Editor- Karen Storey ICP Programme Lead. This document can, on request, be made available in alternative formats

Transcription

1 Borderline Personality Disorder (Emotionally Unstable Personality Disorder) Integrated Care Pathway for service users in the Mental Health and Learning Disability Services within NHS Forth Valley Date of First Issue 27/04/2011 Approved 11/05/2016 Current Issue Date 11/01/2016 Review Date 11/05/2018 Version 2 EQIA 27/04/2011 Author / Contact Group Committee Final Approval (Clinical Lead- Jannat Saleem) Editor- Karen Storey ICP Programme Lead Mental Health Executive Group This document can, on request, be made available in alternative formats Version 2 Jan 2016 Page 1 of 29

2 NHS Forth Valley Consultation and Change Record Contributing Authors: Consultation Process: Sheila Brown, Dr Lisa Gadon, Leanne Gauld, Yvonne Glen, Margaret Jamieson, Claire Lamza, Louise Leiper,Rhona Mackie, Dr Morag McLeod, Linda McAuslan, Dr Humera Millar,Dr Mary Morton, Jannat Saleem, Fiona Smith, Ian Tannahill. Dr Rosa Serrano Division of Psychiatry, Old age Executive group, Forth Valley Mental Health Service User/Carer Forums, Drug and therapeutic committee, the Clinical Governance groups, Mental Health Care Group, Distribution: Quality Improvement website Change Record Date Author Change Version J. Logan Paragraph added to introduction section on medications being prescribed out with product licence K. Storey Change of format. Flowchart replaced by flow diagram. Governance and Executive summary sections added, 1.2 changed from must do s to guidance for best practice K. Storey Amendments made after consultation with development group Version 2 Jan 2016 Page 2 of 29

3 Contents 1 Executive Summary... Error! Bookmark not defined. 1.1 Introduction... Error! Bookmark not defined. 1.2 When do we deliver care through a condition-specific ICP?Error! Bookmark not defined. 1.3 Diagnosis... Error! Bookmark not defined. 1.4 Assessment... Error! Bookmark not defined. 1.5 Risk assessment... Error! Bookmark not defined. 1.6 Planning Care/ Interventions... Error! Bookmark not defined. 1.7 Pharmacological Treatment... Error! Bookmark not defined. 1.8 Physical Health... Error! Bookmark not defined. 1.9 Psychological Therapies... Error! Bookmark not defined Occupational/Educational/ Vocational TherapiesError! Bookmark not defined Governance... Error! Bookmark not defined. 2 Introduction... Error! Bookmark not defined. 3 When do we deliver care through a condition specific ICP?... Error! Bookmark not defined. 4 Why have a Bipolar Disorder ICP?... Error! Bookmark not defined. 5 What is Bipolar Disorder?... Error! Bookmark not defined. 6 Diagnosis... Error! Bookmark not defined. 7 Post Diagnostic Support... Error! Bookmark not defined. 8 Assessment... Error! Bookmark not defined. 8.1 The symptoms experienced during an episode of mania may include:.. Error! Bookmark not defined. 8.2 The symptoms experienced during an episode of depression may include:error! Bookmark not defined. 8.3 Recognising Mania in those with a learning disabilityerror! Bookmark not defined. 9 Risk Assessment and Risk Management... Error! Bookmark not defined. 9.1 Risk to themselves... Error! Bookmark not defined. 9.2 Risk of exploitation... Error! Bookmark not defined. 9.3 Risk to other people... Error! Bookmark not defined. 10 Planning of care/ treatment... Error! Bookmark not defined Apply a Care Programme Approach when:... Error! Bookmark not defined Pharmacological Treatment... Error! Bookmark not defined Pharmacology Management of Bipolar Disorder AlgorithmError! Bookmark not define As Required Medication... Error! Bookmark not defined Emergency Sedation... Error! Bookmark not defined Physical Health... Error! Bookmark not defined Psychological Therapies... Error! Bookmark not defined Psycho-education... Error! Bookmark not defined Interpersonal Social Rhythms Therapy (IPSRT)Error! Bookmark not defined Behavioural Family Therapy (BFT)... Error! Bookmark not defined Cognitive Behavioural Therapy (CBT)... Error! Bookmark not defined Individualised treatment... Error! Bookmark not defined Occupational/Educational/ Vocational TherapiesError! Bookmark not defined. 11 Apply a Care Programme Approach when:... Error! Bookmark not defined. 12 Transfer of Care and Discharge... Error! Bookmark not defined. 13 Appendixes... Error! Bookmark not defined Appendix 1: Resource List for Bipolar DisorderError! Bookmark not defined. Version 2 Jan 2016 Page 3 of 29

