Borderline and antisocial personality disorders: summary of NICE guidance
BMJ 2009; 338 doi: https://doi.org/10.1136/bmj.b93 (Published 28 January 2009) Cite this as: BMJ 2009;338:b93
- Tim Kendall, joint director1, deputy director 2, consultant psychiatrist and medical director3,
- Stephen Pilling, joint director4, director 5, consultant psychologist6,
- Peter Tyrer, professor of community psychiatry7, honorary consultant psychiatrist8,
- Conor Duggan, professor of forensic mental health9, honorary consultant psychiatrist10,
- Rachel Burbeck, systematic reviewer4,
- Nicholas Meader, systematic reviewer1,
- Clare Taylor, editor1
- On behalf of the guideline development groups
- 1National Collaborating Centre for Mental Health, Royal College of Psychiatrists’ Research and Training Unit, London E1 8AA
- 2Royal College of Psychiatrists’ Research and Training Unit, London E1 8AA
- 3Sheffield Health and Social Care Trust, Sheffield S10 3TH
- 4National Collaborating Centre for Mental Health, British Psychological Society—CORE, Sub-Department of Clinical Health Psychology, University College London, London WC1E 7HB
- 5Centre for Outcomes Research and Effectiveness, University College London, London WC1E 7HB
- 6Camden and Islington Foundation Trust, London NW1 0PE.
- 7Imperial College, London SW7 2AZ
- 8West London Mental Health NHS Trust, Southall UB1 3EU
- 9The University of Nottingham, Nottingham NG7 2RD
- 10Nottinghamshire Healthcare Trust, Nottingham NG3 6AA
- Correspondence to: T Kendall Tim.Kendall{at}shsc.nhs.uk
Why read this summary?
Personality disorders are common, with an estimated prevalence in the community of 4.4%.1 They can significantly impair personal and social functioning, with considerable cost to health services, society, the criminal justice system, and the individual. Of the 10 classified types of personality disorder, borderline and antisocial personality disorder are the most prominent in forensic and general psychiatric settings. People with borderline personality disorder tend to have volatile relationships, an unstable self image, labile affects, and impulsiveness; they also frequently self harm. People with antisocial personality disorder characteristically break rules routinely; engage in criminal behaviour; and have a strong tendency to be reckless, irresponsible, and deceitful. People with both disorders often report a history of serious family problems, domestic violence, abuse, and inconsistent and often violent punishment in childhood.
Separate guidelines were developed for these two disorders because of differences in diagnostic criteria and contact with services. People with borderline personality disorder tend to be “treatment seeking,” whereas the antisocial group are “treatment resisting,”2 and they are unlikely to come into contact with services except for the treatment of comorbid conditions or when legally mandated to attend treatment programmes.3
This article summarises the key recommendations from the National Institute for Health and Clinical Excellence (NICE) on the management of both borderline and antisocial personality disorder.2 3 Because about 50% of children with conduct disorder develop antisocial personality disorder, the guideline for this disorder includes preventive strategies—namely, interventions for conduct disorder in childhood and adolescence.
Recommendations
NICE recommendations are based on systematic reviews of best available evidence. When minimal evidence is available, recommendations are based on the guideline development group’s opinion of what constitutes good practice. Evidence levels for the recommendations are given in italic in square brackets.
Recommendations for borderline personality disorder
The role of psychological treatment
When providing psychological treatment, especially for people with multiple comorbidities or severe impairment (or both), include:
An explicit and integrated theoretical approach used by both the treatment team and the therapist, and shared with the service user
Structured care in accordance with this guideline
Provision for supervision by a therapist.
Although the frequency of psychotherapy sessions should be adapted to the person’s needs and context of living, consider twice weekly sessions. [All points are based on high quality randomised controlled trials and the experience of the Guideline Development Group]
Do not use brief psychological interventions (of less than three months’ duration) specifically for borderline personality disorder or for its individual symptoms outside a service that has the characteristics outlined above. [Based on high quality randomised controlled trials]
The role of drug treatment
Do not use drug treatment specifically for borderline personality disorder or for the individual symptoms or behaviour associated with it. [Based on moderate quality randomised controlled trial]
Access to services
People with borderline personality disorder should not be excluded from any health or social care service because of their diagnosis, their sex, or because they have self harmed. [Based on the experience of the Guideline Development Group]
Developing an optimistic and trusting relationship
Explore treatment options in an atmosphere of hope and optimism.
