Borderline personality disorder: recognition and management

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.

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 children and adolescent mental health services (CAMHS).

When language is a barrier to accessing or engaging with services for people with borderline personality disorder, provide them with psychological or other interventions in their preferred language.

When a person with a mild learning disability has a diagnosis of borderline personality disorder, they should have access to the same services as other people with borderline personality disorder.

When care planning for people with a mild learning disability and borderline personality disorder, follow the Care Programme Approach (CPA). Consider consulting a specialist in learning disabilities services when developing care plans and strategies for managing behaviour that challenges.

People with a moderate or severe learning disability should not normally be diagnosed with borderline personality disorder.

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

• bear in mind when providing services that many people will have experienced rejection, abuse and trauma, and encountered stigma often associated with self-harm and borderline personality disorder.

Ask directly whether the person with borderline personality disorder wants their family or carers to be involved in their care, and, subject to the person's consent and rights to confidentiality:

• encourage family or carers to be involved

• ensure that the involvement of families or carers does not lead to withdrawal of, or lack of access to, services

• inform families or carers about local support groups for families or carers, if these exist.

CAMHS professionals working with young people with borderline personality disorder should:

• balance the developing autonomy and capacity of the young person with the responsibilities of parents or carers

• be familiar with the legal framework that applies to young people, including the Mental Capacity Act, the Children Acts and the Mental Health Act.

When assessing a person with borderline personality disorder, offer post-assessment support, particularly if sensitive issues (such as childhood trauma) have been discussed.

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.

CAMHS and adult healthcare professionals should work collaboratively to minimise any potential negative effect of transferring young people from CAMHS to adult services. They should continue treatment in CAMHS beyond 18 years if there is a realistic possibility that this may avoid the need for referral to adult mental health services.

Mental health professionals working in secondary care services, including community-based services and teams, CAMHS and inpatient services, should be trained to diagnose borderline personality disorder, assess risk and need, and provide treatment and management in accordance with this guideline. Training should also be provided for primary care healthcare professionals who have significant involvement in the assessment and early treatment of people with borderline personality disorder. Training should be provided by specialist personality disorder teams based in mental health trusts (see recommendation 1.5.1.1 in the section on the role of specialist personality disorder services within trusts ).

Mental health professionals working with people with borderline personality disorder should have routine access to supervision and staff support.

If a person presents in primary care who has repeatedly self-harmed or shown persistent risk-taking behaviour or marked emotional instability, consider referring them to community mental health services for assessment for borderline personality disorder. If the person is younger than 18 years, refer them to CAMHS for assessment.

When a person with an established diagnosis of borderline personality disorder presents to primary care in a crisis:

• assess the current level of risk to self or others

• ask about previous episodes and effective management strategies used in the past

• help to manage their anxiety by enhancing coping skills and helping them to focus on the current problems

• encourage them to identify manageable changes that will enable them to deal with the current problems

• offer a follow-up appointment at an agreed time.

Consider referring a person with diagnosed or suspected borderline personality disorder who is in crisis to a community mental health service when:

• their levels of distress and/or the risk to self or others are increasing

• their levels of distress and/or the risk to self or others have not subsided despite attempts to reduce anxiety and improve coping skills

• they request further help from specialist services.

Community mental health services (community mental health teams, related community-based services, and tier 2 or 3 services in children and adolescent mental health services [CAMHS]) should be responsible for the routine assessment, treatment and management of people with borderline personality disorder.

When assessing a person with possible borderline personality disorder in community mental health services, 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. See the Social Care Institute for Excellence's research briefing on experiences of children and young people caring for a parent with a mental health problem.

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.

Teams should use the CPA when people with borderline personality disorder are routinely or frequently in contact with more than one secondary care service. It is particularly important if there are communication difficulties between the service user and healthcare professionals, or between healthcare professionals.

Risk assessment in people with borderline personality disorder should:

• take place as part of a full assessment of the person's needs

• differentiate between long-term and more immediate risks

• identify the risks posed to self and others, including the welfare of any dependent children.

Agree explicitly the risks being assessed with the person with borderline personality disorder and develop collaboratively risk management plans that:

• address both the long-term and more immediate risks

• relate to the overall long-term treatment strategy

• take account of changes in personal relationships, including the therapeutic relationship.