4 13.2 Appendix 2: Physical Health Monitoring Record SheetError! Bookmark not defined Appendix 3: Mood Chart... Error! Bookmark not defined Appendix 4: Audit Template for Bipolar ICP evidence and variance reporterror! Bookmark not defined. 1 Executive Summary 1.1 Introduction This document replaces the Condition Specific Integrated Care Pathway (ICP) for Borderline Personality Disorder, version 1 and should be used in conjunction with the Generic ICP for Children & Adolescent Mental Health, Adult Mental Health, Older Adult Mental Health and Learning Disability Services 1.2 When do we deliver care through a condition-specific ICP? Once the Service User has a diagnosis of Borderline Personality Disorder (Emotionally Unstable Personality Disorder) their care will continue to follow the generic pathway, which provides the general framework of care, and this Borderline Personality (Emotionally Unstable Personality Disorder) Disorder pathway provides the guidance based on best practice. Discharge or transfer needs to be planned with clarity of who will provide support, for how long, during the transfer At least annually Review effectiveness of interventions/ treatment. Interventions/ treatment suggestions Daily functioning, if threatened consider referral to OT Refer for a Psychological Therapy, the benefit is being in the therapeutic relationship and environment Medication for symptom management, only prescribe antipsychotic or sedative for shortterm crisis management or treatment of co morbid conditions, review regularly and cease if no benefit is seen. Borderline Personality (Emotionally Unstable Personality) Disorder When assessing pay attention to: Relationships and any boundary issues & conflict with others The experience of being parented Own parenting skills and circumstances of own children, where applicable. Any significant traumas Where consent allows, gain the view of informal carers views and the impact on them Whether person agrees with their diagnosis. With consent, provide information and viewpoint of family of the situation. Assessing Risk: Care provided by A&E / hospital admissions & any physical health issues as a consequences of self injurious behaviours History / patterns of impulsive behaviours involving risk to self and /or others Use/misuse of alcohol/drugs /prescriptions Update When Care Plan/ Goal Setting consider: Identifying clearly the roles and responsibilities with manageable treatment aims, both short and long term. Develop a crisis plan with potential triggers, self management strategies and how to access services. Share information and where appropriate via the Key Information Summary system Update Version 2 Jan 2016 Page 4 of 29

5 1.3 Diagnosis The term Borderline Personality Disorder comes from a diagnosis being given using the Diagnostic and Statistics Manual, Version IV (DSM-IV). Particular to Borderline Personality is a pervasive pattern of instability of interpersonal relationships, self-image and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts. However, NHS Scotland uses the term Emotionally Unstable Personality Type (EUPD) ICD 10 as a diagnosis. This is in relation to the data that is gathered for all service users that are in contact with mental health services in Scotland who are given this diagnosis using the International Classification of Disease, Version 10 (ICD 10) This is then recorded on the Scottish Morbidity Record section 04 (SMR04). Clinicians may work between both diagnoses Key Features of EUPD To receive a diagnosis of EUPD someone must present with an enduring pattern of behavior which will included experiencing indicated by five (or more) of the following symptoms. Frantic efforts to avoid real or imagined abandonment A pattern of unstable and intense interpersonal relationships characterised by alternating between extremes of idealisation and devaluation. This is called Splitting. Identity disturbance: markedly and persistently unstable self-image or sense of self. Impulsivity in at least two areas that is potentially self-damaging (for example, spending, sex, substance abuse, reckless driving, binge eating Recurrent suicidal behaviour, gestures, or threats, or self-mutilating behaviour. Affective instability due to a marked reactivity of mood (for example, intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days). Chronic feelings of emptiness Inappropriate, intense anger or difficulty controlling anger (for example, frequent displays of temper, constant anger, recurrent physical fights). Transient, stress-related paranoid ideation or severe dissociative symptoms 1.4 Assessment When assessing pay attention to: History of relationships /attachments/ long term relationships with others. Any relationship boundary issues and experiences of conflict with others Past mental health history of other family members. The experience of being parented and the circumstances of childhood as experienced for themselves. Own parenting skills and circumstances of own children, where applicable. Any significant traumas experienced by self or within the family. History / patterns of impulsive behaviours involving risk to self and /or others Any related care provided such as Accident and Emergency attendances or hospital admissions. Contact with significant others (to obtain a comprehensive assessment, this may be other professionals who have past or current contact with the person.) Version 2 Jan 2016 Page 5 of 29

