1. Implementing NICE guidance
Borderline personality disorder
Implementing NICE guidance
NOTES FOR PRESENTERS:
ABOUT THIS PRESENTATION:
This presentation has been written to help you raise awareness of the NICE clinical guideline on borderline personality disorder. This guideline has been written for healthcare professionals and others involved in the care of people with borderline personality disorder.
The guideline is available in a number of formats, including a quick reference guide (QRG), a condensed NICE version, the full guidance and the patient version: ‘Understanding NICE guidance’ (UNG). You may want to hand out copies of the quick reference guide at your presentation so that your audience can refer to it. See the end of the presentation for ordering details.
You can add your own organisation’s logo alongside the NICE logo.
We have included notes for presenters, broken down into ‘key points to raise’, which you can highlight in your presentation, and ‘additional information’ that you may want to draw on, such as rationale or an explanation of the evidence for a recommendation. Where necessary, the recommendation will be given in full.
DISCLAIMER
This slide set is an implementation tool and should be used alongside the published guidance. This information does not supersede or replace the guidance itself.
PROMOTING EQUALITY
Implementation of this guidance is the responsibility of local commissioners and/or providers. Commissioners and providers are reminded that it is their responsibility to implement the guidance, in their local context, in light of their duties to avoid unlawful discrimination and to have regard to promoting equality of opportunity. Nothing in this guidance should be interpreted in a way which would be inconsistent with compliance with those duties.
2009
NICE clinical guideline 78

2. What this presentation covers
Background
Scope
Key priorities for implementation
Costs
Discussion
Find out more
NOTES FOR PRESENTERS:
In this presentation we will start by providing some background to the guideline, why it is important and what it covers. We will then present the key priorities for implementation. The NICE guideline contains 10 key priorities grouped under 9 headings, which you can find on page 8 of your quick reference guide.
The key priorities for implementation cover the following areas:
Access to services
Autonomy and choice
Developing an optimistic and trusting relationship
Managing endings and supporting transitions
Assessment
Care planning
The role of psychological treatment
The role of drug treatment
The role of specialist personality disorder services within trusts.
Next, we will summarise the costs and savings that are likely to be incurred in implementing the guideline. Then we will open the meeting up with a list of questions to help prompt a discussion on local issues for incorporating the guidance into practice.
Finally, we will end the presentation with further information about the support provided by NICE.

3. Prevalence and risks
Borderline personality disorder is present in just under 1% of the population.
Women present to services more often than men.
Borderline personality disorder rates are estimated to be 23% among male remand prisoners, 14% among sentenced male prisoners and 20% among female prisoners in England and Wales.
60 -70% of people with borderline personality disorder attempt suicide.
Up to 10% of people with borderline personality disorder will commit suicide.
NOTES FOR PRESENTERS:
KEY POINTS TO RAISE:
Borderline personality disorder is often not formally diagnosed before the age of 18 but the features of the disorder can be identified earlier. Its course is variable and although recovery is possible over time, some people may continue to experience social and interpersonal difficulties.
ADDITIONAL INFORMATION:
People with borderline personality disorder may engage in a variety of destructive and impulsive behaviours including self-harm, eating problems and excessive use of alcohol and illicit substances. People with borderline personality disorder may self-harm for a variety of different reasons, including relief from acute distress and feelings such as emptiness and anger, or to reconnect with feelings after a period of dissociation. People with borderline personality disorder are at increased risk of suicide. 60 to 70% attempt suicide, and the rate of completed suicide in people with borderline personality disorder is around 10%. There is a well-documented association between borderline personality disorder and depression, and the combination of the two conditions increases the number and seriousness of suicide attempts.
Borderline personality disorder is particularly common among people who are drug and/or alcohol dependent, those with an eating disorder, and also among people presenting with chronic self-harming behaviour.

