Transcript Slide set

Borderline personality disorder
Implementing NICE guidance
2009
NICE clinical guideline 78
What this presentation covers
Background
Scope
Key priorities for implementation
Costs
Discussion
Find out more
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.
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
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
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
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
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.
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
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
Assessment
Community mental health
services should be
responsible for the routine
assessment, treatment and
management of people
with borderline personality
disorder
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
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
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
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
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.
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
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?
Find out more
Visit www.nice.org.uk/CG78 for:
• Other guideline formats
• Costing report
• Audit support