6 Whether previously has been given a diagnosis of BPD and received information about it and whether person agrees with it. Any physical health issues which have health consequences of self injurious behaviours. Use/misuse of alcohol/drugs /prescriptions Informal carers views and the impact on them 1.5 Risk Assessment The assessment of risk is a constant process which should be undertaken at key stages of the service user s journey; specifically when the level of risk changes. Exploration should include risk to themselves, of exploitation and to other people. Risks should be managed by the whole multi-disciplinary team. When assessing risk consider: Impulsivity. Chronic and regular risky behaviours. Child protection issues and ability to care for self and others 1.6 Planning Care/ Interventions When formulating a care plan, crisis care planning with the service user the following should be considered: Daily functioning, if it is threatened consider referral to Occupational Therapy, Refer for a Psychological Therapy, each therapy has its merits but it s the longer term therapeutic relationship and environment which is beneficial Identifying clearly the roles and responsibilities Identifying manageable treatment aims, both short and long term. Develop a crisis plan with potential triggers, self management strategies and how to access services. Share information and where appropriate via the Key Information Summary system Medication; only prescribe antipsychotic or sedative medication for people with borderline or antisocial personality disorder for short-term crisis management or treatment of comorbid conditions (NICE 2015). Review regularly and cease if no benefit is seen. Involve family/ carers, where appropriate. If the service user gives consent, provide information and assess their view of the situation. 1.7 Managing Transitions There is a need to anticipate the impact of transitions and the likelihood of these to provoke a strong reaction in people with BPD. It is important to note that:- Any changes are discussed in detail beforehand. Encourage good communication and collaboration with other staff/ services during transfer of care or endings of care/ therapy. Plans are to be in place to ensure that the person is supported during the transitional period and these arrangements are agreed prior to referral. Should the service user choose to disengage from treatment and services without prior warning the Access Policy and local Standard Operating Procedures are to be followed. 1.8 Governance Appendix 3 contains a checklist which can be used: by clinicians as a guide, by supervisors monitoring practice and areas of training required, Version 2 Jan 2016 Page 6 of 29

7 by team leaders, as an overview of team practice and uptake of this ICP. See Generic ICP for Children & Adolescent Mental Health, Adult Mental Health, Older Adult Mental Health and Learning Disability Services. Version 2 Jan 2016 Page 7 of 29

8 2 Introduction This pathway provides a structure of the care and treatment of those with a diagnosis of Borderline Personality Disorder (Emotionally Unstable Personality Disorder) within Forth Valley. It is a condition specific care pathway and should be used in conjunction with the Generic ICP for Children & Adolescent Mental Health, Adult Mental Health, Older Adult Mental Health and Learning Disability Services see Quality Improvement Pages Although the terms patient and client can be used to describe those receiving services, for the benefit of this document the term of service user will be used throughout to represent those referred to and receiving care and treatment from the Mental Health and Learning Disability Services. Throughout this document the term Borderline Personality Disorder (BPD) will also relate to those service users diagnosed Emotionally Unstable Personality Disorder. This ICP uses the term 'carer' to apply to everyone who has regular close contact with people with Borderline Personality Disorder, including advocates, friends or family members, although some family members may choose not to be carers. How to use this document The blue highlighted text within the document is web-links to other information to access these press and at the same time A condition-specific Integrated Care Pathway is way of providing structure to care and treatment for service users accessing Mental Health and Learning Disability Services within Forth Valley with a specific diagnosis, in this case Borderline Personality Disorder. This updated ICP has been reviewed the following guidance: National Institute for Health and Clinical Excellence (NICE) Borderline personality disorder guideline 78. National Institute for Health and Clinical Excellence (NICE) Quality Standards for Personality Disorders: Borderline and Antisocial (June 2015) The British Psychological Society Understanding Personality Disorder: A Report by the British Psychological Society (2006). National Institute for Mental Health in England Personality disorder : No longer a diagnosis of exclusion. (2003) Version 2 Jan 2016 Page 8 of 29

9 3 When do we deliver care through a condition specific ICP? Those service users who are already receiving care through the Generic ICP and have been diagnosed with Borderline Personality Disorder (also known as Emotionally Unstable Personality Disorder) will follow this care pathway and based on these stages: Assessment Care planning/ goal setting Interventions/ treatment Review/ evaluation Discharge or transfer needs to be planned with clarity of who will provide support, for how long, during the transfer At least annually Review effectiveness of interventions/ treatment. Interventions/ treatment suggestions Daily functioning, if threatened consider referral to OT Refer for a Psychological Therapy, the benefit is being in the therapeutic relationship and environment Medication for symptom management, only prescribe antipsychotic or sedative for shortterm crisis management or treatment of co morbid conditions, review regularly and cease if no benefit is seen. Borderline Personality (Emotionally Unstable Personality) Disorder When assessing pay attention to: Relationships and any boundary issues & conflict with others The experience of being parented Own parenting skills and circumstances of own children, where applicable. Any significant traumas Where consent allows, gain the view of informal carers views and the impact on them Whether person agrees with their diagnosis. With consent, provide information and viewpoint of family of the situation. Assessing Risk: Care provided by A&E / hospital admissions & any physical health issues as a consequences of self injurious behaviours History / patterns of impulsive behaviours involving risk to self and /or others Use/misuse of alcohol/drugs /prescriptions Update When Care Plan/ Goal Setting consider: Identifying clearly the roles and responsibilities with manageable treatment aims, both short and long term. Develop a crisis plan with potential triggers, self management strategies and how to access services. Share information and where appropriate via the Key Information Summary system Update Version 2 Jan 2016 Page 9 of 29

