A systematic review of the literature

Transcription

1 A systematic review of the literature April 2009 Review of national and international clinical practice guidelines for the management of Borderline Personality Disorder Nimita Arora Adele Weston

2 This report should be referenced as follows: Arora, N and Weston, A. Review of national and international clinical practice guidelines for the management of Borderline Personality Disorder: a systematic review. HSAC Report 2009; 2(2) Health Services Assessment Collaboration (HSAC), University of Canterbury ISBN (online) ISBN (print) ISSN (online) ISSN X (print)

3 i Review Team The review has been undertaken by the Health Services Assessment Collaboration (HSAC). HSAC is a collaboration of the Health Sciences Centre of the University of Canterbury, New Zealand and Health Technology Analysts, Sydney, Australia. The primary reviewer contact for this project is Dr Adele Weston. Nimita Arora is the primary analyst working on this project. Acknowledgements Dr Sarah Norris (HSAC Director) reviewed the final draft. Cecilia Tolan and Lynn Wohlfiel provided administrative support. The review was conducted under the auspices of a contract funded by the New Zealand Ministry of Health. The report was requested by the Mental Health team of the Population Health Directorate. This review, together with two recent Cochrane systematic reviews on pharmacological and psychosocial interventions for borderline personality disorder, will ultimately be used by the New Zealand Ministry of Health and stakeholders to inform policy decision making in conjunction with other information. The content of this review alone does not constitute clinical advice or policy recommendations. Copyright Statement & Disclaimer This report is copyright. Apart from any use as permitted under the Copyright Act 1994, no part may be reproduced by any process without written permission from HSAC. Requests and inquiries concerning reproduction and rights should be directed to the Director, Health Services Assessment Collaboration, Health Sciences Centre, University of Canterbury, Private Bag 4800, Christchurch, New Zealand HSAC takes great care to ensure the accuracy of the information in this report, but neither HSAC, the University of Canterbury, Health Technology Analysts Pty Ltd nor the Ministry of Health make any representations or warranties in respect of the accuracy or quality of the information, or accept responsibility for the accuracy, correctness, completeness or use of this report. The reader should always consult the original database from which each abstract is derived along with the original articles before making decisions based on a document or abstract. All responsibility for action based on any information in this report rests with the reader. This report is not intended to be used as personal health advice. People seeking individual medical advice should contact their physician or health professional. The views expressed in this report are those of HSAC and do not necessarily represent those of the University of Canterbury New Zealand, Health Technology Analysts Pty Ltd, Australia or the Ministry of Health. Review of national and international clinical practice guidelines for the management of BPD: a systematic review

4 ii Contact Details Health Services Assessment Collaboration (HSAC) Health Sciences Centre University of Canterbury Private Bag 4800 Christchurch 8140 New Zealand Tel: Fax: [email protected] Web Site:

5 iii Executive Summary The purpose of this review is to systematically identify and summarise national and international clinical practice guidelines (CPGs) relating to the management of borderline personality disorder (BPD). The review is not limited to interventions, but also includes broader management issues such as diagnosis of the condition, and consideration of the setting in which the treatment is administered. While the report is not intended to be a systematic review of evidence per se, the methodology used to undertake the review was systematic in approach and broadly based upon guidelines published by the NHMRC (2000a, 2000b, 2005). Relevant CPGs were identified through searching international clinical practice guideline clearinghouses, EMBASE and the grey literature. After applying a priori inclusion and exclusion criteria, three guidelines were identified as eligible for inclusion in this review: National Institute for Health and Clinical Excellence (2009) BPD: treatment and management (full guideline) Practice guideline for the treatment of patients with BPD (2001) American Psychiatric Association. American Journal of Psychiatry 158:1-52. Herpertz S, Zanarini M, Schulz C, Siever L, Lieb K, and Moller HJ. (2007) World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for biological treatment of personality disorders. World Journal of Biological Psychiatry 8: Quality assessment of the CPGs was undertaken using the AGREE tool (AGREE collaboration, 2001). Relevant recommendations from the three guidelines were subsequently extracted, compared and qualitatively discussed. While the NICE and APA guidelines are relatively comprehensive and attempt to cover a broad range of issues associated with the management of patients with BPD, the WFSBP guideline is much narrower in scope, focusing on the role of pharmacological interventions. The guidelines generally agree that psychological therapy should be the cornerstone of effective treatment; however they present differing views on the manner in which psychological care should be delivered. While the NICE guideline advocates a multidisciplinary team-based approach to patient care, the APA guideline focuses on the role of psychiatrists. The APA guideline also differs to the NICE guideline in its more permissive attitude towards hospitalisation in the event of a crisis. The final marked point of difference between the three guidelines is their approach to the role of pharmacotherapy in the management of BPD. While the APA and WFSBP guidelines include pharmacological interventions as viable treatment options (especially as an adjunct to psychological treatment), the NICE guideline emphatically recommends against all forms of drug treatment, unless it is in response to a crisis. Finally, the three guidelines were contrasted with the advice included in a discussion paper written by Krawitz and Watson (1999) for the New Zealand Mental Health Commission. It was found that while the Krawitz and Watson discussion paper is now relatively outdated and is not based on a systematic review of the literature, its general principles have more in common with the NICE guideline than the APA guideline.

6 iv Table of Contents Review Team...i Acknowledgements...i Copyright Statement & Disclaimer...i Contact Details...ii Executive Summary...iii Table of Contents...iv List of Tables...vi Introduction...1 Systematic Review of the Literature...3 Literature search...3 Summary of eligible clinical practice guidelines...6 NICE Guidelines...6 APA Guidelines...6 WFSBP Guidelines...7 Quality Assessment of Clinical Practice Guidelines...9 Appraisal of Guidelines Research and Evaluation (AGREE) Instrument...9 Summary of AGREE appraisal...10 NICE Guidelines...10 APA Guidelines...10 WFSBP Guidelines...11 Summary of Recommendations...13 Experience of care...14 Psychological Treatment...16 Pharmacological Treatment...20 Management of crises...29 Configuration of services...32 Young people with BPD...39 Discussion...41 NZ Mental Health Commission (Krawitz & Watson, 1999)...43 References...45 Appendix A...49 PsychINFO and CINAHL searches...49 PsycINFO search strategy...49 CINAHL search strategy...50 Appendix B: AGREE Scores...51 NICE Guidelines (Reviewer 1)...51 NICE Guidelines (Reviewer 2)...55 APA Guidelines (Reviewer 1)...61 APA Guidelines (Reviewer 2)...66

7 v WFSBP Guidelines (Reviewer 1)...71 WFSBP Guidelines (Reviewer 2)...76 Appendix C: Extraction of Recommendations...81 NICE Guidelines...81 APA Guidelines...93 WFSBP Guidelines...97

8 vi List of Tables Table 1: DSM-IV criteria for BPD...1 Table 2: Search strategy for CPGs in BPD...3 Table 3: Exclusion criteria for CPGs...4 Table 4: Included and excluded citations...4 Table 5: Guidelines identified from CPG databases and clearinghouses...5 Table 6: CPGs eligible for inclusion in review...6 Table 7: Domain specific score assigned to each guideline...10 Table 8: Recommendations about experience of care in BPD...15 Table 9: Recommendations about psychological treatment in BPD...17 Table 10: Recommendations about pharmacological treatment in BPD...21 Table 11: Recommendations about the management of crises...29 Table 12: Recommendations about the configuration of services for patients with BPD...33 Table 13: Recommendations about the configuration of services for patients with BPD...40

9 1 Introduction Borderline Personality Disorder (BPD), also known as Emotionally Unstable Personality Disorder, is a condition historically considered to lie between psychosis and neurosis. The condition is characterised by a pervasive pattern of instability in affective regulation, impulse control, interpersonal relationships, and self-image. Causal factors are only partly known, but genetic factors and adverse events during childhood, such as physical and sexual abuse, contribute to the development of the disorder. The nature of the condition is somewhat controversial; however the condition has both a DSM-IV and ICD-10 classification. The DSM-IV criteria for a diagnosis of BPD are presented in Table 1 below: Table 1: Affective criteria Cognitive criteria Behavioural criteria Interpersonal criteria DSM-IV criteria for BPD Inappropriate intense anger or difficulty controlling anger (eg, frequent displays of temper, constant anger, recurrent physical fights) Chronic feelings of emptiness Affective instability due to a marked reactivity of mood (eg, intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days) Transient stress-related paranoid ideation or severe dissociative symptoms Identity disturbance: striking and persistent unstable self-image or sense of self Recurrent suicidal behaviour, gestures, or threats, or self-mutilating behaviour Impulsivity in at least two areas that are potentially self-damaging that do not include suicidal or self-mutilating behaviour Frantic efforts to avoid real or imagined abandonment that do not include suicidal or self-mutilating behaviour A pattern of unstable and intense interpersonal relationships characterised by alternating between extremes of idealisation and devaluation Abbreviations: BPD, Borderline Personality Disorder; DSM-IV, Diagnostic and Statistical Manual of Mental Disorders IV Notes: Adapted by Lieb et al. (2004) Until recently, the prevalence of BPD was estimated to be about 2% of the general population (Swartz et al., 1990); however the results of a 2008 study of 35,000 American adults suggest that the lifetime prevalence is much higher at 5.9% (Grant et al., 2008). It was also previously thought that the diagnosis was several times more common in (especially young) women than in men (DSM-IV-TR 2000); however the same recent study by Grant et al. (2008) found no significant differences in the rates of BPD among men and women. The course of this disorder is quite variable. Whilst short-term outcomes are less favourable, long term follow-up suggests that many patients ultimately cease to meet the criteria for BPD. Nonetheless, the disorder can have serious consequences, with a reported suicide rate of ten percent (Paris, 2002). Patients often need extensive mental health services, and account for 20 percent of psychiatric hospitalisations (Zanarini et al., 2001). BPD is also very damaging to sufferers quality of life with recurrent job losses, interrupted education, and broken marriages commonly experienced. The condition is often misdiagnosed in adolescent patients, due to the fact that their personalities are still forming. BPD is often comorbid with mood disorders, substance-related disorders, eating disorders (usually bulimia), posttraumatic stress disorder, attention-deficit/hyperactivity disorder, and other personality disorders. This can make diagnosis, and assessment of the effectiveness of interventions, problematic. In spite of these complexities, there is a growing belief amongst

10 2 clinicians that BPD is a highly treatable disorder. The last several years have seen the completion of numerous RCTs of psychotherapies for borderline illness, and there is now a sufficient body of research to support the development of evidence-based guidelines for the treatment of BPD. The objective of this report is to provide a systematic review of existing clinical practice guidelines (CPGs) for the treatment of BPD. Quality assessment of eligible CPGs will be undertaken, in this case using the AGREE tool designed specifically for the quality assessment of CPGs (AGREE collaboration, 2001).

11 3 Systematic Review of the Literature Literature search The review methodology used in this review is broadly based upon guidelines published by the NHMRC (2000a, b, 2005); however the systematic review process has been modified so as to be suitable for a review of CPGs. The initial step in the review process was to undertake a comprehensive literature search including EMBASE, the Cochrane Library, PsychINFO, CINAHL and various CPG databases/clearinghouses. The exact terms used and number of citations found in the EMBASE, Cochrane Library, PsychINFO and CINAHL searches are presented in Table 2 below. Full details of the PsychoINFO and CINAHL searches are provided in Appendix A. Table 2: Search strategy for CPGs in BPD Database Search terms Title/ Abstract review EMBASE (08/12/08) Cochrane (08/12/08) PsychINFO and CINAHL ('emotionally unstable personality' OR 'borderline type' OR 'f60.31' OR 'borderland' OR 'bpd' OR 'borderline state'/syn) AND ('clinical practice guidelines'/syn OR 'treatment guidelines' OR 'management guidelines' OR'clinical guidelines' OR 'evidence based guidelines' OR 'consensus guidelines') AND [ ]/py 'BPD' AND 'guideline' 0 0 Refer to Table 1 and Table 2 in Appendix A 80 0 Total a Full text review Abbreviations: BPD, Borderline Personality Disorder; CINAHL, Cumulative Index to Nursing and Allied Health Literature; CPG, Clinical Practice Guideline; EMBASE, Excerpta Medica Database a duplicates were removed manually The searches collectively identified 566 citations which were subsequently reviewed by title and abstract. This list was narrowed down to those citations that presented evidence-based recommendations relevant to BPD. Systematic reviews of evidence that did not make specific recommendations were considered to be ineligible. For example, there are two recent systematic reviews undertaken by the Cochrane Collaboration looking at the efficacy of pharmacological interventions (Binks et al., 2006a) and psychological treatments (Binks et al., 2006b) for BPD. Further eligibility requirements were that CPGs should be relatively recent (i.e. published after 1999), written in English and four or more pages in length. A summary of the exclusion criteria used for the identification of eligible CPGs is presented in Table 3.