4. Characteristics
Borderline personality disorder can be seriously disabling and often takes a huge toll on the individual
It is characterised by a pattern of instability of interpersonal relationships, self-image and affects, and by marked impulsivity
A common factor is a history of traumatic events during childhood and adolescence
People with borderline personality disorder are amongst the most likely to use mental health services
NOTES FOR PRESENTERS:
ADDITIONAL INFORMATION:
There is a pattern of fluctuations from periods of confidence to times of absolute despair, markedly unstable self-image, rapid changes in mood, with fears of abandonment and rejection, and a strong tendency towards suicidal thinking and self-harm. Transient psychotic symptoms may also be present, including brief delusions and hallucinations. The cluster of symptoms and behaviour associated with the disorder include striking fluctuations in self- perception ranging from over-confidence to self-loathing, a tendency to self-harm and suicidal ideation, uncertain identity, periods of intolerable distress, and occasional brief psychotic episodes.
Many people with borderline personality disorder have experienced some form of physical, emotional or sexual abuse in childhood (which has led to the view that borderline personality disorder is a delayed form of post-traumatic stress disorder). Although some people with borderline personality disorder come from stable and caring families, deprivation and instability in relationships are likely to promote borderline personality development and should be the focus of preventive strategies.
People with borderline personality disorder use mental health services more often than people from other mental health diagnostic groups, except for people with schizophrenia.

5. Scope of guidance
Adults diagnosed with borderline personality disorder ; young people with borderline symptoms and people with learning disabilities and borderline personality disorder
NHS services providing treatment
Interface with other services
Effective clinical management
NOTES FOR PRESENTERS:
KEY POINTS TO RAISE:
This guidance covers adults diagnosed with borderline personality disorder ; young people (under the age of 18) with borderline symptoms and people with learning disabilities and borderline personality disorder .
It considers the NHS services providing treatment.
It comments on the interface with other services, including prison health services, forensic services, social services and the voluntary sector.
It recommends the most effective clinical management.
ADDITIONAL INFORMATION:
This guidance uses the DSM-IV diagnostic criteria for borderline personality disorder. According to DSM-IV, the key features of borderline personality disorder are instability of interpersonal relationships, self-image and affect, combined with marked impulsivity beginning in early adulthood.
The criteria for diagnosing borderline personality disorder are: A pervasive pattern of instability of interpersonal relationships, self-image and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:
Frantic efforts to avoid real or imagined abandonment.
A pattern of unstable and intense interpersonal relationships characterised by alternating between extremes of idealisation and devaluation.
Identity disturbance: markedly and persistently unstable self-image or sense of self.
Impulsivity in at least two areas that are potentially self-damaging (for example, spending, sex, substance abuse, reckless driving, binge eating).
Recurrent suicidal behaviour, gestures, or threats, or self-mutilating behaviour.
Affective instability due to a marked reactivity of mood (for example, intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days).
Chronic feelings of emptiness.
Inappropriate, intense anger or difficulty controlling anger (for example, frequent displays of temper, constant anger, recurrent physical fights).
Transient, stress-related paranoid ideation or severe dissociative symptoms.

6. Key areas for implementation
Access to services
Autonomy and choice
Developing an optimistic and trusting relationship
Managing endings and transitions
Assessment
Care planning in community mental health teams
The role of psychological treatment
The role of drug treatment
The role of specialist personality disorder services within trusts
NOTES FOR PRESENTERS:
KEY POINTS TO RAISE:
‘The role of psychological treatment’ contains two key priorities.

7. Access to services
People with borderline personality disorder should not be excluded from any health or social care service because of their diagnosis or because they have self-harmed
NOTES FOR PRESENTERS:
KEY POINTS TO RAISE:
There is a general consensus that there are not enough services for people with personality disorder, and access to services may be compromised for people of black and minority ethnic backgrounds. Service users feel that specialist services are most effective in treating personality disorders and that it is important to recognise that treatment may need to be long term. Early intervention is crucial in preventing a major deterioration in the disorder, and having the option to self-refer could prevent unhelpful and negative experiences.
Related recommendations from the full guideline:
Young people with a diagnosis of borderline personality disorder, or symptoms and behaviour that suggest it, should have access to the full range of treatments and services recommended in this guideline, but within child and adolescent mental health services (CAMHS). ( )
Healthcare professionals should ensure that people from black and minority ethnic groups with borderline personality disorder have equal access to services based upon clinical need. ( )
When language is a barrier to accessing or engaging with services for people with borderline personality disorder, healthcare professionals should provide the person with:
information in their preferred language and/or in an accessible format
psychological or other interventions in their preferred language
independent interpreters. ( )