10 4 Why have a Borderline (or Emotionally Unstable) Personality Disorder ICP? This document identifies what needs to be offered to those with a diagnosis of Borderline Personality Disorder and their carers. This pathway promotes the: Understanding for people with Borderline Personality Disorder and their informal carers individuality, capabilities and ensures that they are treated with dignity and respect. Help of the person with Borderline Personality Disorder to understand and manage their illness 5 What is Borderline Personality Disorder? The term Borderline Personality Disorder comes from a diagnosis being given using the Diagnostic and Statistics Manual, Version IV (DSM-IV). See section 6: Diagnosis Personality disorder characterized by a definite tendency to act impulsively and without consideration of the consequences; the mood is unpredictable and capricious. There is a liability to outbursts of emotion and an incapacity to control the behavioural explosions. There is a tendency to quarrelsome behaviour and to conflicts with others, especially when impulsive acts are thwarted or censored. Two types may be distinguished: the impulsive type, characterized predominantly by emotional instability and lack of impulse control, and the borderline type, characterized in addition by disturbances in self-image, aims, and internal preferences, by chronic feelings of emptiness, by intense and unstable interpersonal relationships, and by a tendency to self-destructive behaviour, including suicide gestures and attempts.(icd 10 F60.3) However, NHS Scotland uses the term Emotionally Unstable Personality Type ICD 10 as a result of data gathered from service users who receive input from mental health services in Scotland. Diagnoses are recorded on the Scottish Morbidity Record section 04 (SMR04). Borderline Personality Disorder (BPD) is characterised by:..significant instability of interpersonal relationships, self-image and mood, and impulsive behaviour. There is a pattern of sometimes rapid fluctuation from periods of confidence to despair, with fear of abandonment and rejection, and a strong tendency towards suicidal thinking and self-harm. Transient psychotic symptoms, including brief delusions and hallucinations, may also be present. It is also associated with substantial impairment of social, psychological and occupational functioning and quality of life. People with BPD are particularly at risk of suicide. The course of Borderline (or Emotionally Unstable) Personality Disorder is variable and although many people recover over time, some people may continue to experience social and interpersonal difficulties. It is important that they should not be excluded from any health or social care service because of their diagnosis or because they have self-harmed. Version 2 Jan 2016 Page 10 of 29

11 Given the complex needs of people with Borderline (or Emotionally Unstable) Personality Disorder, there will often be a number of different teams and agencies involved in their treatment. A whole systems approach must ensure that there are robust systems in place for liaison and communication between services involved. Good communication between Work in partnership with people with Borderline (or Emotionally Unstable) 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. exploring treatment options in an atmosphere of hope and optimism, explaining that recovery is possible and attainable. building a trusting relationship, work in an open, engaging and non-judgemental manner, and be consistent and reliable. bearing in mind when providing services that many people will have experienced rejection, abuse and trauma, and encountered stigma often associated with selfharm and borderline personality disorder. (NICE Guidelines). agencies should be a cornerstone of any treatment plan. 6 Diagnosis Disorders of adult personalities in ICD 10 are described as conditions not directly attributable to gross brain damage or disease, or another psychiatric disorder, meeting the following criteria: Markedly disharmonious attitudes and behaviour involving several areas of functioning. Enduring. Pervasive and clearly maladaptive patterns of behaviour. Appear during childhood or adolescence and continue into adulthood. Leads to considerable marked personal distress. Usually, but not invariably, associated with significant problems in occupational and social performance. According to the Diagnostic Statistical Manual (DSM-IV) the key features of BPD are instability of interpersonal relationships, self-image and affect, combined with marked impulsivity beginning in early adulthood. Version 2 Jan 2016 Page 11 of 29