12 4 Table 3: Exclusion criteria for CPGs Not BPD Not a CPG Published prior to 1999 Not in English Publications were excluded if the guidance presented did not relate specifically to BPD. Publications were excluded if they were not clinical practice guidelines (e.g. original studies, reviews and systematic reviews of the literature). Only CPGs published after 1999 were eligible for inclusion in this review. Eligible CPGs were restricted to those published in English. < 4 pages CPGs of less than four pates were excluded. Not evidencebased CPGs should be based on the systematic identification and synthesis of the best available scientific evidence. Abbreviations: BPD, Borderline Personality Disorder; CPG, Clinical Practice Guideline Following the title/abstract review, 14 papers were subject to a full text review in which the same exclusion criteria were applied. All citations that were reviewed in full text are listed in Table 4, along with reasons for exclusion or inclusion. Two citations were identified as eligible for inclusion in this review: one guideline produced by the American Psychiatric Association in 2001, and another produced by the World Federation of Societies of Biological Psychiatry (WFSBP) in 2007 (Herpetz et al., 2007). Table 4: Included and excluded citations Citation Included/excluded Included Practice guideline for the treatment of patients with BPD (2001) American Psychiatric Association. American Journal of Psychiatry 158:1-52. Herpertz S, Zanarini M, Schulz C, Siever L, Lieb K, and Moller HJ. (2007) World federation of societies of biological psychiatry (WFSBP) guidelines for biological treatment of personality disorders. World Journal of Biological Psychiatry 8: Excluded Bellino S, Paradiso E, Fenocchio M, and Bogetto F. (2007) Pharmacological treatment of BPD: Guidelines and research findings. Minerva Psichiatrica 48: Durham JD, Arthur Grube RR, and Fuller SH. (2007) BPD. U. S. Pharmacist 32:52-58 (copyright) Jobson Medical Information LLC McGlashan TH. (2002) The BPD practice guidelines: The good, the bad, and the realistic. Journal of Personality Disorders 16: Morana HCP and Camara FP. (2006) International guidelines for the management of personality disorders. Current Opinion in Psychiatry 19: Nissen T. (2000) Psychopharmacological treatment of BPD. Tidsskrift for den Norske Laegeforening 120: Renaud S and Lecomte Y. (2003) Guidelines for the treatment of patients with BPD. Sante mentale au Quebec 28: Stone MH. (2000) Clinical guidelines for psychotherapy for patients with BPD. Psychiatric Clinics of North America 23: Turbott J. (2004) Treatment of BPD. Australasian Psychiatry 12:289. Tyrer P and Duggan C. (2008) NICE guidelines for the treatment of personality disorder. Psychiatry 7: (copyright) 2008 Tyrer P. (2002) Practice guideline for the treatment of BPD: A bridge too far. Journal of Personality Disorders 16: Included Included Not in English Not evidence-based Not a CPG Not evidence-based Not in English Not evidence-based Not evidence-based Not evidence-based Not a CPG Not a CPG

13 5 Table 4: Included and excluded citations (continued) Verheul R and Herbrink M. (2007) The efficacy of various modalities of psychotherapy for personality disorders: A systematic review of the evidence and clinical recommendations. International Review of Psychiatry 19: (copyright) 2007 Informa UK Ltd Woeller W and Tress W. (2005) Psychotherapeutic treatment of personality disorders. Zeitschrift fur Psychosomatische Medizin und Psychotherapie. 51: Not a CPG Not in English Abbreviations: BPD, Borderline Personality Disorder; CPG, Clinical Practice Guideline In addition to the aforementioned search, a search of CPG databases and clearinghouses was undertaken. A full list of searched databases and the guidelines identified in each search is presented in Table 5. Table 5: Database Guidelines identified from CPG databases and clearinghouses Guidelines identified US National Guidelines Clearing House CMA Infobase Guidelines International Network (G-I-N) National Institute for Clinical Excellence NLH National Library of Guidelines (U.K.) New Zealand Guidelines Group Scottish Intercollegiate Guidelines Network Recommended Clinical Practice Guidelines Recommended Clinical Practice Guidelines Abbreviations: BPD, Borderline Personality Disorder Practice guideline for the treatment of patients with BPD (2001) American Psychiatric Association. American Journal of Psychiatry 158:1-52. None Practice guideline for the treatment of patients with BPD (2001) American Psychiatric Association. American Journal of Psychiatry 158:1-52. National Institute for Health and Clinical Excellence (2009) BPD: treatment and management (full guideline) None None None None None Two individual guidelines were identified: a practice guideline produced by the American Psychiatric Association (APA, 2001), and a recently published CPG by National Institute for Health and Excellence (NICE, 2009). Since the APA guideline was also identified in the EMBASE search, there are in total, three guidelines eligible for consideration in this review. These are summarised in Table 6.

14 6 Table 6: Guideline NICE Guideline CPGs eligible for inclusion in review Included documents National Institute for Health and Clinical Excellence (2009) BPD: treatment and management (full guideline) National Institute for Health and Clinical Excellence (2009) BPD (costing report) APA Guideline National Institute for Health and Clinical Excellence (2009) BPD (quick reference guide) Practice guideline for the treatment of patients with BPD (2001) American Psychiatric Association. American Journal of Psychiatry 158:1-52. WFSBP Guideline Oldham JM (2005) Guideline Watch: Practice Guideline for the Treatment of Patients with BPD. Available at: Accessed December 11, 2008 American Psychiatric Association (2006). Treating BPD: a quick reference guide. Available at: Accessed December 11, 2008 Herpertz S, Zanarini M, Schulz C, Siever L, Lieb K, and Moller HJ. (2007) World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for biological treatment of personality disorders. World Journal of Biological Psychiatry 8: Abbreviations: BPD, Borderline Personality Disorder; APA, American Psychiatric Association; NICE, National Institute of Clinical Excellence; WFSBP, World Federation of Societies of Biological Psychiatry Summary of eligible clinical practice guidelines NICE Guidelines The National Institute for Health and Clinical Excellence (NICE) practice guideline entitled BPD: treatment and management was published in January The guideline was designed to provide advice to clinicians and service commissioners on the treatment and management of BPD. A range of evidence-based clinical practice recommendations are made in relation to management of BPD in primary and secondary care, as well as the organisation and planning of services. Where research-based evidence is not available, consensus by experts, patients and carers forms the basis of this guideline. The guideline also makes a number of research recommendations to address gaps in the evidence base. Future revisions of the guideline are planned to incorporate new scientific evidence as it develops. To assist with the implementation of NICE guidance, the guideline is accompanied by a separate costing report and clinical reference guide, both of which are available on the NICE website. APA Guidelines The American Psychiatric Association (APA) published a practice guideline in 2001 for the treatment of patients with BPD. This guideline presents a set of best practice recommendations for the psychiatric community, using a symptom-targeted approach. Based on a systematic review of the literature, psychotherapy was designated as the primary treatment, with pharmacotherapy recommended as an adjunctive, symptom-targeted component of treatment. Where insufficient evidence was available, recommendations were based on clinical consensus. Specific algorithms were developed to guide clinicians in the use of psychotropic medications. These medication algorithms address three clusters of BPD symptoms: Cognitive-perceptual symptoms Affective dysregulation Impulsive-behavioural dyscontrol

15 7 A Guideline Watch summarising significant developments in practice since the publication of the original guideline, was published in March 2005 and is available from the American Psychiatric Association Web site. The website also provides access to a quick reference guide which is intended to assist clinical decision-making by distilling key points from the full guideline. WFSBP Guidelines This guideline, published in January 2007, was developed by an international Task Force of the World Federation of Societies of Biological Psychiatry (WFSBP). The guideline relates specifically to the biological treatment of personality disorders in primary care settings. The recommendations are based on the results of a systematic review of all available clinical and scientific evidence pertaining to the biological treatment of three personality disorders: borderline, schizotypal and anxious/avoidant personality disorder. The guideline covers disease definition, classification, epidemiology, course and current knowledge on biological underpinnings, and provides an evidence-based overview of clinical management. It deals primarily with biological treatments including antidepressants, neuroleptics, mood stabilizers and other pharmacological agents.

16 8

17 9 Quality Assessment of Clinical Practice Guidelines Appraisal of Guidelines Research and Evaluation (AGREE) Instrument Clinical practice guidelines are systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances (Field & Lohr 1990). A guideline s main purpose is to achieve better health outcomes by improving the practice of health professionals and providing consumers with better information about treatment options. Given the growing role of CPGs in advising the course of clinical practice, it is imperative that there are well-validated tools available to assess the quality of guidelines and measure their impact on health outcomes. The Appraisal of Guidelines for Research and Evaluation (AGREE) instrument was developed by a group of researchers from 13 countries to provide a systematic framework for assessing guideline quality. This instrument was thoroughly evaluated and refined and is now a commonly used assessment instrument for CPGs (MacDermid et al., 2004). The AGREE instrument consists of 23 key items which are intended to collectively reflect guideline quality. The items are categorised into the following six domains: Scope and purpose are concerned with the overall aim of the guideline, the specific clinical questions and the target patient population Stakeholder involvement focuses on the extent to which the guideline represents the views of its intended users Rigor of development relates to the process used to gather and synthesize the evidence, and the methods used to formulate the recommendations and to update them Clarity and presentation deal with the language and format of the guideline Applicability pertains to the likely organizational, behavioural and cost implications of applying the guideline Editorial independence is concerned with the independence of the recommendations and acknowledgement of possible conflict of interest from the guideline development group Each item is scored from 1 (complete disagreement) to 4 (complete agreement). The instrument accommodates marking by multiple raters. In this review, each CPG was independently scored by two reviewers, and the results were averaged. A final score for each domain was arrived at using the following method proposed by AGREE: Obtained score minimum possible score Maximum possible score minimum possible score

18 10 Summary of AGREE appraisal A domain-specific score for each guideline was calculated using the above-cited formula, and the results are presented in Table 7 below. Full AGREE evaluations by each rater for each guideline are available in Appendix B of this report. Table 7: Scope and purpose Domain specific score assigned to each guideline Stakeholder involvement Rigour and development Clarity and presentation Applicability NICE a 94.44% 66.67% 78.57% 91.67% 72.22% 83.33% APA b 66.67% 37.50% 71.43% 87.50% 44.44% 75.00% WFSBP c 33.33% 25.00% 42.86% 33.33% 0.00% 75.00% Editorial independence a National Institute for Clinical Excellence (NICE). BPD: Treatment and Management (draft for consultation) b American Psychiatric Association (2001). Practice Guideline for the Treatment of Patients with BPD. American Journal of Psychiatry 158:1-52 c Herpertz S, Zanarini M, Schulz C, Siever L, Lieb K, and Moller HJ. (2007) World federation of societies of biological psychiatry (WFSBP) guidelines for biological treatment of personality disorders. World Journal of Biological Psychiatry 8: NICE Guidelines The results of the evaluation show that the NICE guideline is superior or equivalent to the other CPGs in every domain. This is not surprising given that the NICE guidelines were almost certainly developed according to the methodology promoted by the AGREE collaboration. The CPG is thorough in scope and purpose, with clearly stated objectives, clinical questions and target patient group. The development process for this guideline was rigorous, including input from service users/carers, professional stakeholders, commercial stakeholders, government stakeholders, Primary Care Trusts and patients. While there was considerable time allowed for feedback after the publication of draft guidelines, the CPG was penalised for not having been formally piloted. The systematic review was comprehensive, and the methods used to undertake the search and synthesis of evidence are presented in thorough detail. It was noted that the guidelines could have included better cross-referencing between the final list of recommendations and chapters describing the literature review and formulation of recommendations. The recommendations are relatively specific, however it is unclear which are evidence-based, and which are based on consensus and patient/carer accounts. The NICE guidance would also be more meaningful if it included a grading system to reflect clinical confidence for individual recommendations. The NICE guideline scores strongly in clarity/presentation and applicability, although it lacks key review criteria for monitoring and/or audit purposes. The introduction refers to future revisions of the CPG; however the procedures for carrying out the update are not provided. The CPG was also judged as editorially independent with no conflicts of interest. APA Guidelines The APA guideline was published in the same year as the AGREE instrument (2001) and as such, was developed to comply with a different set of standards. The methods used to develop these guidelines are described in a document available on the APA website, titled Practice Guideline Development Process.

19 11 The guideline is adequate in terms of scope and purpose; however it is not as specific as the NICE guideline and does not present key clinical questions in as much detail. The CPG also failed to adequately involve stakeholders and patients during its development. The systematic review supporting the recommendations in the guideline appears to be thorough, however some methodological details (e.g. inclusion/exclusion criteria for citations) are not provided. The recommendations in the CPG are generally clear, and it is worth noting that some perceived ambiguity reflects the poor evidence base in BPD at the time the CPG was written. As was the case for the NICE guidelines, the CPG also fails to clearly identify which recommendations are evidence-based and which are consensus-based. Unlike the NICE guidelines, the APA recommendations are presented with a grading to denote clinical confidence. Applicability issues are well presented; however the CPG does not provide specific review criteria that could assist in the conduct of an audit to measure the impact of the guidelines. The CPG was also judged as editorially independent with no conflicts of interest. WFSBP Guidelines The WFSBP guidelines scored the most poorly out of the three CPGs. This is partially due to the fact that they were only disseminated via publication in a journal (Herpetz et al., 2007) and were thus restricted in length and scope. Areas such as applicability and stakeholder involvement were particularly lacking in detail. The CPG scored most highly in editorial independence and rigour of development, although some items pertaining to the methodology of the systematic review and synthesis of recommendations were penalised due to a lack of detail.

20 12

21 13 Summary of Recommendations The three guidelines included in the scope of this review adopt different approaches to the presentation of recommendations. The NICE guidelines present recommendations in categories relating to stages of management in BPD, including: General principles for working with people with BPD Recognition and management in primary care Assessment and management by community mental health services Inpatient services Organisation and planning of services As mentioned previously, it is not made clear which recommendations are evidence-based, and which are based on consensus and patient/carer accounts. Nor does the NICE guideline include a grading system to indicate the strength of evidence or level of clinical confidence associated with individual recommendations. The APA guideline presents specific algorithms which are related to the three main symptom categories: cognitive-perceptual symptoms, affective disturbance, and impulsive-behavioural dyscontrol. There is some controversy about whether a symptom-targeted approach is sufficiently evidence based, or may favour the practice of poly-pharmacy frequently observed in BPD (Herpetz et al., 2007). Recommendations are presented in the Section I Executive Summary of Recommendations. Each recommendation is graded according to the level of clinical confidence with which it was made, indicated by a bracketed Roman numeral following the statement. The coding system used to grade the recommendations is presented below: [I] Recommended with substantial clinical confidence [II] Recommended with moderate clinical confidence [III] May be recommended on the basis of individual circumstances Individual recommendations are explained and elaborated upon in Sections II-IV, under the following headings: Formulation and Implementation of a Treatment Plan Special Features Influencing Treatment Risk Management Issues Where a particular issue is not the subject of a specific recommendation in Section I, this review refers to the advice contained in Sections II-IV. In addition to the evidence-based recommendations, the APA guideline includes some consensus-based recommendations that were based on an informal assessment of the qualitative literature and expert opinion. As was the case for the NICE guideline, consensus-based and evidence-based pieces of guidance are not clearly differentiated from each other. The WFSBP guidelines present information according to pharmaceutical drug-class, with the goal of providing healthcare providers with information that allows them to select the drug best-suited to the psychopathology of an individual patient. Most of the recommendations included in the WFSBP document are evidence-based; however the guidelines also subsume the opinions of a range of experts in BPD.