Build a trusting relationship; work in an open, engaging, and non-judgmental manner; and be consistent and reliable.
Bear in mind that many people will have experienced rejection, abuse, and trauma and will have been stigmatised. [All three points are based on the experience of the Guideline Development Group]
Autonomy and choice
Work in partnership with people who have borderline personality disorder to develop their autonomy and promote choice by:
Ensuring they remain actively involved in finding solutions to their problems.
Encouraging them to consider different treatments and life choices, and to consider the consequences of the choices they make. [All points based on the experience of the Guideline Development Group]
Managing endings and transitions
Anticipate that withdrawal of treatments, coming to the end of treatments or services, and transition to other services may elicit strong emotions and reactions in service users.
Discuss such changes with the person (and their family or carers if appropriate) beforehand, and ensure that the changes are structured and phased.
Ensure the care plan supports effective collaboration with other care providers during endings and transitions, and that provision is made for access to services during a crisis.
When referring a person for assessment by another service, ensure support during the referral period; agree arrangements for support in advance. [All points based on the experience of the Guideline Development Group]
Assessment
Community mental health services should be responsible for routine assessment, treatment, and management. [Based on the experience of the Guideline Development Group]
Planning care in community mental health teams
Teams should develop comprehensive multidisciplinary care plans with service users (and their families or carers, where appropriate) and share these with service users and their general practitioners. Ensure that care plans:
Identify the roles and responsibilities of all healthcare and social care professionals
Specify short term treatment aims and the steps needed to achieve them
Identify long term goals
Include a crisis plan. [All points based on the experience of the Guideline Development Group]
The role of specialist personality disorder services within trusts
Mental health trusts should develop multidisciplinary specialist teams or services (or both) for people with personality disorders. Teams should have expertise in the diagnosis and management of borderline personality disorder and should:
Provide consultation and advice to primary and secondary care
Provide assessment and treatment services for people who have particularly complex needs or high levels of risk (or both)
Offer a diagnostic service when general psychiatric services are unclear about the diagnosis or management (or both)
Develop communication systems and protocols in different services, collaborate with all relevant local agencies, and ensure clear lines of communication between primary and secondary care
Work with child and adolescent mental health services to develop local protocols for transition to adult services
Oversee the implementation of this guideline
Develop and provide training programmes on diagnosis, management, and guideline implementation
Monitor the provision of services for minority ethnic groups. [All points based on the experience of the Guideline Development Group]
Recommendations for antisocial personality disorder
Developing an optimistic and trusting relationship
Recognise that a positive and rewarding approach is more likely than a punitive approach to engage people and retain them in treatment.
Explore treatment options in an atmosphere of hope and optimism.
Build a trusting relationship; work in an open, engaging, and non-judgmental manner; and be consistent and reliable. [All points based on the experience of the Guideline Development Group]
Children with conduct problems
Group based parent training programmes are recommended in the management of children with conduct disorders. [This recommendation comes from “Parent-training/education programmes in the management of children with conduct disorders” (NICE technology appraisal 102)]
For children 8 years or more with conduct problems, consider cognitive problem solving skills training to reduce the likelihood of developing antisocial personality disorder in adulthood if:
The family is unwilling or unable to engage with a parent training programme
Additional factors, such as callous and unemotional traits in the child, may reduce the effectiveness of a parent training programme. [All points based on high quality randomised controlled trials]
Assessment by forensic or specialist personality disorder services
As part of a structured clinical assessment, consider routinely using:
A standardised measure of severity (for example, psychopathy checklist–revised (PCL-R)4 or psychopathy checklist–screening version (PCL-SV)5
A formal assessment tool such as the historical, clinical, risk management-20 (HCR-20)6 to develop a risk management strategy. [All points based on moderate quality cohort studies and the experience of the Guideline Development Group]
Treatment of comorbid disorders
Offer treatment for any comorbid disorders in line with recommendations in the relevant NICE clinical guideline. This should happen regardless of whether the person is receiving treatment for antisocial personality disorder, because such people are often excluded from routine care. [Based on systematic reviews and the experience of the Guideline Development Group]
Psychological interventions
For people with antisocial personality disorder with a history of offending behaviour who are in community or institutional care, consider group based cognitive and behavioural interventions focused on reducing offending and other antisocial behaviour. [Based on moderate quality randomised controlled trials and experience of the Guideline Development Group]
Multiagency networking
Service provision for people with antisocial personality disorder often involves a considerable amount of interagency working. To provide the most effective multiagency care, services should ensure that there are clear pathways that:
Specify the various interventions available at each point
Enable effective communication among clinicians and organisations.