8. Autonomy and choice
Work in partnership with people with borderline personality disorder to develop their autonomy and promote choice by:
ensuring they remain actively involved in finding solutions to their problems, including during crises
encouraging them to consider the different treatment options and life choices available to them, and the consequences of the choices they make.
NOTES FOR PRESENTERS:
KEY POINTS TO RAISE:
Being able to have a choice about services and treatment is important to people with borderline personality disorder and increases the service user’s cooperation and engagement. If this choice is lacking and the service user opts not to engage with a particular treatment people often feel that this leads to them being labelled as non-compliant. Service users’ own judgement about suitability or unsuitability of a service or treatment should be respected.
Recommendation in full: Given on slide ( ) 8

9. Developing an optimistic and trusting relationship
Explore treatment options in an atmosphere of hope and optimism, explaining that recovery is possible and attainable
Build a trusting relationship, work in an open, engaging and non-judgemental manner, and be consistent and reliable
Bear in mind when providing services that many people will have experienced rejection, abuse and trauma, and will have encountered stigma often associated with self-harm and borderline personality disorder
NOTES FOR PRESENTERS:
KEY POINTS TO RAISE:
When working with people with borderline personality disorder, healthcare professionals need to establish a collaborative partnership with the service user that is non-judgemental, supportive, caring, genuine and positive. They should encourage the service user to believe in their capacity to change, and encourage and support them to achieve their goals. Healthcare professionals also need to be sensitive in their handling of the therapeutic relationship, particularly regarding issues of attachment, sexual orientation and abuse history. They need to be consistent in their assertion of boundaries and willing to commit time to clients.
Recommendation in full:
When working with people with borderline personality disorder:
explore treatment options in an atmosphere of hope and optimism, explaining that recovery is possible and attainable
build a trusting relationship, work in an open, engaging and non-judgmental manner, and be consistent and reliable
bear in mind when providing services that many people will have experienced rejection, abuse and trauma, and will have encountered stigma often associated with self-harm and borderline personality disorder. ( ) 9

10. Managing endings and supporting transitions
The ending of treatments or services, and transition between services can evoke strong emotions and reactions
Anticipate, discuss, structure and phase changes carefully beforehand
Build collaboration with other care providers into the care plan during endings and transitions – include access to services in times of crisis
Ensure and agree support during referral periods to other services
NOTES FOR PRESENTERS:
KEY POINTS TO RAISE:
Leaving a treatment or service is often difficult for people with borderline personality disorder, particularly if they have issues concerning rejection, and can evoke strong emotions. A structured approach to ‘endings’ is needed and people like reassurance that they can access the service again in a crisis. Information about support groups, activity groups and self-management techniques may also be useful.
Recommendation in full:
Anticipate that withdrawal and ending of treatments or services, and transition from one service to another, may evoke strong emotions and reactions in people with borderline personality disorder. Ensure that:
such changes are discussed carefully beforehand with the person (and their family or carers if appropriate) and are structured and phased
the care plan supports effective collaboration with other care providers during endings and transitions, and includes the opportunity to access services in times of crisis
when referring a person for assessment in other services (including for psychological treatment), they are supported during the referral period and arrangements for support are agreed beforehand with them. ( ) 10

11. Assessment
Community mental health services should be responsible for the routine assessment, treatment and management of people with borderline personality disorder
NOTES FOR PRESENTERS:
ADDITIONAL INFORMATION:
Recommendation in full:
Community mental health services (community mental health teams, related community-based services, and tier 2/3 services in child and adolescent mental health services – CAMHS) should be responsible for the routine assessment, treatment and management of people with borderline personality disorder. ( )
Related recommendations from the full guideline:
When assessing a person with possible borderline personality disorder in community mental health services, healthcare professionals should fully assess:
psychosocial and occupational functioning, coping strategies, strengths and vulnerabilities
comorbid mental disorders and social problems
the need for psychological treatment, social care and support, and occupational rehabilitation or development
the needs of any dependent children. ( ) 11