22 14 In the current report, the recommendations presented in each of the CPGs are compared and discussed under the following subject headings: Experience of care Psychological treatments Pharmacological treatments Management of crises Configuration of services Inpatient admission Young people with BPD For each guideline, a list of all extracted recommendations is presented in Appendix C. The numbering system for NICE recommendations is identical to that used in the published guideline. Recommendations in the APA and WFSBP guidelines were not numbered in the original reports, so a numbering system has been applied post hoc. The numbering system used in Appendix C is applied in the referencing of recommendations throughout this report. Experience of care Experience of care includes recommendations about how patients should be managed in order to maximise their satisfaction with the health-care process. The NICE and APA guidelines both provide advice on experience of care, while the WFSBP guideline does not include this topic within its scope. Recommendations categorised under this heading are presented in Table 8.

23 15 Table 8: NICE Access to services Recommendations about experience of care in BPD People with BPD should not be excluded from any health or social care service because of their diagnosis or because they have self-harmed. Developing an optimistic and trusting relationship When working with people with BPD: explore treatment options in an atmosphere of hope and optimism, explaining that recovery is possible and attainable build a trusting relationship, work in an open, engaging and non-judgemental manner, and be consistent and reliable 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 BPD Involving families or carers Ask directly whether the person with BPD 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 APA Not specifically addressed in recommendations. Not specifically addressed in recommendations; however in Section IIB (Principles of Psychiatric Management), the guideline notes the importance of establishing a therapeutic framework and alliance. [Page 11, C.4a, R6] While data on family therapy are also limited, they suggest that a psychoeducational approach may be beneficial [II]. [Page 11, C.4a, R7] Published clinical reports differ in their recommendations about the appropriateness of family therapy and family involvement in the treatment; family therapy is not recommended as the only form of treatment for patients with BPD [II]. In Section IID (Specific Treatment Strategies for the Clinical Features of BPD) it is further noted that "family work is most apt to be helpful and can be of critical importance when patients with BPD have significant involvement" with, or are financially dependent on, the family. Principles for healthcare professionals undertaking assessment When assessing a person with BPD: explain clearly the process of assessment use non-technical language whenever possible explain the diagnosis and the use and meaning of the term BPD offer post-assessment support, particularly if sensitive issues, such as childhood trauma, have been discussed Not specifically addressed in recommendations; however in Section IIB (Principles of Psychiatric Management) and Section IIC (Principles of Treatment Selection) the guideline presents some information about providing education about the disorder principles surrounding patient interactions.

24 16 Table 8: Recommendations about experience of care in BPD (continued) Managing endings and supporting transitions 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 BPD. 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 [Page 12, C.6, R1] Attention to risk management issues is important [I]. Risk management considerations include the need for collaboration and communication with any other treating clinicians as well as the need for careful and adequate documentation. Any problems with transference and counter-transference should be attended to, and consultation with a colleague should be considered for unusually high-risk patients. Standard guidelines for terminating treatment should be followed in all cases. Psycho-education about the disorder is often appropriate and helpful. Other clinical features requiring particular consideration of risk management issues are the risk of suicide, the potential for boundary violations, and the potential for angry, impulsive, or violent behaviour. Abbreviations: APA, American Psychiatric Association; BPD, Borderline Personality Disorder; NICE, National Institute of Clinical Excellence The NICE guideline strongly emphasises that no patient with BPD should be excluded from access to health or social care services, and that treatment should be undertaken in an optimistic environment [ and ]. These issues are not explicitly addressed in the APA recommendations; however in Section IIB (Principles of Psychiatric Management), the guideline notes the importance of establishing a therapeutic framework and alliance. The NICE guideline suggests that while involvement of families and carers should be subject to patient preference, their inclusion in the patient s care should be encouraged [ ]. The APA guideline addresses the issue of family involvement in the context of formal therapy rather than general patient care (as per the NICE guideline). The guideline suggests that while family therapy can be helpful, it is not recommended as the only form of treatment for patients with BPD [Page 11, C.4a, R6-R7]. According to the NICE guideline, general principles for healthcare professionals when assessing a person with BPD include using nontechnical language to clearly explain the process of assessment. While they are not the subject of specific recommendations in the APA guideline, some of these issues are very broadly discussed in Section IIB (Principles of Psychiatric Management). The NICE recommendations provide detailed advice about how best to manage endings or transitions from one service or treatment to another. The APA recommendation on this topic is less explicit, stating that standard guidelines for terminating treatment should be followed in all cases. Psychological Treatment Studies on effectiveness of psychotherapeutic interventions meet some special methodological restrictions inherent to psychotherapy research because trials are never performed in a double-blind and placebo-controlled manner. Taking these factors into consideration, both the NICE and APA guidelines suggest that psychotherapy should be the primary approach to treatment of BPD. In the case of the NICE guidelines psychological treatments are the only recommended approach. The WFSBP guideline does not include issues associated with psychological treatment within its scope, but notes that psychotherapeutic regimes have an important place in the treatment of personality disorders. For a full list of recommendations categorised under psychological treatment, refer to Table 9.

25 17 Table 9: NICE Recommendations about psychological treatment in BPD General principles in psychological treatment When considering a psychological treatment for a person with BPD, 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 BPD 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 BPD and any comorbid conditions When providing psychological treatment for people with BPD, 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 When providing psychological treatment to people with BPD, 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 BPD APA [Page 10, C.3a, R1] Certain types of psychotherapy (as well as other psychosocial modalities) and certain psychotropic medications are effective in the treatment of BPD [I]. [Page 10, C.3a, R2] Although it has not been empirically established that one approach is more effective than another, clinical experience suggests that most patients with BPD will need extended psychotherapy to attain and maintain lasting improvement in their personality, interpersonal problems, and overall functioning [II]. [Page 10, C.3a, R4] No studies have compared a combination of psychotherapy and pharmacotherapy to either treatment alone, but clinical experience indicates that many patients will benefit most from a combination of these treatments [II]. [Page 11, C.4a, R2] Clinical experience suggests that there are a number of common features that help guide the psychotherapist, regardless of the specific type of therapy used [I]. These features include building a strong therapeutic alliance and monitoring selfdestructive and suicidal behaviours. Some therapists create a hierarchy of priorities to consider in the treatment (e.g., first focusing on suicidal behaviour). Other valuable interventions include validating the patient s suffering and experiences as well as helping the patient take responsibility for his or her actions. Because patients with BPD may exhibit a broad array of strengths and weaknesses, flexibility is a crucial aspect of effective therapy. Other components of effective therapy for patients with BPD include managing feelings (in both patient and therapist), promoting reflection rather than impulsive action, diminishing the patient s tendency to engage in splitting, and setting limits on any self-destructive behaviour.

26 18 Table 9: Recommendations about psychological treatment in BPD (continued) Choice of psychological treatment For women with BPD for whom reducing recurrent self-harm is a priority, consider a comprehensive dialectical behaviour therapy programme. [Page 10, C.4a, R1] Two psychotherapeutic approaches have been shown in randomized controlled trials to have efficacy: psychoanalytic/psychodynamic therapy and dialectical behaviour therapy [I]. The treatment provided in these trials has 3 key features: weekly meetings with an individual therapist, one or more weekly group sessions, and meetings of therapists for consultation/supervision. No results are available from direct comparisons of these two approaches to suggest which patients may respond better to which type of treatment. Although brief therapy for BPD has not been systematically examined, studies of more extended treatment suggest that substantial improvement may not occur until after approximately 1 year of psychotherapeutic intervention has been provided; many patients require even longer treatment. [Page 11, C.4a, R3] Individual psychodynamic psychotherapy without concomitant group therapy or other partial hospital modalities has some empirical support [II]. [Page 11, C.4a, R4] The literature on group therapy or group skills training for patients with BPD is limited but indicates that this treatment may be helpful [II]. Group approaches are usually used in combination with individual therapy and other types of treatment. [Page 11, C.4a, R5] The published literature on couples therapy is limited but suggests that it may be a useful and, at times, essential adjunctive treatment modality. However, it is not recommended as the only form of treatment for patients with BPD [II]. [Page 11, C.4a, R6] While data on family therapy are also limited, they suggest that a psycho-educational approach may be beneficial [II]. Duration and frequency of psychological treatment Do not use brief psychological interventions (of less than 3 months duration) specifically for BPD or for the individual symptoms of the disorder, outside a service that has the characteristics outlined in Although the frequency of psychotherapy sessions should be adapted to the person s needs and context of living, twice-weekly sessions may be considered. [Page 11, C.4a, R7] Published clinical reports differ in their recommendations about the appropriateness of family therapy and family involvement in the treatment; family therapy is not recommended as the only form of treatment for patients with BPD [II]. Not specifically addressed

27 19 Table 9: Organisational issues Recommendations about psychological treatment in BPD (continued) When providing psychological treatment to people with BPD 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. Not specifically addressed Abbreviations: APA, American Psychiatric Association; BPD, Borderline Personality Disorder; NICE, National Institute of Clinical Excellence The NICE recommendations regarding psychological treatment were based on an extremely comprehensive review of psychological and psychosocial treatments, covering arts therapies, brief psychological interventions, complementary therapies, individual psychological therapies, combination therapy, psychological therapy programmes and therapeutic communities. The guideline concluded that the overall evidence base for psychological therapies in the treatment of BPD is relatively poor: there are few studies; low numbers of patients and therefore low power; multiple outcomes with few in common between studies; and a heterogeneous diagnostic system. There is some evidence that psychological therapy programmes, specifically dialectical behavioural therapy (DBT) and mentalisation based therapy (MBT) with partial hospitalisation, are effective in reducing suicide attempts and self-harm, anger, aggression and depression. Nonetheless, the evidence supporting the use of psychological therapies is at best weak and does not suggest that any individual therapy is superior to another. As a result, only a few specific recommendations are made regarding the most appropriate choice of therapy. These include the suggestions that brief psychological interventions (< 3 months) should be avoided [ ], and women with BPD in whom reducing self-harm is a priority should be treated with DBT [ ]. Other recommendations include general principles regarding the delivery of psychological programmes, treatment planning, frequency of sessions, and monitoring of outcomes. The APA guidance is more specific about the relative merits of individual treatments, and seems to favour psychoanalytic therapies over cognitive behavioural therapies. The guidelines recommend with substantial clinical confidence that both psychoanalytic/psychodynamic therapy and dialectical behaviour therapy have demonstrated efficacy in BPD [Page 10, C.4a, R1]. The APA guidelines also discuss the merits of brief psychological interventions, coming to the conclusion that substantial improvement may not occur until after approximately one year of treatment [Page 10, C.4a, R1]. Individual psychodynamic psychotherapy without concomitant group therapy and other partial hospital modalities are recommended with a moderate level of clinical confidence [Page 11, C.4a, R3], as are group therapy and group skills training [Page 11, C.4a, R4]. Couples therapy and/or family therapy (using a psycho-educational approach) may be recommended based on a limited amount of evidence; however neither of these interventions is recommended as the only form of treatment for patients with BPD [Page 11, C.4a, R5-R7].

28 20 Pharmacological Treatment At the time of this review, no drug for the treatment of BPD had been approved for marketing in the U.K., U.S.A. or Australia. Nonetheless, psychotropic medications are often prescribed based on specific target symptoms shown by the individual patient. The CPGs included in this review differ in their conclusions about the role of pharmacological treatments in BPD. The recently published NICE guideline advises against the use of pharmacotherapy, with the recommendation that drug treatment should not be used specifically for BPD 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). For patients who are already receiving prescribed drugs to treat BPD symptoms, it is recommended that treatment should be reviewed, with the ultimate goal of reducing and stopping unnecessary drug treatment. Patients with comorbidities may receive drug treatment in accordance with the NICE clinical guideline for that condition. By contrast, the APA and WFSBP guidelines both recommend that it is appropriate to use pharmacological treatments for symptoms associated with BPD. While the APA guidelines recommend psychotherapy as the primary treatment, pharmacotherapy is suggested as an adjunctive, symptom-targeted component of treatment. The WFSBP guidelines focus primarily on the biological pharmacological treatment of BPD; however they do note that psychotherapeutic regimes have an important place in the treatment of personality disorders. The sections below discuss advice provided in the CPGs regarding the use of drugs to treat BPD, categorised by pharmaceutical drug-class. For a full list of recommendations categorised under pharmacological treatment, refer to Table 10.