Establish clearly agreed local criteria to facilitate transfer between services and develop shared objective criteria on the comprehensive assessment of need and risk. [All points based on the experience of the Guideline Development Group]
Consider establishing antisocial personality disorder networks; wherever possible they should be linked to other personality disorder networks. These networks should be multiagency and should:
Actively involve service users
Have a central role in training staff
Provide specialist support and supervision for staff
Have a central role in developing standards for clinical pathways and coordinating such pathways
Monitor the effective operation of clinical pathways. [All points based on a systematic review of cross sectional studies on service organisation and staff and carers’ experience and the experience of the Guideline Development Group]
Overcoming barriers
In spite of their prevalence, these two personality disorders are often undiagnosed within the National Health Service and the criminal justice system. This is because mental health professionals often do not recognise the main characteristics of these disorders; clinical presentation often results from comorbidities, such as depression or substance misuse7; and people with a personality disorder may be considered responsible for their own condition, which is also often viewed as untreatable.8 9 As a result, these guidelines and the Department of Health10 recommend the development of specialist services for people with personality disorder in each mental health trust. With the development of these services we anticipate that these guidelines will gain support from mental health and social care professionals, with the hope that these two groups of often traumatised and mistreated people will get the help they need and be less stigmatised.
Further information on guidance
Both borderline and antisocial personality disorders can cause serious impairment, and they are commonly associated with comorbid conditions, such as depression, anxiety, alcohol misuse, and drug misuse. Borderline personality disorder can also be comorbid with psychotic disorders, eating disorders, and post-traumatic stress disorder. For people with more severe symptoms, the characteristics of both disorders may overlap and merge with those of other personality disorders.11
The prevalence of borderline personality disorder is estimated to be 0.7% in community samples,1 12 4-6% in primary care,13 14 and more than 20% in mental healthcare settings. It is distributed roughly equally between men and women, although women are more likely to present to services and seek treatment. The estimated prevalence of antisocial personality disorder varies depending on methodology and geographical location, but all studies have found the condition to be more prevalent in men than in women.1 12 15 A worldwide survey of prison populations found that 47% of male prisoners and 21% of female prisoners had antisocial personality disorder.3
All personality disorders are associated with considerable stigma, and although borderline personality disorder is becoming better understood, largely through campaigns to raise awareness in service users, antisocial personality disorder is largely used as a label of rejection.
Evidence shows that people with borderline personality disorder are excluded from services because of their diagnosis,10 and that they are inappropriately prescribed several psychotropic drugs simultaneously, possibly for extended periods. For example, a six year prospective cohort study found that 40% of people with borderline personality disorder were being prescribed three or more drugs.16 People with antisocial personality disorder are often excluded from specialist personality disorder services, despite policies to improve services for this group.17 18
However, both guidelines offer real promise of more positive outcomes. The recognition in the guideline on antisocial personality disorder of the importance of prevention is an important step forward.