12 Particular to Borderline Personality is: A pervasive pattern of instability of interpersonal relationships, self-image and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: 1. Frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or selfmutilating behaviour covered in number A pattern of unstable and intense interpersonal relationships characterised by alternating between extremes of idealisation and devaluation. 3. Identity disturbance: markedly and persistently unstable self-image or sense of self. 4. Impulsivity in at least two areas that is potentially self-damaging (for example, spending, sex, substance abuse, reckless driving, binge eating). Note: Do not include suicidal or self-mutilating behaviour covered in number Recurrent suicidal behaviour, gestures, or threats, or self-mutilating behaviour. 6. Affective instability due to a marked reactivity of mood (for example, intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days). 7. Chronic feelings of emptiness 8. Inappropriate, intense anger or difficulty controlling anger (for example, frequent displays of temper, constant anger, recurrent physical fights). 9. Transient, stress-related paranoid ideation or severe dissociative symptoms Outcome Evidence Complete the Diagnosis within Registration section on FACE/ CARE PARTNER & TOPAS Documentation that the BPD/ EUPD ICP is being followed Version 2 Jan 2016 Page 12 of 29

13 7 Post Diagnostic Support Following a diagnosis of Borderline (or Emotionally Unstable) Personality Disorder Explain the diagnosis and the use and meaning of the term Borderline Personality Disorder to the person, to include information on how the diagnosis was reached. Allow the opportunity to discuss this information fully to enable the service user to make informed choices. Offer post-assessment support, particularly if distressing issues have arisen from the assessment process. Discuss treatment options that are available and the likely course and outlook for the individual. Provide information about the condition e.g. leaflets/booklets, support and resources (see communications section of the generic ICP) Ask directly whether the person with borderline personality disorder wants their family or carers to be involved in their care (see consent section of the generic ICP). Family and carer information and support will also be offered, where appropriate, at this stage. Encourage family or carers to be involved where appropriate and inform them of local support groups for families or carers. Develop the crisis care plan in collaboration with the service user (and their family or carers, where agreed with the person). (See appendix 3 for clinical resources list) Outcome Evidence Update the consent to share information within the comprehensive assessment regarding diagnosis Document when information about BPD is provided e.g. leaflets/ booklets Version 2 Jan 2016 Page 13 of 29

14 8 Assessment In addition to the Comprehensive Assessment completed as part of the Generic ICP, extra considerations within the assessment process need to be considered It is important to ensure that the process of assessment is explained clearly and the use of non-technical language whenever possible. It is important to acknowledge that it may require a longer time to gather assessment information. It is important to consider the management of the assessment process of those presenting with symptoms of BPD; and the need to access supervision and feedback following assessment. Specific focus on the following sections of the comprehensive assessment need to be on the follow: History of relationships /attachments/ long term relationships with others. Any relationship boundary issues and experiences of conflict with others as this can influence and support the management of the care plan and help maintain a therapeutic relationship. Consider personal relationships and relationships with professionals. Past mental health history of other family members. The experience of being parented and the circumstances of childhood as experienced for themselves. Own parenting skills and circumstances of own children where applicable. Any significant traumas experienced by self or within the family. History / patterns of impulsive behaviours involving risk to self and /or others Any related care provided such as Accident and Emergency attendances or hospital admissions. Contact with significant others (to obtain a comprehensive assessment, this may be other professionals who have past or current contact with the person.) Whether previously has been given a diagnosis of BPD and received information about it and whether person agrees with it. Any physical health issues which have health consequences of self injurious behaviours. Use/misuse of alcohol/drugs /prescriptions Informal carers views and the impact on them Outcome Evidence Completed detailed personal and social history within the Comprehensive assessment. Version 2 Jan 2016 Page 14 of 29

15 9 Risk Assessment and Risk Management In addition to the Risk Profile completed as part of the Generic ICP, extra considerations need to be paid attention to: Impulsivity. Chronic and regular behaviours and level of risk. Child protection issues and ability to care for self and others Adult, Support & Protection issues It is important to produce collaborative individualised risk management plans which clearly identify risks both for long term and immediate risks and how to manage these. They must be aligned with the overall treatment strategy for the person. The risks will be managed by the whole multi-disciplinary team with systems of supervision in place to support staff in their role of care provision. The team will review regularly their tolerance and sensitivity to working with those with BPD, particularly if contact is frequent and/ or those presenting with high levels of risk. Outcome Evidence Up to date, Risk Profile as frequently as clinical status dictates or at least 6 monthly Clear, collaborative Crisis plan developed with service user and if appropriate their family/ carers, Version 2 Jan 2016 Page 15 of 29