29 21 Table 10: Recommendations about pharmacological treatment in BPD NICE APA WFSBP SSRIs/antidepressants Not specifically addressed [Page 11, C.4b, R1] Patients with BPD displaying [affective dysregulation] exhibit mood lability, rejection sensitivity, inappropriate intense anger, depressive mood crashes, or outbursts of temper. These symptoms should be treated initially with a selective serotonin reuptake inhibitor (SSRI) or related antidepressant such as venlafaxine [I]. [Page 11, C.4b, R2] Studies of tricyclic antidepressants have produced inconsistent results. When affective dysregulation appears as anxiety, treatment with an SSRI may be insufficient, and addition of a benzodiazepine should be considered, although research on these medications in patients with BPD is limited, and their use carries some potential risk [III]. [Page 11, C.4b, R3] When affective dysregulation appears as disinhibited anger that coexists with other affective symptoms, SSRIs are also the treatment of choice [II]. [Page 12, C.4b, R8] Patients with [impulsive behavioural control symptoms] exhibit impulsive aggression, self-mutilation, or self-damaging behaviour (e.g., promiscuous sex, substance abuse, reckless spending). SSRIs are the initial treatment of choice [I]. [Page 214, C1, L16] Selective serotonin reuptake inhibitors (SSRIs) are best shown to influence emotional dysregulation such as depressive mood, anxiety and mood swings and these effects appear to extend the improvement of comorbid conditions of mood and anxiety disorders. However, there is no evidence that SSRIs are effective for common symptoms such as emotional experiences of emptiness, loneliness, boredom or chronic dysphoria. In addition, there is no conclusive evidence that antidepressants reduce impulsive, aggressive or self-harming behaviours in BPD. [Page 214, C1, L27] SSRIs have shown a benefit for impulsive aggression in BPD patients with a comorbid condition of intermittent explosive disorder revised (IED); however, data from BPD samples without IED present inconsistent results. Although one study showed a superior effect of olanzapine monotherapy compared to fluoxetine alone on impulsive aggression, further studies are needed to test whether in the case of dominance of impulsivity and (auto) aggression, atypical neuroleptics may be recommended as first line treatment.

30 22 Table 10: Recommendations about pharmacological treatment in BPD (continued) NICE APA WFSBP Mood stabilisers Not specifically addressed [Page 11, C.4b, R6] Mood stabilizers (lithium, valproate, carbamazepine) are another second-line (or adjunctive) treatment for affective dysregulation, although studies of these approaches are limited [II]. [Page 12, C.4b, R10] Clinical experience suggests that [in patients with impulsive behavioural control symptoms] partial efficacy of an SSRI may be enhanced by adding lithium [II]. [Page 12, C.4b, R11] If an SSRI is ineffective, switching to an MAOI may be considered [II]. [Page 12, C.4b, R12] Use of valproate or carbamazepine may also be considered for impulse control, although there are few studies of these treatments for impulsive aggression in patients with BPD [II]. [Page 214, C1, L38] If not sufficiently helpful (neuroleptics), mood stabilizers may be indicated such as divalproex sodium, topiramate, or lamotrigine, which have been shown to be effective for impulsive, aggressive behaviour in some controlled trials. However, sample sizes of studies on mood stabilizers are small in general and there is no data at all that indicates their efficacy in the long term. [Page 214, C2, L7] Finally, BPD individuals need safe drugs that have few risks in the case of overdose and parasuicidal gestures, meaning that irreversible MAOIs and lithium, despite some evidence of efficacy, are not likely to find broad application in BPD.

31 23 Table 10: Recommendations about pharmacological treatment in BPD (continued) NICE APA WFSBP Antipsychotics/neuroleptics Antipsychotic drugs should not be used for the medium- and long-term treatment of BPD. [Page 11, C.4b, R4] Clinical experience suggests that for patients with [affective dysregulation symptoms and] severe behavioural dyscontrol, low-dose neuroleptics can be added to the regimen for rapid response and improvement of affective symptoms [II]. [Page 12, C.4b, R9] When behavioural dyscontrol [in patients with impulsive behavioural control symptoms] poses a serious threat to the patient s safety, it may be necessary to add a low-dose neuroleptic to the SSRI [II]. [Page 12, C.4b, R13] Preliminary evidence suggests that atypical neuroleptics may have some efficacy for impulsivity in patients with [impulsive behavioural control symptoms] [II]. [Page 12, C.4b, R14] Patients with [cognitive-perceptual symptoms] exhibit suspiciousness, referential thinking, paranoid ideation, illusions, derealization, depersonalization, or hallucination-like symptoms. Lowdose neuroleptics are the treatment of choice for these symptoms [I]. [Page 12, C.4b, R15] These medications may improve not only psychotic-like symptoms but also depressed mood, impulsivity, and anger/hostility. If response is suboptimal, the dose should be increased to a range suitable for treating axis I disorders [II]. [Page 214, C1, L11] There is moderate evidence for the efficacy of atypical neuroleptics and second-generation antipsychotics on cognitive-perceptual symptoms and impulsive behavioural dyscontrol, including anger in personality disorders. These medications appear to work at lower doses than in schizophrenia. [Page 214, C2, L1] Because adherence to medication is not high in BPD, patients may be particularly vulnerable to even mild adverse effects. Correspondingly, classical neuroleptics are not indicated, all the more so as there is little evidence that classical neuroleptics reduce anxiety, depression, anger or improve global functioning in BPD. [Page 214, C1, L27] SSRIs have shown a benefit for impulsive aggression in BPD patients with a comorbid condition of intermittent explosive disorder revised (IED); however, data from BPD samples without IED present inconsistent results. Although one study showed a superior effect of olanzapine monotherapy compared to fluoxetine alone on impulsive aggression, further studies are needed to test whether in the case of dominance of impulsivity and (auto) aggression, atypical neuroleptics may be recommended as first line treatment. Sedatives Short-term use of sedative medication may be considered cautiously as part of the overall treatment plan for people with BPD in a crisis.[2] The duration of treatment should be agreed with them, but should be no longer than 1 week (see section 1.3.7). [Page 11, C.4b, R2] Studies of tricyclic antidepressants have produced inconsistent results. When affective dysregulation appears as anxiety, treatment with an SSRI may be insufficient, and addition of a benzodiazepine should be considered, although research on these medications in patients with BPD is limited, and their use carries some risk [III]. Not specifically addressed

32 24 Table 10: Recommendations about pharmacological treatment in BPD (continued) NICE APA WFSBP MAOIs Not specifically addressed ECT Not specifically addressed [Page 11, C.4b, R5] Although the efficacy of monoamine oxidase inhibitors (MAOIs) for affective dysregulation in patients with BPD has strong empirical support, MAOIs are not a first-line treatment because of the risk of serious side effects and the difficulties with adherence to required dietary restrictions [I]. [Page 12, C.4b, R10] Clinical experience suggests that [in patients with impulsive behavioural control symptoms] partial efficacy of an SSRI may be enhanced by adding lithium [II]. [Page 12, C.4b, R11] If an SSRI is ineffective, switching to an MAOI may be considered [II]. [Page 11, C.4b, R7] There is a paucity of data on the efficacy of electroconvulsive therapy (ECT) for treatment of affective dysregulation symptoms in patients with border line personality disorder. Clinical experience suggests that while ECT may sometimes be indicated for patients with comorbid severe axis I depression that is resistant to pharmacotherapy; affective features of BPD are unlikely to respond to ECT [II]. [Page 214, C2, L7] Finally, BPD individuals need safe drugs that have few risks in the case of overdose and parasuicidal gestures, meaning that irreversible MAOIs and lithium, despite some evidence of efficacy, are not likely to find broad application in BPD. Not specifically addressed

33 25 Table 10: Recommendations about pharmacological treatment in BPD (continued) NICE APA WFSBP General principles Drug treatment should not be used specifically for BPD 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) Drug treatment may be considered in the overall treatment of comorbid conditions (see section 1.3.6) When considering drug treatment for any reason for a person with BPD, provide the person with written material about the drug being considered. This should include evidence for the drug s effectiveness in the treatment of BPD 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 BPD 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. [Page 10, C.3a, R3] Pharmacotherapy often has an important adjunctive role, especially for diminution of symptoms such as affective instability, impulsivity, psychotic-like symptoms, and self-destructive behaviour [I]. [Page 10, C.3a, R4] No studies have compared a combination of psychotherapy and pharmacotherapy to either treatment alone, but clinical experience indicates that many patients will benefit most from a combination of these treatments [II]. [Page 214, C1, L1] In BPD, there are a limited number of RCTs of only moderate quality, with small sample sizes and short-term observation periods. No class of pharmacological agents appears to improve BPD psychopathology in general although the majority of studies have incorporated measurements of global functioning in addition to targeting special aspects of psychopathology. Medication suggestions will rather be given considering the dominating symptomatology of the individual patient. [Page 214, C1, L46] In addition to an urgent necessity to conduct more controlled studies of good quality in BPD in general, more drug trials are warranted that focus on the improvement of affective instability. This domain of BPD psychopathology is not only known to be the most stable trait in BPD, but it has also been shown to be less changeable by psychotherapeutic interventions compared to impulsivity. Furthermore, effects of drugs on interpersonal relations in BPD patients have not been carefully examined, at all. [Page 214, C2, L12] No reliable comment can be provided on the length of pharmacological treatment, which may also vary as a function of the targeted domain of psychopathology. However, it may be recommended that a drug should be tried for at least 3 months with a sufficient baseline assessment of psychopathology, clearly defined targets of therapy and cessation of the drug if there is no benefit. [Page 214, C2, L20] No medication has been registered for personality disorders, and there is no evidence for a benefit of polypharmacy in these patients. Although there is some evidence for differential effects on psychopathology, classes of psychotropic agents act on a rather broad spectrum of symptoms and there is no database to suggest the combination of several drugs with respect to different targets.

34 26 Table 10: Recommendations about pharmacological treatment in BPD (continued) NICE APA WFSBP General principles [Page 214, C2, L28] Patients with BPD should be informed that there is no strong evidence base for the prescription of any drug. However, the off-label use of psychotropic agents may help individuals with BPD to improve affective symptoms and impulsivity. [Page 214, C2, L32] A pharmacological treatment might also be indicated in severe conditions to support psychosocial interventions or even to make them possible although there is not much of an evidence-base on when/how to combine pharmacotherapy/psychotherapy. [Page 214, C2, L37] Since pharmacotherapy will be part of a multimodal treatment programme including individual and/or group psychotherapy, psychotherapeutic specialists on these disorders should usually be involved rather early on. Abbreviations: APA, American Psychiatric Association; BPD, Borderline Personality Disorder; ECT, Electroconvulsive Therapy; MAOI, Monoamine Oxidase Inhibitors; NICE, National Institute of Clinical Excellence; RCT, Randomised Controlled Trial; SSRI, Selective Serotonin Reuptake Inhibitors; WFSBP, World Federation of Societies for Biological Psychiatry

35 27 SSRIs/antidepressants Outside of the overarching recommendation that pharmaceutical treatments should not be used in the treatment of BPD, the NICE guideline does not provide specific guidance regarding the use of SSRIs or antidepressants. By contrast, the APA guideline suggests that SSRIs and related antidepressants (e.g. venlafaxine) can be used with substantial clinical confidence to treat affective dysregulation symptoms and impulsive-behavioural control symptoms [Page 11, C.4b, R1 and R8]. If anxiety is also present, the APA guideline states that some patients taking SSRIs may benefit from adjunctive treatment with a benzodiazepine [Page 11, C.4b, R2]. The WFSBP guideline is more cautious about antidepressants, concluding that although SSRIs are effective in patients with emotional (affective) dysregulation, there is little evidence to suggest they reduce impulsive, aggressive or self-harming behaviours in BPD [Page 214, C1, L27]. In studies where SSRIs demonstrate a benefit for impulsive aggression, it was found that the patients often had a comorbid condition of intermittent explosive disorder revised (IED), making these results difficult to interpret. Mood Stabilisers Outside of the overarching recommendation that pharmacological treatments should not be used in the treatment of BPD, the NICE guideline does not provide specific guidance about the use of mood stabilisers. The APA guideline suggests with moderate clinical confidence that mood stabilisers can be used as a second-line or adjunctive treadent for affective dysregulation, and that partial efficacy of an SSRI can be enhance with the addition of lithium [Page 11, C.4b, R6]. Use of valproate or carbamazepine may also be considered for impulse control, although there are few studies of these treatments for impulsive aggression in patients with BPD [Page 12, C.4b, R12]. The WFSBP guideline is less permissive in its recommendations about mood stabilisers, stating that there is limited evidence for the use of this drug-class in the treatment of impulsive and aggressive behaviour [Page 214, C1, L38]. Of the common mood stabilisers, it is recommended that lithium should be avoided due to the high risk of overdose [Page 214, C2, L7]. Antipsychotics/neuroleptics While the NICE guideline states that antipsychotic drugs should not be used for the medium- and long-term treatment of borderline personality disorder, the APA and WFSBP guidelines recommend the use of antipsychotics at a low dose, to treat specific symptoms of BPD. The APA guideline recommends with moderate clinical confidence that low-dose neuroleptics can be added to SSRIs for patients with severe behavioural dyscontrol [Page 11, C.4b, R4] and recommend with substantial clinical confidence that they should be used as a first-line treatment for patients with cognitive-perceptual symptoms [Page 12, C.4b, R15]. If response is suboptimal, the dose should be increased to a range suitable for treating axis I disorders (recommended with moderate clinical confidence).

36 28 The WFSBP guideline concurs with the APA guideline, concluding that there is moderate evidence for the efficacy of low-dose atypical neuroleptics and second-generation antipsychotics on cognitive-perceptual symptoms and impulsive behavioural dyscontrol, including anger in personality disorders [Page 214, C1, L11]. Note that classical neuroleptics (typical antipsychotics) are not indicated due to side-effects and a paucity of evidence [Page 214, C2, L1]. Sedatives The NICE guideline recommends the short-term use of sedative medication as part of the overall treatment plan for people with BPD in a crisis. The APA guidelines are more specific, recommending that in individual cases a benzodiazepine may be added to SSRIs for the treatment of affective dysregulation. Monoamine oxidase inhibitors (MAOIs) Outside of the overarching recommendation that pharmaceutical treatments should not be used in the treatment of BPD, the NICE guideline does not provide specific guidance about the use of MAOIs. The APA guideline notes that whilst there is strong empirical evidence for the efficacy of MAOIs in treating affective dysregulation, they are not recommended as a first-line treatment due to the risk of serious side-effects [Page 11, C.4b, R5]. MAOIs may also be considered as a second-line treatment in patients with impulsive-behavioural control symptoms who have failed to respond to SSRIs [Page 12, C.4b, R10]. Because of the harmful side effects and the risk of overdose, the WFSBP guidelines advise against the use of irreversible MAOIs. Electroconvulsive Therapy (ECT) The APA guideline is the only CPG to provide specific advice regarding the use of ECT to treat BPD. These guidelines suggest that while ECT may be useful in patients with comorbid severe axis I depression, affective features of BPD are unlikely to respond to ECT [Page 11, C.4b, R7].