What’s new
The borderline personality disorder guideline integrates evidence from randomised controlled trials with experience from service users and carers. For example, patients may be prescribed multiple drugs because of poor follow-up and because prescribers think that they should do something. The guideline clearly states that drugs should not be prescribed for borderline personality disorder itself, they should be used only in the short term during crisis periods, and that polypharmacy should be avoided. The guideline also recognises that working with people with borderline personality disorder can be difficult and recommends regular supervision and reflection for staff.
The guideline on antisocial personality disorder takes the first comprehensive view of the condition. It draws on a wide literature, including evidence for the management of offending behaviour and evidence on interventions in children and young people with conduct disorder to reduce the likelihood of them developing antisocial personality disorder in adulthood.
Methods
The guidelines were developed according to NICE guideline methodology (see www.nice.org.uk/page.aspx?o=114219) by the National Collaborating Centre for Mental Health. A group of clinicians and representatives of service users and carers was also convened to oversee the work and develop the recommendations of these guidelines. The guideline groups conducted systematic reviews of the clinical literature (and of health economic evidence for antisocial personality disorder) and assessed the quality of this literature, as well as evidence from service users and carers. However, the evidence base for both guidelines has serious limitations. Few randomised controlled trials of interventions have been undertaken, and in those that have, few outcomes are in common, which makes synthesis difficult. For the antisocial disorder guideline, the group also reviewed literature from related populations, including offenders (who often have antisocial personality disorder) and people displaying symptoms and behaviours associated with antisocial personality disorder (such as anger, violence, and impulsivity).
The guidelines went through an external consultation with stakeholders. The development groups assessed the comments, reanalysed the data if necessary, and modified the guidelines. NICE has produced four different versions of each guideline—a full version; a quick reference guide (which combines both guidelines); a version known as the “NICE guideline” that summarises the recommendations; and a version for service users and the public (Understanding NICE guidance). All these versions are available from the NICE website (www.nice.org.uk). Future updates of the guidelines will be produced as part of the NICE guideline development programme.
Future research
Borderline personality disorder
Develop an agreed set of outcome measures to assess interventions.
Evaluate the relative efficacy of psychological treatment programmes delivered within well structured high quality community based services compared with such care delivered without the psychological intervention.
Evaluate the efficacy of outpatient psychosocial interventions for people with less severe disorders.
Evaluate the clinical effectiveness and cost effectiveness of mood stabilisers on symptoms.
Develop an effective care pathway.
Antisocial personality disorder
Assess the role of severity of the condition as a potential moderator of effect in group based cognitive and behavioural interventions.
Evaluate the effectiveness of group based cognitive and behavioural interventions for populations outside criminal justice settings.
Evaluate the effectiveness of multisystemic therapy (the use of strategies from family therapy and behavioural therapy to intervene directly in systems and processes related to antisocial behaviour) versus functional family therapy in treating young people.
Evaluate the effectiveness of specially designed parent training programmes focused on sensitivity enhancement (techniques designed to improve secure attachments between parents and children) to reduce the risk of behavioural disorders in infants.
Assess the effectiveness of treating comorbid anxiety disorders in improving the long term outcome of antisocial personality disorder.
Evaluate the effectiveness of selective serotonin reuptake inhibitors to increase cooperative behaviour in people with antisocial personality disorder in prison.
Evaluate the clinical effectiveness and cost effectiveness of a therapeutic community approach (a group based intervention where the focus is on participation in a community with a more democratic, collaborative, and less hierarchical approach to staff-service user interaction) in treating antisocial personality disorder in prison.
Notes
Cite this as: BMJ 2009;338:b93
Footnotes
This is one of a series of BMJ summaries of new guidelines, which are based on the best available evidence; they highlight important recommendations for clinical practice, especially where uncertainty or controversy exists.
Contributors: TK and CT drafted the summary, and PT, CD, SP, RB, and NM added additional content. All authors reviewed the draft. TK is guarantor.
Funding: The National Collaborating Centre for Mental Health was commissioned and funded by the National Institute for Health and Clinical Excellence to write this summary.
TK and SP have received funding from NICE for the development of clinical guidelines at the National Collaborating Centre for Mental Health.
Provenance and peer review: Commissioned; externally peer reviewed.