12. Care planning
Develop comprehensive multidisciplinary care plans in collaboration with the service user
Identify the responsibilities of health and social care professionals
Manageable treatment aims and specific steps
Long-term treatment strategy underpinned by realistic goals linked to short-term treatment aims
Crisis plan for when self-management strategies are insufficient
Share care plan with GP and service user
NOTES FOR PRESENTERS:
Recommendation in full:
Teams working with people with borderline personality disorder should develop comprehensive multidisciplinary care plans in collaboration with the service user (and their family or carers, where agreed with the person). The care plan should:
identify clearly the roles and responsibilities of all health and social care professionals involved
identify manageable short-term treatment aims and specify steps that the person and others might take to achieve them
identify long-term goals, including those relating to employment and occupation, that the person would like to achieve, which should underpin the overall long-term treatment strategy; these goals should be realistic, and linked to the short-term treatment aims
develop a crisis plan that identifies potential triggers that could lead to a crisis, specifies self-management strategies likely to be effective and establishes how to access services (including a list of support numbers for out-of-hours teams and crisis teams) when self-management strategies alone are not enough
be shared with the GP and the service user. ( ) 12

13. The role of psychological treatment
Service characteristics
Explicit and integrated theoretical approach – shared with service user
Structured care in accordance with guideline
Provision for therapist supervision
Consider twice-weekly sessions according to need and context
Do not use brief psychotherapeutic interventions of less than 3 months’ duration
NOTES FOR PRESENTERS:
Recommendations in full:
When providing psychological treatment for people with borderline personality disorder, especially those with multiple co-morbidities and/or severe impairment, the following service characteristics should be in place:
an explicit and integrated theoretical approach used by both the treatment team and the therapist, which is shared with the service user
structured care in accordance with this guideline
provision for therapist supervision.
Although the frequency of psychotherapy sessions should be adapted to the person’s needs and context of living, twice-weekly sessions may be considered. ( )
Do not use brief psychotherapeutic interventions (of less than 3 months’ duration) specifically for borderline personality disorder or for the individual symptoms of the disorder, outside a service that has the characteristics outlined in ( ) 13

14. The role of drug treatment
Drug treatment should not be used specifically for borderline personality disorder or for the individual symptoms or behaviour associated with the disorder
NOTES FOR PRESENTERS:
Recommendation in full:
Drug treatment should not be used specifically for borderline personality disorder or for the individual symptoms or behaviour associated with the disorder (for example, repeated self-harm, marked emotional instability, risk-taking behaviour and transient psychotic symptoms). ( )
ADDITIONAL INFORMATION:
The following clinical recommendations relate to this key priority for implementation:
Antipsychotic drugs should not be used for the medium- and long-term treatment of borderline personality disorder. ( )
Drug treatment may be considered in the overall treatment of comorbid conditions. ( )
Short-term use of sedative medication may be considered cautiously as part of the overall treatment plan for people with borderline personality disorder in a crisis. ( )
When considering drug treatment for any reason for a person with borderline personality disorder, provide the person with written material about the drug being considered. This should include evidence for the drug’s effectiveness in the treatment of borderline personality disorder and for any comorbid condition, and potential harm. For people who have reading difficulties, alternative means of presenting the information should be considered, such as video or DVD. So that the person can make an informed choice, there should be an opportunity for the person to discuss the material. The duration of treatment should be agreed with them, but should be no longer than 1 week ( ).
Review the treatment of people with borderline personality disorder who do not have a diagnosed comorbid mental or physical illness and who are currently being prescribed drugs, with the aim of reducing and stopping unnecessary drug treatment. ( ) 14