37 29 Management of crises Management of crises comprises recommendations about how patients should be managed during a crisis, including drug treatment, follow-up; the management of insomnia, managing self-harm and attempted suicide, and inpatient admission. The NICE and APA guidelines both address the issue of crisis management through explicit recommendations, while the WFSBP guideline does not include these issues within its scope. Recommendations categorised under this heading are presented in Table 11 below. Table 11: NICE Drug treatment during crises Recommendations about the management of crises Before starting short-term drug treatments for people with BPD during a crisis (see recommendation ): 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 short-term drug treatment for people with BPD in a crisis: 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 with the person a plan for adherence Discontinue a drug after a trial period if the target symptoms do not improve Consider alternative treatments, including psychological treatments, if target symptoms do not improve or the level of risk does not diminish Arrange an appointment to review the overall care plan, including pharmacological and other treatments, after the crisis has subsided. APA Not specifically addressed; however drugs for the treatment of specific symptoms are presented under "Pharmacological Treatments".

38 30 Table 11: NICE Follow-up after a crisis Recommendations about the management of crises (continued) After a crisis has resolved or subsided, ensure that crisis plans, and if necessary the overall care plan, are updated as soon as possible to reflect current concerns and identify which treatment strategies have proved helpful. This should be done in conjunction with the person with BPD and their family or carers if possible, and should include: a review of the crisis and its antecedents, taking into account environmental, personal and relationship factors a review of drug treatment, including benefits, side effects, any safety concerns and role in the overall treatment strategy a plan to stop drug treatment begun during a crisis, usually within 1 week a review of psychological treatments, including their role in the overall treatment strategy and their possible role in precipitating the crisis APA Not specifically addressed If drug treatment started during a crisis cannot be stopped within 1 week, there should be a regular review of the drug to monitor effectiveness, side effects, misuse and dependency. The frequency of the review should be agreed with the person and recorded in the overall care plan. Principles and general management of crises When a person with BPD presents during a crisis, consult the crisis plan and: maintain a calm and non-threatening attitude try to understand the crisis from the person s point of view explore the person s reasons for distress use empathic open questioning, including validating statements, to identify the onset and the course of the current problems seek to stimulate reflection about solutions avoid minimising the person s stated reasons for the crisis refrain from offering solutions before receiving full clarification of the problems explore other options before considering admission to a crisis unit or inpatient admission offer appropriate follow-up within a time frame agreed with the person Managing self-harm and attempted suicide Follow the recommendations in Self-harm (NICE clinical guideline 16) to manage episodes of self-harm or attempted suicide. Not specifically addressed in recommendations; however in Section IIB (Principles of Psychiatric Management), there is an emphasis on monitoring to ensure the safety of patients and of others. Not specifically addressed in recommendations; however in Section IIB (Principles of Psychiatric Management) it is suggested that to prevent self-harm or suicide, monitoring of patient safety is critically important.

39 31 Table 11: NICE Inpatient admission Recommendations about the management of crises (continued) Before considering admission to an acute psychiatric inpatient unit for a person with BPD, first refer them to a crisis resolution and home treatment team or other locally available alternative to admission Only consider people with BPD for admission to an acute psychiatric inpatient unit for: the management of crises involving significant risk to self or others that cannot be managed within other services, or detention under the Mental Health Act (for any reason) When considering inpatient care for a person with BPD, actively involve them in the decision and: ensure the decision is based on an explicit, joint understanding of the potential benefits and likely harm that may result from admission agree the length and purpose of the admission in advance ensure that when, in extreme circumstances, compulsory treatment is used, management on a voluntary basis is resumed at the earliest opportunity Arrange a formal CPA review for people with BPD who have been admitted twice or more in the previous 6 months. APA [Page 9, C.1, R2] Because suicidal ideation and suicide attempts are common, safety issues should be given priority, and a thorough safety evaluation should be done. This evaluation, as well as consideration of other clinical factors, will determine the necessary treatment setting (e.g., outpatient or inpatient). A more comprehensive evaluation of the patient should then be completed [I]. In Section IIA (The Initial Assessment), indications for brief and extended inpatient hospitalization are suggested. Abbreviations: APA, American Psychiatric Association; BPD, Borderline Personality Disorder; CPA, Care Programme Approach; NICE, National Institute of Clinical Excellence According to the NICE guidance, some of the general principles of crisis management in patients with BPD include maintaining a calm, empathetic and non-threatening attitude and seeking to stimulate reflection about solutions. The NICE guideline also advises cautious use of pharmaceutical treatments for BPD patients in a crisis, if other interventions are not appropriate ( ). Drugs should only be prescribed in the short term, using the minimum possible dose ( ). If drug treatment started during a crisis cannot be stopped within one week, there should be a regular review of the drug to monitor effectiveness, side effects, misuse and dependency ( ). For the treatment of insomnia, behavioural approaches are suggested in the first instance ( ). However if drugs are required the reader is referred to the relevant NICE guidance (NICE technology appraisal guidance 77). After a crisis has resolved or subsided, clinicians should ensure that crisis and overall care plans are updated as to reflect current concerns and identify which treatment strategies have proved helpful ( ). Regarding the management of self-harm or attempted suicide, the reader is referred to the recommendations on self-harm included in the NICE guideline on the subject (NICE clinical guideline 16). Many of these issues are not specifically addressed in the APA recommendations; however clinicians providing drug treatment to patients undergoing a crisis will find advice about symptom-targeted treatment of BPD patients in recommendations categorised under pharmacological treatment. Section II of the APA guideline (Principles of Psychiatric Management) discusses some principles of patient management during a crisis, including the importance of ensuring safety through careful monitoring. In general, the APA guideline focuses on describing specific psychotherapeutic strategies, and places less emphasis on the manner in which care is delivered. The NICE guideline suggests that before considering admission to an acute psychiatric inpatient unit, patients with BPD should first be referred to a crisis resolution and home treatment team or other locally available alternative to admission ( ). The decision to

40 32 admit a patient should be in response to a crisis, and should be discussed with the patient beforehand ( ). The APA recommendations provide limited advice in relation to inpatient services, stating that the necessary treatment setting (e.g. outpatient or inpatient) should be selected as part of a safety evaluation [Page 9, C.1, R2]. Later sections of the guideline, however, suggest that hospitalisation is an appropriate response when a patient s safety is considered to be at serious risk. In Section IIA (The Initial Assessment) it is suggested that indications for brief inpatient hospitalization should include the following: Imminent danger to others Loss of control of suicidal impulses or serious suicide attempt Transient psychotic episodes associated with loss of impulse control or impaired judgment Symptoms of sufficient severity to interfere with functioning, work, or family life that are unresponsive to outpatient treatment and partial hospitalization Indications for extended inpatient hospitalization include the following: Persistent and severe suicidality, self-destructiveness, or non-adherence to outpatient treatment or partial hospitalization Comorbid refractory axis I disorder (e.g., eating disorder, mood disorder) that presents a potential threat to life Comorbid substance abuse or dependence that is severe and unresponsive to outpatient treatment or partial hospitalization Continued risk of assaultive behaviour toward others despite brief hospitalization Symptoms of sufficient severity to interfere with functioning, work, or family life that are unresponsive to outpatient treatment, or partial hospitalization, or brief hospitalization Configuration of services Configuration of services includes recommendations about how mental services should be organised for the effective management of patients with BPD. Some of these recommendations are general in nature (e.g. access to black and ethnic minority groups), while other relate specifically to the delivery of services in primary or secondary care. There are disparities between the two guidelines which stem from the fact that the British health system is structured very differently to the American system. The NICE advice is targeted at GPs (primary care) and Community Mental Health Teams (secondary care) that include workers from a number of different professional backgrounds e.g. psychiatrists, psychiatric nurses, social workers, occupational therapists, clinical psychologists, and pharmacists. In the U.S.A., secondary health care for patients with BPD is primarily delivered by psychiatrists, and much of the APA guidance is therefore based on this model of service delivery. For a full list of recommendations categorised under configuration of services, refer to Table 12. The reader should bear in mind differences in definitions of secondary care, in particular when interpreting or applying these recommendations to their context.

41 33 Table 12: NICE Recommendations about the configuration of services for patients with BPD Special considerations for people from black and ethnic minority groups Ensure that people with BPD from black and minority ethnic groups have equal access to culturally appropriate services based on clinical need When language is a barrier to accessing or engaging with services for people with BPD, provide them with: information in their preferred language and in an accessible format psychological or other interventions in their preferred language independent interpreters BPD and learning disabilities When a person with a mild learning disability presents with symptoms and behaviour that suggest BPD, assessment and diagnosis should take place in consultation with a specialist in learning disabilities services When a person with a mild learning disability has a diagnosis of BPD, they should have access to the same services as other people with BPD When care planning for people with a mild learning disability and BPD, 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 BPD. If they show behaviour and symptoms that suggest BPD, refer for assessment and treatment by a specialist in learning disabilities services. Autonomy and choice Work in partnership with people with BPD 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. Training, supervision and support Mental health professionals working in secondary care services, including community-based services and teams, CAMHS and inpatient services, should be trained to diagnose BPD, 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 BPD. Training should be provided by specialist personality disorder teams based in mental health trusts (see recommendation ) Mental health professionals working with people with BPD should have routine access to supervision and staff support. PRIMARY CARE Recognition of BPD in primary care 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 BPD. If the person is younger than 18 years, refer them to CAMHS for assessment. APA Not specifically addressed in recommendations; however in Section III (Special Features Influencing Treatment) it is noted that the cultural context of a patient's presentation should be considered in order to achieve an accurate diagnosis. Not specifically addressed. [Page 10, C.3d, R1] Treatment should be a collaborative process between patient and clinician(s), and patient preference is an important factor to consider when developing an individual treatment plan [I]. Not specifically addressed. Not specifically addressed.

42 34 Table 12: Crisis management in primary care Recommendations about the configuration of services for patients with BPD (continued) When a person with an established diagnosis of BPD 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 Referral to community mental health services Consider referring a person with diagnosed or suspected BPD 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 SECONDARY CARE Assessment Community mental health services (community mental health teams, related community-based services, and tier 2/3 services in CAMHS) should be responsible for the routine assessment, treatment and management of people with BPD When assessing a person with possible BPD 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 Not specifically addressed. [Page 9, C.1, R1] The psychiatrist first performs an initial assessment of the patient to determine the treatment setting [I]. [Page 9, C.1, R2] Because suicidal ideation and suicide attempts are common, safety issues should be given priority, and a thorough safety evaluation should be done. This evaluation, as well as consideration of other clinical factors, will determine the necessary treatment setting (e.g., outpatient or inpatient). A more comprehensive evaluation of the patient should then be completed [I]. [Page 9, C.1, R3] It is important at the outset of treatment to establish a clear and explicit treatment framework [I], which includes establishing agreement with the patient about treatment goals.

43 35 Table 12: NICE Care planning Recommendations about the configuration of services for patients with BPD (continued) Teams working with people with BPD 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 BPD 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. APA [Page 9, C.2, R1] Psychiatric management forms the foundation of treatment for all patients. The primary treatment for BPD is psychotherapy, complemented by symptom-targeted pharmacotherapy [I]. [Page 9, C.2, R2] In addition, psychiatric management consists of a broad array of ongoing activities and interventions that should be instituted by the psychiatrist for all patients with BPD [I]. [Page 9, C.2, R3] Regardless of the specific primary and adjunctive treatment modalities selected, it is important to continue providing psychiatric management throughout the course of treatment. The components of psychiatric management for patients with BPD include responding to crises and monitoring the patient's safety, establishing and maintaining a therapeutic framework and alliance, providing education about BPD and its treatment, coordination treatment provided by multiple clinicians, monitoring the patient's progress, and reassessing the effectiveness of the treatment plan. The psychiatrist must also be aware of and manage potential problems involving splitting and boundaries. [Page 10, C.3e, R1] Treatment by a single clinician and treatment by more than one clinician are both viable approaches [II]. [Page 10, C.3e, R2] Treatment by multiple clinicians has potential advantages but may become fragmented; good collaboration among treatment team members and clarity of roles are essential [I].

44 36 Table 12: NICE Risk assessment and management Recommendations about the configuration of services for patients with BPD (continued) Risk assessment in people with BPD 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 BPD 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 BPD 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 BPD 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). APA [Page 12, C.6, R1] Attention to risk management issues is important [I]. Risk management considerations include the need for collaboration and communication with any other treating clinicians as well as the need for careful and adequate documentation. Any problems with transference and counter-transference should be attended to, and consultation with a colleague should be considered for unusually high-risk patients. Standard guidelines for terminating treatment should be followed in all cases. Psycho-education about the disorder is often appropriate and helpful. Other clinical features requiring particular consideration of risk management issues are the risk of suicide, the potential for boundary violations, and the potential for angry, impulsive, or violent behaviour. The management of comorbidities Before starting treatment for a comorbid condition in people with BPD, review: the diagnosis of BPD 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 BPD Refer people with BPD 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 BPD when appropriate When treating a comorbid condition in people with BPD, follow the NICE clinical guideline for the comorbid condition. [Page 10, C.3b, R1] Treatment planning should address BPD as well as comorbid axis I and axis II disorders, with priority established according to risk or predominant symptoms [I]. [Page 10, C.3c, R1] Because comorbid disorders are often present and each patient s history is unique, and because of the heterogeneous nature of BPD, the treatment plan needs to be flexible, adapted to the needs of the individual patient [I]. Flexibility is also needed to respond to the changing characteristics of patients over time. [Page 12, C.5, R1] Treatment planning and implementation should reflect consideration of the following characteristics: comorbidity with axis I and other axis II disorders, problematic substance use, violent behaviour and antisocial traits, chronic selfdestructive behaviour, trauma and post-traumatic stress disorder (PTSD), dissociative features, psychosocial stressors, gender, age, and cultural factors [I].

