Evidence
Overview of 2018 surveillance methods
Overview of 2018 surveillance methods
NICE's surveillance team checked whether recommendations in the following guidelines remain up to date:
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Antisocial personality disorder (NICE guideline CG77).
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Borderline personality disorder (NICE guideline CG78).
The surveillance process consisted of:
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Initial feedback from topic experts via a questionnaire.
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A search for new or updated Cochrane reviews and national policy.
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A search for ongoing research.
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Examining related NICE guidance and quality standards.
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Examining the NICE event tracker for relevant ongoing and published events.
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Literature searches to identify relevant evidence for borderline personality disorder.
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Assessing the new evidence against current recommendations and deciding whether or not to update sections of the guideline, or the whole guideline.
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Consulting on the decision with stakeholders.
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Considering comments received during consultation and making any necessary changes to the decision.
For further details about the process and the possible update decisions that are available, see ensuring that published guidelines are current and accurate in developing NICE guidelines: the manual.
Evidence considered in surveillance
Search and selection strategy
Antisocial personality disorder
This topic was a static list review and therefore, in accordance with the static list review process, literature searches were not conducted. However, we considered 18 studies identified by previous surveillance.
Borderline personality disorder
We searched for new evidence related to the whole guideline.
We found 19 studies in a search for randomised controlled trials and systematic reviews published between 1 October 2014 and 7 March 2018.
We also included:
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1 relevant study identified by topic experts
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2 studies identified through comments received after publication of the guideline
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29 studies identified by previous surveillance.
From all sources, we considered 51 studies to be relevant to the guideline.
See appendix A: summary of evidence from surveillance for details of all evidence considered, and references.
Ongoing research
We checked for relevant ongoing research. Of the studies identified, 3 studies relating to antisocial personality disorder and 4 studies relating to borderline personality disorder were assessed as having the potential to change recommendations; therefore we plan to regularly check whether these studies have published results, and evaluate the impact of the results on current recommendations as quickly as possible. These studies are:
Antisocial personality disorder
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A small randomised controlled trial on schema mindfulness training versus COMET (correcting a dysfunctional self-image using counter-conditioning) for patients with a personality disorder (also relevant to borderline personality disorder).
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Dialectical behavior therapy for men with borderline personality disorder and antisocial behavior (also relevant to borderline personality disorder).
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Mentalization-based therapy (MBT) for individuals with antisocial personality disorder.
Intelligence gathered during surveillance
Views of topic experts
We sent questionnaires to 16 topic experts and received 7 responses for antisocial personality disorder and 6 for borderline personality disorder. The topic experts either:
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participated in the guideline committee who developed the guideline, or
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were recruited to the NICE Centre for Guidelines Expert Advisers Panel to represent their specialty.
Topic experts were asked some specific questions about evidence and information identified during the surveillance reviews of the personality disorders guidelines:
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Some evidence was identified suggesting instruments for assessing personality disorders can increase personality disorder diagnoses. However experts had mixed opinions on these tools, with some noting the risk of false positives.
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Experts noted that although the new Diagnostic and Statistical Manual of Mental Disorders (DSM-5) has been published, it essentially retains the personality disorder classification structure of the previous version 4 and therefore is unlikely to affect the guidelines.
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Experts suggested that the new ICD-11 could have an impact on the guidelines, but they noted that it may be appropriate to gauge the community's reaction before any update is considered.
Other areas of interest noted by topic experts included:
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The NHS and National Offender Management Service (which is now Her Majesty's Prison and Probation Service) have a joint responsibility for this population.
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The Dangerous and Severe Personality Disorder (DSPD) Programme, in place when NICE guideline CG77 was developed, has been replaced by the Offender Personality Disorder (OPD) Pathway.
NICE has now published a guideline on mental health of adults in contact with the criminal justice system which includes recommendations on organisation of services for commissioners and providers of criminal justice services and healthcare services. Adding a link to this guideline in NICE guidelines CG77 and CG78 will go towards addressing some of the issues raised by topic experts.
Implementation of the guideline
Topic experts raised the issue that many people with diagnosable borderline personality disorder receive help, support and sometimes treatment in non-health settings, where there may be little awareness of relevant NICE guidelines. This information has been passed to the NICE field team.
Views of stakeholders
Stakeholders are consulted on all surveillance decisions except if the whole guideline will be updated and replaced. Because this surveillance decision was to not update the guidelines, we consulted on the decision.
Antisocial personality disorder
Overall, 7 stakeholders commented (3 royal colleges, 2 NHS trusts, a government department, and a charity): 1 agreed with the decision; 2 disagreed with the decision; 4 did not provide an answer.
