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NICE guidelines: borderline personality disorder

A couple of days ago I blogged on the National Institute for Health and Clinical Excellence's (NICE's) January guidance on a diverse range of fifteen clinical, technology, interventional and public health subjects including Antisocial Personality Disorder.  In today's post, I discuss NICE's hot-off-the-press guidance on Borderline Personality Disorder.  This addresses a very large, mostly unmet, need.  As I quoted in Thursday's post, Dr Tim Kendall, Joint Director, National Collaborating Centre for Mental Health, states: "Approximately 2 million people in the UK have personality disorders, with antisocial and borderline disorders being the most common. We have largely ignored this problem or have been too dependent on drug treatments that don't work and in some cases (for example the use of antipsychotics) can be harmful."  The size of the need is further underlined by recent US research (Grant, Chou et al. 2008) involving face-to-face interviews with a nationally representative sample of 34,653 adults.  They found "Prevalence of lifetime BPD was 5.9% (99% CI = 5.4 to 6.4). There were no differences in the rates of BPD among men (5.6%, 99% CI = 5.0 to 6.2) and women (6.2%, 99% CI = 5.6 to 6.9)."  They also found that BPD " ... is associated with considerable mental and physical disability, especially among women."

The press release  on Borderline Personality Disorder reads: "NICE guidance published today (28 January) outlines how healthcare professionals can identify, treat and manage people with borderline personality disorder.  Borderline personality disorder is a condition that affects a person's thoughts, emotions and behaviour. Symptoms include having emotions that are up and down, with feelings of emptiness and often anger, difficulty in making and maintaining relationships, having an unstable sense of identity and harming yourself or thinking about harming yourself (for example, cutting yourself or overdosing). People with borderline personality disorder come from many different backgrounds, but most will have suffered some kind of trauma or neglect as children. Key recommendations from the guideline include:
• 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.
• 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
• Community mental health services should be responsible for the routine assessment, treatment and management of people with borderline personality disorder.
• 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)."

As Professor Peter Tyrer, one of the authors of the guideline, comments: "The diagnosis of personality disorder often carries with it the notion of untreatability and persistence. Neither of these is true, especially with respect to borderline personality disorder. Patients are often pleasurably surprised that problems that have formerly appeared to be misunderstood, ignored or dismissed, are appreciated as a source of real suffering and treated with much greater respect when they are seen in a personality context. The notion of a ‘quick fix' is not appropriate for this group of conditions and far too many are given treatments such as drugs for their symptoms that only give brief relief and when they return more drugs are added. Many people with this disorder suffer all the adverse effects of multiple drug prescription (polypharmacy) and this is not only unhelpful but carries the risk of serious adverse effects. When people with these disorders are treated consistently with primarily psychological approaches the outcome is good and relapse unlikely, so these longer term treatments are much more cost-effective."  

The 495 page full guideline has large sections on psychological therapies (the core of treatment e.g. with dialectical behaviour therapy, mentalisation-based therapy, schema-focused cognitive therapy, etc), pharmacological therapies (not recommended for treatment of BPD itself, although pharmacological treatment of comorbid conditions to be considered, and mood stabililisers like topiramate & lamotrigine look worth investigating further), management of crises, configuration and organisation of services, and young people with borderline personality disorder.  Cost implications are also considered in a separate 28 page booklet, but it proves hard to quantify potential costs and savings.

To scan other posts on this website about borderline personality disorder, including a variety of relevant handouts & questionnaires, click here.  For a list of several potentially helpful websites, click here.

Grant, B. F., S. P. Chou, et al. (2008). "Prevalence, correlates, disability, and comorbidity of DSM-IV borderline personality disorder: results from the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions." J Clin Psychiatry 69(4): 533-45.  [PubMed] 

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