45 37 Table 12: NICE Discharge to primary care Recommendations about the configuration of services for patients with BPD (continued) When discharging a person with BPD 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. The role of specialist personality disorder services within trusts APA Not specifically addressed Mental health trusts should develop multidisciplinary Not specifically addressed specialist teams and/or services for people with personality disorders. These teams should have specific expertise in the diagnosis and management of BPD and should: provide assessment and treatment services for people with BPD 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 BPD 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 BPD, including multi-centre research oversee the implementation of this guideline develop and provide training programmes on the diagnosis and management of BPD and the implementation of this guideline (see ) 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 BPD) Specialist teams should develop and provide training programmes that cover the diagnosis and management of BPD 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 BPD. The programmes should also address problems around stigma and discrimination as these apply to people with BPD 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. Abbreviations: APA, American Psychiatric Association; BPD, Borderline Personality Disorder; CAMHS, Child and Adolescent Mental Health Services; CPA, Care Programme Approach; NICE, National Institute of Clinical Excellence

46 38 One of the recurring themes of the NICE guideline is that all patients with BPD should have access to services and treatment regardless of age, gender, cultural background or disease severity. Consistent with this approach, a number of recommendations are made regarding the treatment of patients from black and ethnic minority groups ( ), and those with learning disabilities ( ). These issues are not the subject of specific recommendations in the APA guideline; however in Section III (Special Features Influencing Treatment) it is noted that the cultural context of a patient's presentation should be considered in order to achieve an accurate diagnosis. The NICE guideline also notes the importance of promoting autonomy and choice in patient s with BPD, ensuring they are properly engaged in all treatment decisions ( ). The APA recommendations also emphasise this point, stating that treatment should be a collaborative process between patient and clinician(s), and patient preference is an important factor to consider when developing an individual treatment plan (Page 10, C.3d, R1). Primary care As mentioned previously the NICE guideline makes a number of recommendations in relation to the management of BPD in primary care. It is suggested that if a patient presents who has repeatedly self-harmed or shown persistent risk-taking behaviour or marked emotional instability, they should be referred to community mental health services for further assessment ( ). For patients with an established diagnosis, advice is given about how to deal with a crisis ( ), and when a patient in crisis should be referred to community mental health services ( ). The APA guideline is targeted at psychiatrists and does not include the management of BPD in primary care within its scope. Secondary care During the assessment phase, the NICE guideline emphasises the assessment of psychosocial and occupational functioning, comorbid mental disorders, the need for treatment care or support, and the needs of any dependent children ( ). By contrast, the APA guideline stresses the importance of evaluating safety (Page 9, C.1, R2), establishing an appropriate treatment setting (Page 9, C.1, R1) and developing a care plan (Page 9, C.1, R3). Following assessment, the NICE guideline suggests that teams working with people with BPD should develop comprehensive multidisciplinary care plans in collaboration with the patient. The care plan should identify the role of all health/social care providers, set shortterm and long-term goals, include a crisis plan, and should be shared with the GP and serviceuser ( ). The approach of the APA guideline is far less multidisciplinary, with psychiatric management considered to be the foundation of treatment (Page 9, C.2, R1). The components of psychiatric management for patients with BPD should include responding to crises and monitoring the patient's safety, establishing and maintaining a therapeutic framework and alliance, providing education about BPD and its treatment, coordination treatment provided by multiple clinicians, monitoring the patient's progress, and reassessing the effectiveness of the treatment plan (Page 9, C.2, R3). Treatment by multiple clinicians is acknowledged as a potentially useful approach, but is not recommended in preference to treatment by a single clinician (Page 10, C.3e, R1). Risk assessment and management is highlighted as an important issue in both the NICE and APA guidelines. The NICE guideline advocates agreeing on risks with the patient, and developing a collaborative risk management plan ( ). The risks should be managed by a community mental health team ( ) whose members are reviewed regularly to ensure tolerance and sensitivity towards patients ( ). The APA guideline recommends that risk management requires collaboration and communication with other treating clinicians, and

47 39 consultation with a colleague for unusually high-risk patients. Both guidelines also emphasise the importance of recognising and managing comorbid mental disorders, and ensuring that comorbidities should be incorporated into the treatment plan. The APA guideline further recommends that treatment planning should address BPD as well as comorbid axis I and axis II disorders, with priority established according to risk or predominant symptoms (Page 10, C.3b, R1), while the NICE guideline recommends that people with BPD who also have major psychosis, dependence on alcohol or Class A drugs, or a severe eating disorder should be referred to an appropriate service ( ). Following assessment and treatment by Community Mental Health Teams, the NICE guideline recommends that patients may be discharged to primary care ( ). The guideline also discusses the role of specialist personality disorder services within Mental Health Trusts ( ). These issues are not applicable to the American health care system, and are therefore excluded from the APA guideline. Young people with BPD While BPD is very common in adolescents, patients in this group are frequently precluded from treatment due to misdiagnosis and the fact that their personalities are still forming. Furthermore, young people often experience multiple comorbidities and have variable responses to treatment. As a result, the NICE guideline includes specific treatment recommendations for young people with BPD (under the age of 18 years). Many of these recommendations describe how young patients should be managed through specific British healthcare services, and are therefore applicable in the U.K. only. The APA guidance acknowledges that treatment for young people is an issue due to a lack of evidence; however it does not make any specific recommendations in relation to this group. For a full list of recommendations categorised under organisation and planning, refer to Table 13.

48 40 Table 13: NICE Recommendations about the configuration of services for patients with BPD Young people with a diagnosis of BPD, or symptoms and behaviour that suggest it, should have access to the full range of treatments and services recommended in this guideline, but within CAMHS CAMHS professionals working with young people with BPD 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 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: time the transfer to suit the young person, even if it takes place after they have reached the age of 18 years 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 NHS trusts providing CAMHS should ensure that young people with severe BPD have access to tier 4 specialist services if required, which may include: inpatient treatment tailored to the needs of young people with BPD specialist outpatient programmes home treatment teams APA Not specifically addressed in recommendations; however in Section III-J, it is noted that the diagnosis of BPD should be made with care in adolescents. Although treatments effective in adults would be expected to be efficacious in this age group, there is a paucity of evidence. Abbreviations: APA, American Psychiatric Association; BPD, Borderline Personality Disorder; CAMHS, Child and Adolescent Mental Health Services; NICE, National Institute of Clinical Excellence

49 41 Discussion Of the three guidelines included in this review, the NICE guidelines were ranked the highest in all of the AGREE domains. The validity of the guideline is also strengthened by the fact that it is very recent and is based on a much greater breadth of evidence than the APA or WFSBP guidelines. The NICE advice is based around the central recommendation that psychological therapies (e.g. dialectical behaviour therapy, mentalisation-based therapy and schema-focused cognitive therapy) should form the cornerstone of treatment for patients with BPD. This advice is slightly at odds with a Cochrane review (Binks et al., 2006b) which found that all psychological therapies for the treatment of BPD remain experimental and the studies are too few and small to inspire full confidence in their results. It is further suggested in the NICE guideline that bi-weekly treatment sessions should be considered, that therapists working with BPD clients should receive appropriate supervision, that comprehensive care plans should be established, and that care should be taken when ending treatment or services with BPD clients (who may be particularly vulnerable at such times). NICE recommends that pharmacological therapies should not be used for the treatment of BPD itself, although pharmacological treatment of comorbid conditions may be considered. This is consistent with a recent Cochrane review (Binks et al., 2006a) which concludes that pharmacological treatments for BPD are not based on good evidence. Unlike other guidelines, the NICE document has detailed recommendations relating specifically to the management of crises, configuration and organisation of services, and young people with BPD. Cost implications are also considered in a separate booklet. One of the key criticisms of the NICE guideline is that there could have been better cross-referencing between individual recommendations and their sources of evidence. While the recommendations are relatively direct, it is unclear which are evidence-based, and which are based on consensus and patient/carer accounts. Unlike the APA guidelines, recommendations were not graded according to the level of confidence with which they were made. Published in 2001, the APA guidelines are now comparatively outdated and do not incorporate some of the features advocated by the AGREE instrument (e.g. detailed clinical questions and stakeholder involvement). Nonetheless, the systematic review supporting the recommendations in the guideline appears to be thorough. The guideline concludes that the first approach for patients with BPD should be psychotherapy complemented by symptomtargeted pharmacotherapy if required. These recommendations were made with substantial clinical confidence, and were based on published randomized controlled trials and clinical consensus. While no individual psychotherapy is advocated, there is a preference for psychoanalytically-informed treatments over cognitive behavioural therapies. In addition to psychotherapy, the APA practice guideline recommends symptom-targeted pharmacotherapy. Based on clinical judgment derived from a synthesis of the evidence, three algorithms were included in the APA guideline reflecting prominence of cognitive/perceptual symptoms, affective dysregulation symptoms or impulsive-behavioural dyscontrol symptoms. The usefulness of these guidelines is limited by the poor level of evidence available at the time they were written. This is especially apparent in the sections of the guideline presenting psychotherapy data and ensuing recommendations. In relation to the management of suicide risk, the APA guidelines have also been criticised for being risk averse. According to Pascual et al. (2007), if the APA guideline recommendations are applied, most patients with BPD who visit psychiatric emergency services would require hospital admission, but in reality, very few patients are actually hospitalized. Furthermore, some authors such as Paris et al. (2004) believe that hospitalization can be regressive, harmful, and counter-therapeutic. In

50 42 this respect, the NICE guidelines are more conservative, recommending that alternative options should be explored before admission to a crisis unit or hospital is considered. Another major shortcoming of the APA guidelines is that while it provides detailed advice on the selected psychological and pharmacological treatments, it lacks specific detail about treating patients with learning disabilities, treating young people, developing an optimistic and trusting relationship, training, supervision and support, referral to community mental health services and issues to do with the management of BPD in a primary care setting. As they were intended for application in the American healthcare system, the APA guidelines place much more emphasis on the role of psychiatrists in treating patients with BPD. The WFSBP guidelines were restricted in length and scope due to the fact that they were disseminated as a journal publication (Herpetz et al., 2007). As a consequence, the guidelines fail to achieve an adequate standard in most of the AGREE domains, especially in areas such as applicability and stakeholder involvement. Nonetheless, these guidelines are useful in that they provide relatively up-to-date guidance on the use of pharmacological treatments in BPD. In general terms, these guidelines are more conservative in their advocacy of pharmacological treatments than the APA guidelines. However unlike the NICE guidelines, they recognise psychoactive drugs as a legitimate treatment option for BPD. While the WFSBP recommendations focus primarily on the biological pharmacological treatment of BPD, they do note that psychotherapeutic regimes have an important place in the treatment of personality disorders.

51 43 NZ Mental Health Commission (Krawitz & Watson, 1999) In addition to the aforementioned CPGs, a commonly consulted resource for health professionals treating BPD patients in New Zealand is a discussion paper commissioned by the NZ Mental Health Commission (Krawitz and Watson, 1999). The report was written in order to provide some clearer direction to service providers about more effective ways of treating patients with BPD. While the discussion paper is not intended to serve the purpose of a clinical guideline per se, it draws together the available evidence on treatment and approaches to provide guidance to the New Zealand mental health sector. Although it is now relatively dated, the report continues to be widely consulted by practicing clinicians. The key recommendations pertaining to treatment issues and clinical pathways are listed below: Risk assessment and general assessment need to be highly individualised. An identified key clinician will be at the core of the team. A clinical plan created by client and key clinician is at the core of treatment. There is a paucity of treatment research to recommend evidence based practice, so clinician focus has to be on best practice recommendations. The best researched psychosocial treatments for people with severe forms of the disorder are DBT (dialectical behaviour therapy) and self psychology as carried out by Stevenson/Meares. Taking what is similar in different models can guide clinicians in their practice. Pharmacological treatment can have an adjunctive role to psychosocial treatments. A long-term perspective (years) needs to be held with regard to treatment. Treatment is prioritised to that which will achieve greatest client stability. The goal of crisis work is to assist the client s return to their pre-crisis level of function and will include a hierarchy of actions which may include anti-suicide interventions. Distinguishing self-harm intended to suicide from that intended for other reasons will critically influence treatment pathways. The commonest reason for self-harm is relief of internal emotional distress especially anxiety and anger. Limit setting to enable the clinician to retain positivity for the client is legitimate. Acute inpatient stays should, wherever possible, be brief (measured in hours). Acute hospitalisation is avoided, where possible, by use of resourced alternatives. Lengthy hospitalisation should be subject to routine, local peer review. Client controlled brief acute hospitalisation holds considerable promise. Often public mental health services only respond to this client group when they are suicidal. This encourages the very behaviour clinicians are trying to decrease. Authorities on Maori and Pacific Island peoples who are also knowledgeable about BPD and its relevance within these cultures need to be identified and encouraged. Clinician values and feelings are critical determinants for effective treatment. Stigmatisation has led to discrimination, most evident in the paucity of intensive, proactive treatment for those people most severely affected. Individual and institutional avoidance of proactively treating this group is the single most important impediment to effective service provision. The Krawitz and Watson discussion paper and the NICE guideline are similar in that they both highlight the importance of ensuring access to services for all patients with BPD, and avoiding stigmatisation. The two guidelines also share a similar approach to inpatient admission, with the view that acute hospitalisations should be avoided where possible. This is

52 44 in contrast to the APA guideline, where brief hospitalisation is recommended for certain indications and the mitigation of risk is the highest priority. Due to similarities between the British and NZ healthcare systems, the NICE guideline and the Krawitz and Watson discussion paper also share a focus on publicly provided care using a team-based approach. Both documents note the importance of ensuring that patients are treated in a positive and optimistic environment. Regarding the use of pharmaceutical treatments in patients with BPD, NICE recommends against all forms of pharmacotherapy for managing BPD symptoms while the NZ discussion paper states that pharmacological treatment can have an adjunctive role to psychosocial treatments. This is more in line with the guidance provided by the APA and the WFSBP, where pharmacological treatment is considered to be an important component of treatment. Although the evidence base is poor for psychological treatment, the Krawitz and Watson discussion paper is in agreement with the other three guidelines about the value of psychotherapeutic interventions in treating BPD. In summary, while the Krawitz and Watson discussion paper is now relatively outdated and is not based on a systematic review of the literature, its general principles have more in common with the NICE guideline than the APA guideline. Its major difference with the NICE guideline is its more permissive approach to the adjunctive use of pharmacotherapy for the treatment of BPD.