The following issues were raised in disagreement with the proposal not to update.
A stakeholder stated that treatment recommendations in NICE guideline CG77 are overly focused on the prison population. The evidence base for treatment outside the criminal justice system is limited, and NICE guideline CG77 does acknowledge that '…the focus of several interventions is offending behaviour'. However some treatment recommendations do include mental health services settings. A NICE research recommendation was made to attempt to address the lack of evidence in this area: '4.2 Group-based cognitive and behavioural interventions for populations outside criminal justice settings'.
A stakeholder noted issues with the construct and labelling of personality disorder (the same comment was also made about borderline personality disorder). However, any decision on changes to the guideline in this area will be best made once NICE and the wider community have had chance to review and respond to ICD-11, which introduces substantial changes in the classification of personality disorders and could have major implications for NICE guidelines CG77 and CG78.
A stakeholder was concerned that the decision not to update the guideline could lead to failures to fund adequately in these areas (the same comment was also made about borderline personality disorder). However, the guideline retains the status of NICE guidance whether it is updated or not. No reduction in funding as a result of the decision not to update it at this time is anticipated.
A stakeholder stated that the focus is predominantly on men in NICE guideline CG77 and women in NICE guideline CG78 (the same comment was also made about borderline personality disorder). However, the guideline scopes do not specify any particular focus on men or women, and only 1 recommendation in each guideline is specific to a particular sex.
Borderline personality disorder
Overall, 8 stakeholders commented (3 royal colleges, 2 NHS trusts, a government department, a charity, and a non-profit organisation): 2 agreed with the decision; 2 disagreed with the decision; 4 did not provide an answer.
The following issues were raised in disagreement with the decision not to update.
A stakeholder commented that NICE guideline CG78 does not recommend any pharmacological treatments, but many people are taking these and an update is needed to emphasise not prescribing. As noted by the stakeholder, NICE guideline CG78 makes an explicit recommendation that drug treatment should not be used specifically for borderline personality disorder or for the individual symptoms or behaviour associated with the disorder. Implementation of the guideline, which includes the monitoring of 'do not do' recommendations, is outside the remit of surveillance reviews. However concerns about the use of drugs in this population will be passed on to our implementation team.
A stakeholder noted there are still no NICE-recommended, evidence-based treatments or managements, and that NICE should consider lobbying for urgently needed research. The surveillance review identified several studies on management strategies for borderline personality disorder but it was felt that there was not enough evidence to indicate any need to update the guideline. NICE is able to suggest areas for research through its research recommendations. NICE guideline CG78 has 4 research recommendations about management of borderline personality disorder.
A stakeholder indicated a need to address that personality disorders affect men, women and ethnicities differently. NICE guideline CG78 does acknowledge differences among these groups, for example a recommendation is made about a specific approach to management in women. Additionally, the guideline recommends that people from black and minority ethnic groups have equal access to culturally appropriate services based on clinical need.
Additional consultation questions
Additionally, stakeholders were asked for their views on whether or not they anticipated ICD-11 classification would be adopted in the UK, and if they felt that would impact on the guidelines. Of the 5 stakeholders responding, 4 felt it would be adopted and 3 felt it would impact on the guidelines.
The majority of stakeholders responding yes to these questions lends support to the decision not to update the guidelines at this time, but to perform a further surveillance review in 2021 to gauge the reaction of the community to ICD-11 and examine any potential impact on NICE guidelines CG77 and 78.
See appendix B for full details of stakeholders' comments and our responses.
See ensuring that published guidelines are current and accurate in developing NICE guidelines: the manual for more details on our consultation processes.
Editorial amendments
During surveillance of the guideline we identified the following points in the guideline that should be amended.
Antisocial personality disorder
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In the full version of NICE guideline CG77, page 139/140: recommendation 5.4.24.1 on multisystemic therapy will be deleted because the corresponding recommendation (1.2.7.6) in the short guideline has been deleted (now replaced by recommendation 1.5.13 in NICE's guideline on antisocial behaviour and conduct disorders in children and young people).
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The person-centred care section of the short version of NICE guideline CG77 will be replaced with the following box in line with newer NICE guidelines:
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People have the right to be involved in discussions and make informed decisions about their care, as described in your care. Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding. |
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Footnote 2 in recommendation 1.6.3.1 contains a hyperlink to 'The Essential Shared Capabilities'. This link goes to the wrong page; this is the correct link to the Essential Shared Capabilities).