16 10 Planning of care/ treatment Clinicians working with people with BPD (EUPD) will develop a service user centered, individualized, comprehensive multi-disciplinary care/ treatment/ service plan in collaboration with the service user/ carer. Care provision may follow the conceptual framework of Judith Herman s 3 stages of recovery which includes 1. Safety (and stabilizing) 2. Remembrance & Mourning (psychological therapy) 3. Reconnection (moving on) In addition to the care/ treatment/ service plan pay attention to: Identifying clearly the roles and responsibilities of all health and social care professionals involved. Identifying manageable short-term treatment aims. Specify steps that the person and others might take to achieve them. Identifying 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. when self-management strategies alone are not enough., develop a crisis plan that identifies potential triggers to a crisis, specifies potentially effective self management strategies and establishes how to access services (including a list of support numbers for out-of-hours teams and crisis teams) Share with the GP, the service user, the carer, if appropriate, and other key workers and where appropriate via the Key Information Summary system to allow sharing of essential information to services such as NHS 24, Out of Hours Services, Accident and Emergency and the Scottish Ambulance Service. Involve family/carers, where appropriate, taking into consideration the needs of any dependants Apply a Care Programme Approach when: The service user is routinely or frequently in contact with more than one secondary care service and has had more than two admissions to hospital in the period of a year. There are challenges to communication between the service user and healthcare professionals, or between healthcare professionals. A consistent approach to care and treatment will be adhered to and where there are difficulties with engagement in treatment. Failure to engage is included within the Standard Operating Procedure for Access to services should be followed when there are difficulties of engagement Outcome Evidence Care plan to have clear regarding roles and responsibilities. Version 2 Jan 2016 Page 16 of 29

17 10.2 Psychological Therapies There are a range of psychological interventions with promising and growing evidence which can be applied with regard to the care and treatment for people with BPD/ EUPD. See Psychological Therapy Matrix within the Generic Integrated Care Pathway for Children & Adolescent Mental Health, Adult Mental Health, Older Adult Mental Health and Learning Disability Services What is known is that: Treatments that are both structured and focussed serve to increase engagement and the likelihood of therapists and service users forming a collaborative working alliance. A good therapeutic relationship serves to increase the likelihood that the treatment will be effective. Under most circumstances brief interventions (of less than 3 months duration) are not recommended as the sole component of treatment for people with a diagnosis of BPD. Special considerations may need to be given to those with Learning Disabilities as treatment may not be easy to apply to this service user group. Timescales for interventions may be much longer. Whilst a variety of different therapies are effective, evidence suggests that it is certain therapeutic components which are essential to any therapy as being effective for people with BPD. (Bateman & Fonagy, 2000). Such as: Encouragement of a positive attachment relationship between therapist and service user, with considerable effort devoted to the enhancement of engagement Good integration with other services available to the service user. An individualised approach tailored to the service user, which enables a clear and shared focus. Collaboratively set, realistic, and prioritised goals. Tolerance of intense emotions. Flexibility Consistent and reliable implementation. High level of structure. Intensity according to need. Such social and personal experiences are not specific to any treatment model. Instead, these components indicate the level of seriousness and commitment with which clinicians approach the issues. The evidence indicates that they may have been deprived of exactly such consideration during their early experiences and often throughout their later life. (Bateman & Fonagy, 2000). Version 2 Jan 2016 Page 17 of 29

18 If a service user is referred for a Psychological Therapy, there should be a shared and consistent approach between all those involved with the service user. Whenever possible the care should be: Maintained within community settings and hospital admissions should be kept to a minimum. Working with and building on people s existing strengths, resources, and skills will be most effective. It is recognised that at times hospital admission may be necessary These psychological approaches can be carried out both in individual and group work settings(see Psychological Therapy Matrix) Outcome Evidence Any planned Psychological interventions to be identified within the Care plan and Care Programme Approach (CPA) as appropriate. Care plan to be clear regarding roles and responsibilities. Version 2 Jan 2016 Page 18 of 29

19 10.3 Occupational/ Vocational/ Educational Interventions Referral to Occupational Therapy (O.T) will be considered particularly if it is evident that the service user is having difficulty coping with aspects of everyday living such as domestic or self care tasks, social interaction, access to community supports, leisure, vocational or work activities. This will include service users who have a dual diagnosis or physical disability. Outcome Evidence Referral to Occupational Therapy, Resource Centre programme, Employability etc Completed Model of Human Occupation Screening Tool (OT only), on FACE 10.4 Pharmacological Treatment The current evidence for the benefits of medication use in BPD (EUPD) is limited and the research available is hampered by poor methodology, small sample sizes, and short duration of study, high dropout rates and strong placebo effect. Many people with BPD receive medical treatment, however at present no medication is licensed for use in borderline personality disorder therefore all prescribing is off license although some product licences are broad and cover symptoms or symptom clusters. 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) NICE (2009) Where there is a diagnosis of co -morbid depression, psychosis or bipolar disorder, the use of antidepressants, antipsychotic and mood stabilisers would be within their product licence. NICE (2015) recommends Only prescribe antipsychotic or sedative medication for people with borderline or antisocial personality disorder for short-term crisis management or treatment of co morbid conditions. Version 2 Jan 2016 Page 19 of 29