53 45 References Agree Collaboration (2001). Appraisal of guidelines for research and evaluation (AGREE) Instrument. Accessed 20 Nov American Psychiatric Association. (2006). Treating BPD: a quick reference guide. Available at: Accessed December 11, American Psychiatric Association. (2001). Practice guideline for the treatment of patients with BPD. American Journal of Psychiatry, 158, Bellino S., Paradiso E., Fenocchio M., & Bogetto F. (2007). Pharmacological treatment of BPD: Guidelines and research findings. Minerva Psichiatrica, 48, Binks C. A., Fenton M., McCarthy L., Lee T., Adams C. E., & Duggan C. (2006a). Pharmacological interventions for people with borderline personality disorder. Cochrane Database of Systematic Reviews, CD Binks C. A., Fenton M., McCarthy L., Lee T., Adams C. E., & Duggan C. (2006b) Psychological therapies for people with borderline personality disorder. Cochrane Database of Systematic Reviews, CD American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders TR 4th edition. Washington, DC. Durham J. D., Arthur Grube R. R., & Fuller S. H. (2007). Borderline Personality Disorder. U. S. Pharmacist, 32, Field, M. J. & Lohr, K. N. (eds) (1990) Clinical Practice Guidelines: directions for a new program, Institute of Medicine, National Academy Press, Washington, DC. Grant B. F., Chou S. P., Goldstein R. B., Huang B., Stinson F. S., Saha T. D. et al. (2008). Prevalence, correlates, disability, and comorbidity of DSM-IV borderline personality disorder: results from the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions. J Clin Psychiatry, 69(4), Herpertz S., Zanarini M., Schulz C., Siever L., Lieb K., & Moller H. J. (2007). World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for biological treatment of personality disorders. World Journal of Biological Psychiatry, 8, Krawitz, R. & Watson, C. (1999). Borderline Personality Disorder: pathways to effective service delivery and clinical treatment options [Discussion paper]. Wellington: Mental Health Commission Occasional Publications. Lieb K., Zanarini M. C., Schmahl C., et al. (2004) Borderline personality disorder. Lancet, 364, MacDermid J. C., Brooks D., Solway S. et al. (2005) Reliability and validity of the AGREE instrument used by physical therapists in assessment of clinical practice guidelines. BMC Health Serv Res 5, 18. McGlashan T. H. (2002) The BPD practice guidelines: The good, the bad, and the realistic. Journal of Personality Disorders, 16, Morana H. C. P. & Camara F. P. (2006). International guidelines for the management of personality disorders. Current Opinion in Psychiatry, 19,

54 46 National Institute for Health and Clinical Excellence (NICE). (2009). Borderline personality disorder (costing report). London: NICE National Institute for Health and Clinical Excellence (NICE). (2009). Borderline personality disorder (quick reference guide). London: NICE National Institute for Health and Clinical Excellence (NICE). (2009). Borderline personality disorder: treatment and management (full guideline). London: NICE National Health and Medical Research Council (NHMRC). (2000a). How to review the evidence: systematic identification and review of the scientific literature. Canberra: NHMRC. National Health and Medical Research Council (NHMRC). (2000b). How to use the evidence: assessment and application of scientific evidence. Canberra: NHMRC. National Health and Medical Research Council (NHMRC). (2005). Interim Levels of Evidence. Canberra: NHMRC. Nissen T. (2000). Psychopharmacological treatment of BPD. Tidsskrift for den Norske Laegeforening, 120, Oldham J. M. (2005). Guideline Watch: Practice Guideline for the Treatment of Patients with BPD. Available at: Accessed December 11, Paris J. (2004). Is hospitalization useful for suicidal patients with borderline personality disorder? Journal of Personality Disorders, 18, Paris, J. (2002). Chronic suicidality among patients with borderline personality disorder. Psychiatr Services, 53, Pascual J. C., Córcoles D., Castaño J., Ginés J. M., Gurrea A., Martín-Santos R. et al. (2007). Hospitalization and pharmacotherapy for borderline personality disorder in a psychiatric emergency service. Psychiatric services, 58(9), Renaud S. & Lecomte Y. (2003). Guidelines for the treatment of patients with BPD. Sante mentale au Quebec, 28, Stone M. H. (2000). Clinical guidelines for psychotherapy for patients with BPD. Psychiatric Clinics of North America, 23, Swartz M. D. & Blazer L. (1990). Estimating the prevalence of borderline personality disorder in the community. Journal of Personality Disorders, 4(3), Turbott J. (2004). Treatment of Borderline Personality Disorder. Australasian Psychiatry, 12, 289. Tyrer P. & Duggan C. (2008). NICE guidelines for the treatment of personality disorder. Psychiatry, 7, Tyrer P. (2002). Practice guideline for the treatment of Borderline Personality Disorder: A bridge too far. Journal of Personality Disorders, 16, Verheul R. and Herbrink M. (2007). The efficacy of various modalities of psychotherapy for personality disorders: A systematic review of the evidence and clinical recommendations. International Review of Psychiatry, 19,

55 47 Woeller W. & Tress W. (2005). Psychotherapeutic treatment of personality disorders. Zeitschrift fur Psychosomatische Medizin und Psychotherapie, 51, Zanarini M. C., Frankenburg F. R., Khera G. S., & Bleichmar J. (2001) Treatment histories of borderline inpatients. Compr Psychiatry, 42(2),

56 48

57 49 Appendix A PsychINFO and CINAHL searches Database: PsycINFO Period Covered: 1806 to present Platform: OvidSP Last Updated: December Week Date of Search: 18 December 2008 Search Strategy: see Table 1 below Database: CINAHL (Nursing and Allied Health) Period Covered: 1982 to present Platform: OvidSP Date of Search: 18 December 2008 Search Strategy: see Table 2 below PsycINFO search strategy PsycINFO 1806 to December Week # Searches Results 1 BPD/ borderline states/ emotionally unstable personality.ti,ab BPD.ti,ab (borderline type or borderland or bpd).ti,ab (f60 adj "31").ti,ab. 0 7 f60 31.ti,ab or 2 or 3 or 4 or 5 or 6 or treatment guidelines/ best practices/ (treatment guideline or treatment guidelines).ti,ab (management guideline or management guidelines).ti,ab (clinical adj1 guideline$).ti,ab (evidence based guideline or evidence based guidelines).ti,ab (consensus guideline or consensus guidelines).ti,ab (best practice or best practices).ti,ab evidence based practice/ or 9 or 17 or 12 or 15 or 14 or 10 or 13 or and 18 61

58 50 CINAHL search strategy CINAHL (Nursing and Allied Health) 1982 to present # Searches Results 1 BPD/ emotionally unstable personality.ti,ab. 0 3 BPD.ti,ab (borderline type or borderland or bpd).ti,ab (f60 adj "31").ti,ab. 0 6 f60 31.ti,ab or 2 or 3 or 4 or 5 or Practice Guidelines/ exp Professional Practice, Evidence-Based/ (treatment guideline or treatment guidelines).ti,ab (management guideline or management guidelines).ti,ab (clinical adj1 guideline$).ti,ab (evidence based guideline or evidence based guidelines).ti,ab (consensus guideline or consensus guidelines).ti,ab (best practice or best practices).ti,ab or 9 or 12 or 15 or 14 or 8 or 10 or and 16 23

59 51 Appendix B: AGREE Scores NICE Guidelines (Reviewer 1) Scope and Purpose The overall objective(s) of the guideline is (are) specifically described. Strongly Agree 3 Strongly Disagree The objectives of the CPG are clearly stated. Specific health outcomes are not included in the list of guideline aims; however it is stated that the guidelines are intended to promote the implementation of best clinical practice. The clinical question(s) covered by the guideline is (are) specifically described. Strongly Agree 4 Strongly Disagree One of the key steps in the development of this CPG was defining the clinical questions considered important for practitioners and service users. A comprehensive list of these questions is provided in Appendix 6 of the document. The patients to whom the guideline is meant to apply are specifically described. Strongly Agree 4 Strongly Disagree The guideline applies to adults and young people with BPD. The scope of the guideline (Appendix 1) further defines the groups that are covered under the CPG; however it might be clearer for readers if this were included in the Introduction. Stakeholder Involvement The guideline development group includes individuals from all the relevant professional groups. Strongly Agree 4 Strongly Disagree Stakeholders involved in the process included service users/carers, professional stakeholders, commercial stakeholders, government stakeholders and Primary Care Trusts. A complete list of Guideline Development Group members is provided. The patients views and preferences have been sought. Strongly Agree 4 Strongly Disagree

60 52 The CPG Guideline Development Group included representatives of service users (i.e. patients) and carer groups. Chapter 4 provides an overview of the experience of patients with BPD and their carers, including first-hand personal accounts written by service users, former service users and a carer. The CPG also includes a review of qualitative literature review of service user experience. The target users of the guideline are clearly defined. Strongly Agree 3 Strongly Disagree The guideline scope in Appendix 1 describes the healthcare settings to which the CPG is applicable, including care in general practice, hospitals, primary/secondary interface of care, prisons and the transition from child/adolescent services to adult services. The professional groups to whom the guideline is relevant could be presented more specifically. The guideline has been piloted among target users. Strongly Agree 1 Strongly Disagree Whether the pilot was piloted among the target users prior to publication was not specified Rigour of development Systematic methods were used to search for evidence. Strongly Agree 4 Strongly Disagree The CPG recommendations were based on a computerised literature search that is described in detail in the Methods section of the report. The search strings applicable to specific clinical questions are presented in Appendix 6. The criteria for selecting the evidence are clearly described. Strongly Agree 4 Strongly Disagree The standard inclusion and exclusion criteria are provided Appendix 8, while more specific eligibility criteria for specific clinical questions are presented in the relevant clinical evidence chapters. Studies were also appraised for methodological quality and external validity (in the UK context). The methods used for formulating the recommendations are clearly described. Strongly Agree 4 Strongly Disagree

61 53 The procedures used to extract, synthesise and determine the clinical significance of evidence are described in detail, including examples of evidence profile tables. The methods used to formulate the recommendations were based on the method described by Eccles et al. (1998), and achieving informal consensus (in the absence of high-quality evidence). The health benefits, side effects and risks have been considered in formulating the recommendations. Strongly Agree 4 Strongly Disagree Benefits and risks were included in the summary evidence profiles of different interventions, and were therefore included in the formulation of final recommendations. There is an explicit link between the recommendations and the supporting evidence. Strongly Agree 2 Strongly Disagree The summaries of evidence (which form the basis for the recommendations) for efficacy, cost-effectiveness, adverse effects, length/frequency of treatment and implementation issues are referenced in the clinical evidence chapters. The recommendations themselves, however, are not directly linked to a list of references. The CPG also fails to clearly identify which recommendations are evidence-based and which are consensus-based. The guideline has been externally reviewed by experts prior to its publication. Strongly Agree 4 Strongly Disagree The draft is currently under review. A list of stakeholders and experts who submitted comments in response to the consultation draft of the guideline is provided in Appendix 4. A procedure for updating the guideline is provided. Strongly Agree 2 Strongly Disagree The introduction refers to future revisions of the CPG; however the procedures for carrying out the update are not provided. Clarity and presentation The recommendations are specific and unambiguous. Strongly Agree 3 Strongly Disagree

62 54 The recommendations are relatively specific, however it is unclear which recommendations are evidence-based, and which are based on consensus and patient/carer accounts. Where there is insufficient evidence to make recommendations, this has been specified. The different options for management of the condition are clearly presented. Strongly Agree 4 Strongly Disagree The options for treatment are presented as clinical evidence headings in each chapter. Key recommendations are easily identifiable. Strongly Agree 4 Strongly Disagree Key recommendations are presented at the end of each chapter and in the Summary of Recommendations in Chapter 10. The guideline is supported with tools for application. Strongly Agree 4 Strongly Disagree The guidelines are accompanied by a reference guide that summarises, and is intended to be used in conjunction with the full text of the CPG. Applicability The potential organisational barriers in applying the recommendations have been discussed. Strongly Agree 4 Strongly Disagree The CPG includes a chapter on the configuration and organisation of services, which includes a set of clinical practice recommendations. The potential cost implications of applying the recommendations have been considered. Strongly Agree 4 Strongly Disagree The CPG included a separate search for health economics evidence. The methodology for conducting this search is described in detail in the Methods section and in Appendix 12 (Search strategies for the identification of health economics evidence). For each clinical question, a separate systematic search of the economic literature was undertaken and the costeffectiveness was presented.