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The following cross-referrals will be added to NICE guideline CG77:
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From recommendation 1.1.2.2: 'Staff providing interventions for people with antisocial personality disorder with learning or physical disabilities or acquired cognitive impairments…': a link will be added to NICE's guideline on mental health problems in people with learning disabilities: prevention, assessment and management.
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From recommendation 1.2.9.1 'Health and social care services should consider referring vulnerable young people with a history of conduct disorder or contact with youth offending schemes, or those who have been receiving interventions for conduct and related disorders, to appropriate adult services for continuing assessment and/or treatment': a link will be added to NICE's guideline on transition from children's to adults' services for young people using health or social care services.
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From recommendation 1.3.3.1 'Services should develop a comprehensive risk management plan for people with antisocial personality disorder who are considered to be of high risk…', and recommendation 1.4.3.1 'Pharmacological interventions should not be routinely used for the treatment of antisocial personality disorder or associated behaviours of aggression, anger and impulsivity': a link will be added to NICE's guideline on violence and aggression: short-term management in mental health, health and community settings (from recommendation 1.4.3.1, the link will be to the specific recommendations in NICE guideline NG10 about rapid tranquilisation).
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From recommendation 1.6.1.1 'Provision of services for people with antisocial personality disorder ….': a link will be added to NICE's guideline on mental health of adults in contact with the criminal justice system.
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In recommendations 1.4.1.1, 1.4.3.2 and 1.4.4.1 (which state that comorbid disorders should be treated in line with recommendations in the relevant NICE guideline, and provide a link to an outdated and incomplete list of related NICE guidance in section 6), the link to section 6 will be replaced with: see the NICE mental health and behavioural conditions topic page, or search the NICE find guidance page.
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In recommendation 1.5.1.2 'For people who meet criteria for psychopathy or DSPD, offer treatment for any comorbid disorders in line with existing NICE guidance…', the following text will be added: See the NICE mental health and behavioural conditions topic page, or search the NICE find guidance page.
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Research recommendations 4.3 effectiveness of multisystemic therapy versus functional family therapy and 4.4 interventions for infants at high risk of developing conduct disorders will be deleted because these areas are now covered by recommendations in NICE's guideline on antisocial behaviour and conduct disorders in children and young people: recognition and management.
Borderline personality disorder
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The person-centred care section of the short version of NICE guideline CG78 will be replaced with the following box in line with newer NICE guidelines:
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People have the right to be involved in discussions and make informed decisions about their care, as described in your care. Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding. |
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In footnote 2 to recommendation 1.3.1.2, the hyperlink to the SCIE research briefing 'Experiences of children and young people caring for a parent with a mental health problem' is broken and will be fixed. This is the correct link to the SCIE research briefing on the experience of children and young people caring for a parent with a mental health problem.
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The hyperlink in recommendation 1.3.8.2 to NICE technology appraisal guidance 77 is broken and will be fixed. This is the correct link to NICE technology appraisal guidance 77.
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The following cross-referrals will be added to the guideline:
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From recommendation 1.1.2.4 'People with a moderate or severe learning disability should not normally be diagnosed with borderline personality disorder…': a link will be added to NICE's guideline on mental health problems in people with learning disabilities: prevention, assessment and management.
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From recommendation 1.1.7.2 'CAMHS and adult healthcare professionals should work collaboratively to minimise any potential negative effect of transferring young people from CAMHS to adult services…': a link will be added to the NICE topic overview page for service transition.
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The wording of recommendation 1.1.8.1 'Follow the recommendations in 'Self-harm' (NICE clinical guideline 16) to manage episodes of self-harm or attempted suicide' will be changed to 'Follow the recommendations in NICE's guidelines on self-harm in over 8s: short-term management and prevention of recurrence and self-harm in over 8s: long-term management to manage episodes of self-harm or attempted suicide'.
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The wording of recommendation 1.3.6.4 will be changed from: 'When treating a comorbid condition in people with borderline personality disorder, follow the NICE clinical guideline for the comorbid condition' to: 'When treating a comorbid condition in people with borderline personality disorder, follow the NICE clinical guideline for the comorbid condition (see the NICE mental health and behavioural conditions topic page, or search the NICE find guidance page)'.
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From recommendation 1.3.7.1 'When a person with borderline personality disorder presents during a crisis…': a link will be added to NICE's guideline on violence and aggression: short-term management in mental health, health and community settings.
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From recommendation 1.5.1.1: '…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 and social services, the criminal justice system, CAMHS and relevant voluntary services': a link will be added to NICE's guideline on mental health of adults in contact with the criminal justice system.
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