20 General guidance rather than a formal algorithm should be followed. Co-existing disorders such as anxiety or depression should be treated. Medication may alleviate some symptoms. The treatment should be individualised to the service user s symptom profile rather than a generic protocol. Service users should be made aware of the limitations of medication so they do not develop unrealistic expectations. Any decision to use drug treatment should be made and agreed with the service user, including target symptoms, monitoring arrangements, plan for adherence and anticipated duration of treatment. Medication should be introduced for distinct trial periods and stopped if there is no obvious effect. Avoid the use of poly pharmacy or increasing doses if there is little response as this may increase the risk of undesirable side-effects and potential overdose. Provide information on the benefits and possible side effects of medication Printable leaflets available at NHS Inform. Outcome Evidence Documented discussions with Service user and information provision e.g.. This should focus on expected effects and side effects, limitations and frequency of review. It should also be made clear that should there be a lack of response then the treatment will be stopped after an agreed period. Clear agreement of the responsibilities documented in the careplan of support required, supply, storage and administration of treatment (if required) and any monitoring requirements. Version 2 Jan 2016 Page 20 of 29

21 10.5 Crisis Flowchart. Version 2 Jan 2016 Page 21 of 29

22 NICE (2014) recommends before starting short-term drug treatments: ensure that there is consensus among prescribers and other involved professionals about the drug used and that the primary prescriber is identified establish likely risks of prescribing, including alcohol and illicit drug use take account of the psychological role of prescribing (both for the individual and for the prescriber) and the impact that prescribing decisions may have on the therapeutic relationship and the overall care plan, including long-term treatment strategies ensure that a drug is not used in place of other more appropriate interventions use a single drug avoid polypharmacy whenever possible. When prescribing: choose a drug (such as a sedative antihistamine) that has a low side-effect profile, low addictive properties, minimum potential for misuse and relative safety in overdose use the minimum effective dose prescribe fewer tablets more frequently if there is a significant risk of overdose agree with the person the target symptoms, monitoring arrangements and anticipated duration of treatment agree a plan for adherence discontinue the drug after a trial period if the target symptoms do not improve consider alternative treatments, including psychological treatments, if target symptoms or level of risk do not improve arrange an appointment to review the overall care plan, including pharmacological and other treatments, after the crisis has subsided After the Crisis Flowchart. Version 2 Jan 2016 Page 22 of 29

23 Version 2 Jan 2016 Page 23 of 29

24 11 Transfer of Care and Discharge There is a need to anticipate that transitions may potentially provoke a strong reaction in people with BPD. These include; the withdrawal or ending of treatments, therapy, or services and the transfer from one service or worker to another. It is important to note that:- any changes are discussed in detail beforehand with the person and their family or carers [as appropriate] and are structured and phased. the plan of care supports good communication and collaboration with other staff or services during transfer of care or endings. This will also include details of a crisis plan. when referring someone on to another service, plans are to be in place to ensure that the person is supported during the transitional period and these arrangements are agreed prior to referral. the service user may choose to disengage from treatment and services without prior warning or mutual agreement. The Failure to Engage Protocol will be applied where appropriate. (follow the Failure to Engage Protocol ) Outcome Evidence Documented discussions with services and referral, if required Documented agreed plan of support Version 2 Jan 2016 Page 24 of 29

25 12 Appendices 12.1 Structured Clinical Interview for DSM (SCID-II) Assessment Tool SCID-II (VERSION 1.0) BORDERLINE PERSONALITY DISORDER CRITERIA A pervasive pattern of instability of mood, interpersonal relationships and self image, beginning by early adulthood and present in a variety of contexts, as indicated by at least 5 of the following: Circle each question either:?= inadequate information 1= absent or false. 2=sub threshold 3=threshold or true. 1. You ve said that (do) your relationships with people you really care about have lots of ups and downs Tell me about them. (Were there times when you thought they were everything you wanted and then other times when you thought they were terrible? How many relationships were like this?) 2. 2You ve said that you ve (have you). often done things impulsively. What kind of things? How about Buying things you really couldn t afford. Having sex with people you hardly knew or unsafe sex? 3. 3You ve said that you are (are you) a. moody person? Tell me about that. (How long do your bad moods last? How often do these changes happen? 4. 4You ve said that (do) you often have. temper out bursts of get so angry that you lose control. Tell me about this. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of over idealization and devaluation. 3= either one prolonged relationship or several briefer relationships in which the alternating pattern occurs at least twice. Impulsivity in at least two areas that are potentially self-damaging, e.g. spending, sex. Substance use, shoplifting, reckless driving, binge eating (do not include suicidal of self-mutilating behaviour covered in 5) 3=several examples indicating a pattern of impulsive behaviour (not necessarily limited to above examples). Affective instability: marked shifts from baseline mood to depression, irritability, or anxiety, usually lasting a few hours and only rarely more than a few days. 3= frequent shifts of mood. Inappropriate, intense anger or lack of control of anger, e.g. frequent displays of temper, constant anger, and recurrent physical fights.? ? ? ? 1. You ve said that (do) you hit people or throw things when you get angry. Tell me about this.. (Does this happen often)? You ve said that (Do) even little things get you very angry. When does this happen? Does it happen often? 3= several examples or one example and acknowledges trait Version 2 Jan 2016 Page 25 of 29

