vital
in a high-quality service. It is important to consider these factors when planning and
delivering services relevant to borderline or antisocial personality disorder.
NICE has developed guidance and associated quality standards on patient
experience in adult NHS services and service user experience in adult mental health
services (see the NICE pathways on patient experience in adult NHS services and
service user experience in adult mental health services), which should be considered
Quality standard for personality disorders (borderline and antisocial) DRAFT (November 2014) 7 of 39
DRAFT
alongside this quality standard. They specify that people receiving care should be
treated with dignity, have opportunities to discuss their preferences, and be
supported to understand their options and make fully informed decisions. They also
cover the provision of information to patients and service users. Quality statements
on these aspects of patient experience will not usually be included in topic-specific
quality standards. However, recommendations in the development sources for
quality standards that impact on patient experience and are specific to the topic will
be considered during quality statement development.
Coordinated services
The quality standard for personality disorders (borderline and antisocial) specifies
that services should be commissioned from and coordinated across all relevant
agencies encompassing the whole borderline or antisocial personality disorder care
pathway. A person-centred, integrated approach to providing services is fundamental
to delivering high-quality care to people with borderline or antisocial personality
disorder in a range of settings.
The Health and Social Care Act 2012 sets out a clear expectation that the care
system should consider NICE quality standards in planning and delivering services,
as part of a general duty to secure continuous improvement in quality.
Commissioners and providers of health and social care should refer to the library of
NICE quality standards when designing high-quality services. Other quality
standards that should also be considered when choosing, commissioning or
providing a high-quality borderline or antisocial personality disorder service are listed
in related quality standards.
Training and competencies
The quality standard should be read in the context of national and local guidelines on
training and competencies. All health, public health and social care practitioners
involved in assessing, caring for and treating people with borderline or antisocial
personality disorder should have sufficient and appropriate training and
competencies to deliver the actions and interventions described in the quality
standard. Quality statements on staff training and competency are not usually
included in quality standards. However, recommendations in the development
Quality standard for personality disorders (borderline and antisocial) DRAFT (November 2014) 8 of 39
DRAFT
sources on specific types of training for the topic that exceed standard professional
training will be considered during quality statement development.
Role of families and carers
Quality standards recognise the important role families and carers have in supporting
people with borderline or antisocial personality disorder. If appropriate, health, public
health and social care practitioners should ensure that family members and carers
are involved in the decision-making process about investigations, treatment and
care.
Quality standard for personality disorders (borderline and antisocial) DRAFT (November 2014) 9 of 39
DRAFT
List of quality statements
Statement 1. People have a structured assessment before they are given a
diagnosis of borderline or antisocial personality disorder.
Statement 2. People with borderline or antisocial personality disorder are offered
psychological therapies relevant to the disorder or individual symptoms of the
disorder.
Statement 3. People with borderline or antisocial personality disorders are not
prescribed antipsychotic or sedative medication for medium or long term
management unless there is a diagnosed psychotic disorder.
Statement 4. People with borderline or antisocial personality disorder have the risks
associated with transitions and changes to services addressed in their care plan.
Statement 5. People with borderline or antisocial personality disorder have their
social care, social support and occupational needs identified in their care plan.
Statement 6. Mental health professional supporting people with borderline or
antisocial personality disorder are routinely supervised.
Questions for consultation
Questions about the quality standard
Question 1 Does this draft quality standard accurately reflect the key areas for
quality improvement?
Question 2 If the systems and structures were available, do you think it would be
possible to collect the data for the proposed quality measures?
Question 3 For each quality statement what do you think could be done to support
improvement and help overcome barriers?
Quality standard for personality disorders (borderline and antisocial) DRAFT (November 2014) 10 of 39