15. The role of specialist personality disorder services
Assessment and treatment services
Consultation and advice to primary and secondary care services
Diagnostic services when general psychiatric services are in doubt about the diagnosis and/or management
Facilitate information sharing among different services and collaborate with all relevant agencies within the local community
Provide and/or advise on social and psychological interventions, and advise on the safe use of drug treatment in crises and for co-morbidities and insomnia
NOTES FOR PRESENTERS:
Recommendation in full: (Continued on slide 16)
Mental health trusts should develop multidisciplinary specialist teams and/or services for people with personality disorders. These teams should have specific expertise in the diagnosis and management of borderline personality disorder and should:
provide assessment and treatment services for people with borderline personality disorder who have particularly complex needs and/or high levels of risk;
provide consultation and advice to primary and secondary care services;
offer a diagnostic service when general psychiatric services are in doubt about the diagnosis and/or management of borderline personality disorder;
develop systems of communication and protocols for information sharing among different services, including those in forensic settings, and collaborate with all relevant agencies within the local community including health, mental health, social services, the criminal justice system, CAMHS and relevant voluntary services;
be able to provide and/or advise on social and psychological interventions, including access to peer support, and advise on the safe use of drug treatment in crises and for co-morbidities and insomnia;
(Continued on slide 16) 15

16. The role of specialist personality disorder services
Develop protocols to govern arrangements for the transition of
young people from CAMHS to adult services
Establish and maintain clear lines of communication between
primary and secondary care
Support, lead and participate in the local and national
development of treatments
Oversee the implementation of this guideline
Develop and provide training programmes on diagnosis and
management
Monitor the provision of services for minority ethnic
groups to ensure equality of service delivery.
NOTES FOR PRESENTERS:
Recommendation in full:
Mental health trusts should develop multidisciplinary specialist teams and/or services for people with personality disorders. These teams should have specific expertise in the diagnosis and management of borderline personality disorder and should:
work with CAMHS to develop local protocols to govern arrangements for the transition of young people from CAMHS to adult services;
ensure that clear lines of communication between primary and secondary care are established and maintained;
support, lead and participate in the local and national development of treatments for people with borderline personality disorder, including multi-centre research;
oversee the implementation of this guideline;
develop and provide training programmes on the diagnosis and management of borderline personality disorder and the implementation of this guideline (see )
monitor the provision of services for minority ethnic groups to ensure equality of service delivery.
The size and time commitment of these teams will depend on local circumstances (for example, the size of trust, the population covered and the estimated referral rate for people with borderline personality disorder). [ ] 16

17. Costs
Training healthcare professionals in recognition, diagnosis and treatment
Establishing multidisciplinary teams
Cross-organisation communication
Consultation and treatment with a learning disabilities specialist
An increase in the use of services because of greater awareness/diagnoses
Provision of patient literature and video materials for treatment options
NOTES FOR PRESENTERS:
KEY POINTS TO RAISE:
The recommendations on the slides are the most likely to have a resource impact, depending on local circumstances.
There is a paucity of borderline personality disorder services and those that exist vary considerably throughout the country. This has made it difficult to obtain cost data specific to this condition and the delivery of services, although data on personality disorders as a whole does exist. NICE has identified the areas of cost impact on the slide that result from the publication of this guideline in consultation with mental health professionals.
Full details are included in the costing report (see slide 19)

18. Discussion What services currently exist in this area?
What provision do we have for people from minority ethnic groups or whose first language is not English?
How effective is communication between services?
How do we manage people with learning disabilities?
How do we build openness and optimism?
How do current local prescribing practices compare with the recommendations?
NOTES FOR PRESENTERS:
These questions are suggestions that have been developed to help provide a prompt for a discussion at the end of your presentation – please edit and adapt these to suit your local situation.

19. Find out more Visit www.nice.org.uk/CG78 for: Other guideline formats
Costing report
Audit support
NOTES FOR PRESENTERS:
You can download the guidance documents from the NICE website.
The NICE guideline – all the recommendations.
A quick reference guide – a summary of the recommendations for healthcare professionals.
‘Understanding NICE guidance’ – information for patients and carers.
The full guideline – all the recommendations, details of how they were developed, and reviews of the evidence they were based on.
For printed copies of the quick reference guide or ‘Understanding NICE guidance’, phone NICE publications on or and quote reference numbers N1765 (quick reference guide) and/or N1766 (‘Understanding NICE guidance’).
NICE has developed tools to help organisations implement this guideline, which can be found on the NICE website.
Costing report –gives the background to the national savings and costs associated with implementation.
Audit support – for monitoring local practice.