When managing the risks posed by people with borderline personality disorder in a community mental health service, risks should be managed by the whole multidisciplinary team with good supervision arrangements, especially for less experienced team members. Be particularly cautious when:

• evaluating risk if the person is not well known to the team

• there have been frequent suicidal crises.

Teams working with people with borderline personality disorder should review regularly the team members' tolerance and sensitivity to people who pose a risk to themselves and others. This should be reviewed annually (or more frequently if a team is regularly working with people with high levels of risk).

When considering a psychological treatment for a person with borderline personality disorder, take into account:

• the choice and preference of the service user

• the degree of impairment and severity of the disorder

• the person's willingness to engage with therapy and their motivation to change

• the person's ability to remain within the boundaries of a therapeutic relationship

• the availability of personal and professional support.

Before offering a psychological treatment for a person with borderline personality disorder or for a comorbid condition, provide the person with written material about the psychological treatment being considered. 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 them to discuss not only this information but also the evidence for the effectiveness of different types of psychological treatment for borderline personality disorder and any comorbid conditions.

When providing psychological treatment for people with borderline personality disorder, especially those with multiple comorbidities 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 psychological 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 recommendation 1.3.4.3.

For women with borderline personality disorder for whom reducing recurrent self-harm is a priority, consider a comprehensive dialectical behaviour therapy programme.

When providing psychological treatment to people with borderline personality disorder as a specific intervention in their overall treatment and care, use the CPA to clarify the roles of different services, professionals providing psychological treatment and other healthcare professionals.

When providing psychological treatment to people with borderline personality disorder, monitor the effect of treatment on a broad range of outcomes, including personal functioning, drug and alcohol use, self-harm, depression and the symptoms of 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).

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 (see section 1.3.6 on the management of comorbidities).

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. Sedative antihistamines are not licensed for this indication and informed consent should be obtained and documented. The duration of treatment should be agreed with them, but should be no longer than 1 week (see section 1.3.7 on the management of crises).

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.

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.

Before starting treatment for a comorbid condition in people with borderline personality disorder, review:

• the diagnosis of borderline personality disorder and that of the comorbid condition, especially if either diagnosis has been made during a crisis or emergency presentation

• the effectiveness and tolerability of previous and current treatments; discontinue ineffective treatments.

Treat comorbid depression, post-traumatic stress disorder or anxiety within a well-structured treatment programme for borderline personality disorder.

Refer people with borderline personality disorder who also have major psychosis, dependence on alcohol or Class A drugs, or a severe eating disorder to an appropriate service. The care coordinator should keep in contact with people being treated for the comorbid condition so that they can continue with treatment for borderline personality disorder when appropriate.

Provide people with borderline personality disorder who have sleep problems with general advice about sleep hygiene, including having a bedtime routine, avoiding caffeine, reducing activities likely to defer sleep (such as watching violent or exciting television programmes or films), and employing activities that may encourage sleep.

For the further short-term management of insomnia follow the recommendations in the NICE technology appraisal guidance on the use of zaleplon, zolpidem and zopiclone for the short-term management of insomnia. However, be aware of the potential for misuse of many of the drugs used for insomnia and consider other drugs such as sedative antihistamines.

For guidance on safe prescribing of Z-drugs (such as zolpidem and zopiclone) and managing withdrawal, see NICE's guideline on medicines associated with dependence or withdrawal symptoms.

When discharging a person with borderline personality disorder from secondary care to primary care, discuss the process with them and, whenever possible, their family or carers beforehand. Agree a care plan that specifies the steps they can take to try to manage their distress, how to cope with future crises and how to re-engage with community mental health services if needed. Inform the GP.

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 and 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 comorbidities and insomnia

• 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 recommendation 1.5.1.2)

• 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).

Specialist teams should develop and provide training programmes that cover the diagnosis and management of borderline personality disorder and the implementation of this guideline for general mental health, social care, forensic and primary care providers and other professionals who have contact with people with borderline personality disorder. The programmes should also address problems around stigma and discrimination as these apply to people with borderline personality disorder.

Specialist personality disorder services should involve people with personality disorders and families or carers in planning service developments, and in developing information about services. With appropriate training and support, people with personality disorders may also provide services, such as training for professionals, education for service users and families or carers, and facilitating peer support groups.