26 5. 5You ve said that you have (Have you). tried to hurt or kill yourself or threatened to do so. 6. You ve said that you are (are you) different with different people or in different situations so that you sometimes don t know who you really are. Give me some examples of this. (Do you feel this way a lot?) You ve said that you re (are you) often confused about your long term goals or career plans. Tell me more about that. You ve said that (do) you often change your mind about the types of friends or lovers you want. Tell me more about that. (Do you ever feel confused about whether you re gay or straight?) You ve said that you re (are you) often not sure about what your real values are. Tell me more about that. 7. You ve said that (do) you often feel bored or empty inside. Tell me more about this. Recurrent suicidal threats, gestures, or behaviour or self-mutilating behaviour. 3 = two or more times (when not in a major depression) Marked and persistent identity disturbance manifested by uncertainty about at least two of the following: selfimage, sexual orientation, long-term goals or career choice, type of friends desired, preferred values. (NOTE: do not include normal adolescent uncertainty about these issues) 3= often uncertain about identity and is not limited to a circumscribed period of time. Chronic feelings of emptiness or boredom. 3= acknowledges often feeling empty or bored.? ? ? You ve said that you have (have you) often become frantic when you thought that someone you really cared about was going to leave you. What have you done? (Do you plead with him/her or try to prevent him/her from leaving?) Frantic efforts to avoid real or imagined abandonment (do not include suicidal of self-mutilating behaviour covered in 5) 3= at least two examples.? AT LEAST 5 ARE CODED 3 Version 2 Jan 2016 Page 26 of 29

27 12.2 Specific Websites Specific Websites Borderline Personality information on NHS Inform website at BPDWorld A website providing advice, support to those affected by personality disorder. ( requires a log in) Emergence is a service user-led website at Personality disorder leaflet - Royal College of Psychiatry Scottish Personality Disorder Network A network for professionals, service users and carers at Carers4PD website at supporting those who care for people with personality disorders. They also have a blog Rethink, Borderline Personality Disorder Factsheet Version 2 Jan 2016 Page 27 of 29

28 12.3 Audit Template for Borderline Personality Disorder outcome and variance report (including Generic ICP elements) Care Partner/ FACE Audit Example Have the following been offered or completed? Has Legal status been completed Any history of mental health legislation use? Is an Advanced Statement in place? If so. Has a Named person been identified? Has a Care Coordinator been identified? Has a Diagnosis recorded on FACE& TOPAS? Recorded application of BPD? EUPD ICP? Has information on Borderline Personality been offered? Medicine Reconciliation (inpatient only) completed? Has medicine information been given/ offered? Comprehensive assessment <1 yr old? With the following sections completed, appropriate Consent to share information Has there been a review of Current Medicine? Has a Side effect profile been completed? Is there any Alcohol / Substance misuse? Any Gender based violence issues? Impact on social circumstances explored? Is the Risk Profile <6 months old? Carer/ family impact been explored? Has a My View been completed? Is there a Collaborative Crisis/ relapse/ default care plan? Have Early warning signs been identified? Assessed Physical health and family history Care plan shared, if consented? Is there a Care Plan <1 yr old? Have the responsibilities for medication supply/ administration & monitoring been agreed? When transferring from a service or planning discharge- Transitions SBAR completed Discharge Care plan (inpatient only) HONOSCA completed (CAMHS only) Version 2 Jan 2016 Page 28 of 29

29 Publications in Alternative Formats NHS Forth Valley is happy to consider requests for publications in other language or formats such as large print. To request another language for a patient, please contact For other formats contact , text , fax or - fv-uhb.nhsfv-alternativeformats@nhs.net Version 2 Jan 2016 Page 29 of 29