63 55 The guideline presents key review criteria for monitoring and/or audit purposes. Strongly Agree 1 Strongly Disagree The CPG identifies key areas of clinical practice and service delivery for local and national audit; however it is anticipated that a more broadly based implementation strategy (including audit standards) will be developed in time. The Healthcare Commission will monitor the extent to which healthcare authorities have implemented the CPGs, but the specific review criteria that will be assessed have not been described. Editorial independence The guideline is editorially independent from the funding body. Strongly Agree 3 Strongly Disagree The Guideline Development Group was supported by funding from NICE. While there is not explicit statement that the views and interests of the funding body have not influenced the final recommendations, it is clear that every effort was made to minimise conflicts of interest during the guideline development process. Conflicts of interest of guideline development members have been recorded. Strongly Agree 4 Strongly Disagree All members of the Guideline Development Group were required to publically declare potential conflicts of interest before they were allowed to participate in the project. Members were also asked to declare interests at each Guideline Development Group meeting during the guideline development process. NICE Guidelines (Reviewer 2) Scope and Purpose The overall objective(s) of the guideline is (are) specifically described. Strongly Agree 4 Strongly Disagree The aim of the guideline is to: (i) evaluate the role of specific psychosocial interventions in the treatment of borderline personality disorder; (ii) evaluate the role of specific pharmacological interventions in the treatment of borderline personality disorder; (iii) integrate the previous to provide best-practice advice on the care of individuals with a diagnosis of borderline personality disorder; and (iv) promote the implementation of best clinical practice through the development of recommendations tailored to the requirements of the NHS in England and Wales. The clinical question(s) covered by the guideline is (are) specifically described.

64 56 Strongly Agree 4 Strongly Disagree Specific clinical questions were assessed and are provided in Appendix 6. There are 17 questions (some with multiple components). The clinical questions were initially drafted by the review group and then finalised in conjunction with the guideline development group. The patients to whom the guideline is meant to apply are specifically described. Strongly Agree 4 Strongly Disagree The relevant patient group is defined within each of the specific clinical questions (ie, general or subpopulation of people with borderline personality disorder). Appendix 1 defines, the population covered by the guideline as (i) adults with borderline personality disorder, (ii) people < 18 with BPD or putative BPD and (iii) people with BPD and a learning disability. Stakeholder Involvement The guideline development group includes individuals from all the relevant professional groups. Strongly Agree 4 Strongly Disagree The guideline development group includes individuals from a number of relevant professional groups including psychiatry, nursing, general practice, psychology, pharmacy, and patient/carer representatives as well as systematic review and health economics specialists. The patients views and preferences have been sought. Strongly Agree 4 Strongly Disagree Three patient/carer representatives were included in the guideline development group. In addition, they included personal accounts of the experience of people with borderline personality disorder from service users, former service users and a carer. Finally, a review of the qualitative literature was carried out in order to identify the broad themes of receiving the diagnosis, accessing services and having treatments. The target users of the guideline are clearly defined. Strongly Agree 3 Strongly Disagree Appendix 1 defines, the healthcare settings covered by the guideline as (i) general practice and NHS community care, (ii) hospital outpatient, day and inpatient care including secure hospitals, (iii) primary/secondary interface of care; (iv) transition from child and adolescent services to adult services and (v) prisons and transition from prison health services to NHS services.

65 57 The guideline has been piloted among target users. Strongly Agree 1 Strongly Disagree Whether the guideline has been targeted among target users has not been stated. Rigour of development Systematic methods were used to search for evidence. Strongly Agree 4 Strongly Disagree A comprehensive search for evidence has been undertaken. The search strategies are outlined in detail in Appendix 7. The criteria for selecting the evidence are clearly described. Strongly Agree 3 Strongly Disagree The guideline states that eligibility criteria were developed in consultation with the guideline development group; however, these are not specifically described. The methods used for formulating the recommendations are clearly described. Strongly Agree 3 Strongly Disagree The methods used for formulating the recommendations are described in the Methods section. Recommendations were made once evidence profile tables and clinical summaries were finalised and took into account the trade-off between benefits/risks and other considerations (eg, economic, values, practical issues). The health benefits, side effects and risks have been considered in formulating the recommendations. Strongly Agree 4 Strongly Disagree The methods section states that benefits/risks and other considerations (eg, economic, values, practical issues) were taken into account when formulating the recommendations. There is an explicit link between the recommendations and the supporting evidence. Strongly Agree 3 Strongly Disagree

66 58 The clinical practice and research recommendations are listed at the end of each section after the evidence has been presented; however these are not directly linked to the specific evidence or given levels of evidence. The guideline has been externally reviewed by experts prior to its publication. Strongly Agree 4 Strongly Disagree A list of stakeholders and experts who contributed comments to the consultative draft is provided in Appendix 4. This includes a broad range of government and professional organisations. A procedure for updating the guideline is provided. Strongly Agree 2 Strongly Disagree There is a statement regarding future revisions but no specific procedure is described. Clarity and presentation The recommendations are specific and unambiguous. Strongly Agree 3 Strongly Disagree The recommendations are generally specific and unambiguous although there is no statement for each regarding the level of evidence upon which it is based. The different options for management of the condition are clearly presented. Strongly Agree 4 Strongly Disagree A wide range of management options are covered by the guideline and clearly presented under separate subheadings. Key recommendations are easily identifiable. Strongly Agree 4 Strongly Disagree Key recommendations are presented following the summary of evidence for each management option.

67 59 The guideline is supported with tools for application. Strongly Agree 4 Strongly Disagree The guideline is supported with a quick reference guide A number of tools are also available to help in implementation including a slide set, cost report and audit report. Applicability The potential organisational barriers in applying the recommendations have been discussed. Strongly Agree 4 Strongly Disagree The guideline includes a chapter on the configuration and organisation of services. The potential cost implications of applying the recommendations have been considered. Strongly Agree 4 Strongly Disagree A separate cost report looks at the resource impact of implementing the guideline in England. The guideline presents key review criteria for monitoring and/or audit purposes. Strongly Agree 2 Strongly Disagree Key review criteria are not described. However, the guideline makes the following general statement regarding monitoring/auditing of implementation: this guideline identifies key areas of clinical practice and service delivery for local and national audit. Although the generation of audit standards is an important and necessary step in the implementation of a guideline, a more broadly based implementation strategy will be developed. Nevertheless, it should be noted that the Healthcare Commission will monitor the extent to which Primary Care Trusts, trusts responsible for metal health and social care and Health Authorities have implemented the CPGs. Editorial independence The guideline is editorially independent from the funding body. Strongly Agree 3 Strongly Disagree

68 60 The guideline development group was supported by funding from NICE. The statements and recommendations in the guideline were generated and agreed by the whole guideline development group. Conflicts of interest of guideline development members have been recorded. Strongly Agree 4 Strongly Disagree Conflicts of interest were sought from all participants in the guideline development process and these were updated at every meeting. Declarations of interest for all members of the guideline development group are provided in Appendix 2.

69 61 APA Guidelines (Reviewer 1) Scope and Purpose The overall objective(s) of the guideline is (are) specifically described. Strongly Agree 3 Strongly Disagree The Statement of Intent provides some precautions to ensure that the CPGs are not applied indiscriminately and used as a substitute for individualised clinical care. The Introduction states that the document summarises data regarding the care of patients with BPD (BPD) and reviews the treatment that patients with BPD may need. The CPG also fails to present any health-related impacts or benefits that are expected to occur as a result of their use in patients with BPD. The clinical question(s) covered by the guideline is (are) specifically described. Strongly Agree 2 Strongly Disagree The CPG categorises advice under broad headings e.g. treatment of affective dysregulation symptoms and then makes a general recommendation based on the best available data and clinical consensus. Specific questions (e.g. should patients with affective dysregulation receive SSRIs?) are not asked. This is probably attributable to the poor level of evidence supporting most aspects of BPD patient management and the arguably nebulous nature of the condition, rather than a lack of rigour on the part of the authors. The patients to whom the guideline is meant to apply are specifically described. Strongly Agree 3 Strongly Disagree The CPGs are intended for patients who fulfil the diagnostic criteria for BPD provided in the Diagnostic and Statistical Manual of Mental disorders (DSM-IV).Further specifications to define the target patient population are not provided. This may be because the CPGs are intended to be used in a broad range of patients with BPD (e.g. across all ages, comorbidities etc.) however this point should probably be stated more explicitly. Stakeholder Involvement The guideline development group includes individuals from all the relevant professional groups. Strongly Agree 2 Strongly Disagree

70 62 The drafting process involved input from a work group that included psychiatrists with clinical and research expertise in BPD. Further information about the composition, discipline and relevant expertise of the guideline development group is not provided. Whether there was input from other disciplines outside of psychiatry (e.g. allied health) is also not specified. The patients views and preferences have been sought. Strongly Agree 1 Strongly Disagree Based on the description of the Development Process, information from patient interviews or literature reviews of patients experiences was not collected. The target users of the guideline are clearly defined. Strongly Agree 4 Strongly Disagree The CPG is intended for use by psychiatrists. The guideline has been piloted among target users. Strongly Agree 1 Strongly Disagree Whether the pilot was piloted among the target users prior to publication was not specified Rigour of development Systematic methods were used to search for evidence. Strongly Agree 4 Strongly Disagree The CPG recommendations were based on a computerised literature search of MEDLINE and PsycINFO, using a set of relevant keywords. This search yielded 1,562 citations in MEDLINE and 2,460 citations in PsycINFO. Additional, less formal literature searches were conducted by APA staff and the individual members of the working group. It is not specified if databases of systematic reviews (e.g. Cochrane or DARE) or guideline clearinghouses were searched; however it is likely that at the time, the authors were aware that guidelines or systematic reviews in BPD did not exist. The criteria for selecting the evidence are clearly described. Strongly Agree 2 Strongly Disagree

71 63 The keywords used in the initial MEDLINE and PsycINFO search are provided in the Development Process. The citations retrieved from this search were narrowed down to a final list of 198 citations; however the criteria applied in the inclusion/exclusion of citations are not described. The methods used for formulating the recommendations are clearly described. Strongly Agree 2 Strongly Disagree Under Development Process, it is stated that the recommendations are based on the best available data and clinical consensus. Where available (especially in relation to psychopharmacological treatment), recommendations are accompanied by summary tables listing interventions, the symptoms for which they should be used, and the strength of available evidence. Methods for obtaining consensus were not described. The health benefits, side effects and risks have been considered in formulating the recommendations. Strongly Agree 4 Strongly Disagree For each category of intervention, the CPG provides a summary of evidence for efficacy, cost-effectiveness, adverse effects, length/frequency of treatment and implementation issues. There is an explicit link between the recommendations and the supporting evidence. Strongly Agree 3 Strongly Disagree The summaries of evidence (which form the basis for the recommendations) for efficacy, cost-effectiveness, adverse effects, length/frequency of treatment and implementation issues are referenced appropriately. The recommendations themselves, however, are not directly linked to a list of references. The CPG also fails to clearly identify which recommendations are evidence-based and which are consensus-based. The guideline has been externally reviewed by experts prior to its publication. Strongly Agree 4 Strongly Disagree Prior to publication the CPGs were externally reviewed, with substantial comments received from 13 organisations and 60 individuals. A procedure for updating the guideline is provided. Strongly Agree 3 Strongly Disagree

72 64 A procedure is not provided, however the APA published a guideline watch for BPD in The APA website states that the purpose of the guideline watch is to briefly summarize significant developments in the scientific literature since publication of the original guideline. Clarity and presentation The recommendations are specific and unambiguous. Strongly Agree 3 Strongly Disagree The recommendations are sometimes specific and sometimes relatively ambiguous (e.g. recommendations relating pharmacotherapy are quite specific; however the recommendations relating to psychotherapy are less direct). Considering the poor evidence base in BPD at the time this CPG was written, this probably reflects uncertainty associated with particular aspects of management rather than a lack of rigour on the part of the authors. The level of uncertainty associated with each recommendation is quantified via a coding system. The different options for management of the condition are clearly presented. Strongly Agree 3 Strongly Disagree Patients with BPD often receive a range of concomitant treatments to address individual symptoms (e.g. affective dysregulation, cognitive perceptual symptoms), as well as psychotherapy. Treatment options to address these symptoms are discussed in the Review and Synthesis of Available Evidence. Key recommendations are easily identifiable. Strongly Agree 4 Strongly Disagree The key recommendations are presented in the Executive Summary at the front of the report. For psychopharmacological treatments, recommendations for different symptoms are presented in the form of suggested treatment algorithms. The guideline is supported with tools for application. Strongly Agree 4 Strongly Disagree The guidelines are accompanied by a reference guide that summarises, and is intended to be used in conjunction with the full text of the CPG.

73 65 Applicability The potential organisational barriers in applying the recommendations have been discussed. Strongly Agree 3 Strongly Disagree Reference is made to the need to coordinate the treatment effort through a team involving several clinicians; however the organisational implications of this are not discussed. For each individual treatment strategy, implementation issues are discussed, which include organisational issues where applicable. The potential cost implications of applying the recommendations have been considered. Strongly Agree 3 Strongly Disagree Where available, data from cost-effectiveness studies associated with different treatments were presented and discussed. The level of importance assigned to these considerations during the formulation of recommendations is not described. The guideline presents key review criteria for monitoring and/or audit purposes. Strongly Agree 1 Strongly Disagree The CPG does not provide specific review criteria that could assist in the conduct of an audit to measure adherence to these guidelines. Editorial independence The guideline is editorially independent from the funding body. Strongly Agree 3 Strongly Disagree While it is possible that some contributors received income related to treatments discussed in the CPG, a number of mechanisms (described in the report) were instituted in order to minimise bias resulting from conflict of interest. The development of the APA CPG was not financially supported by any commercial organisation. There is however, no explicit statement that the view or interests of the funding body have not influenced the final recommendations. Conflicts of interest of guideline development members have been recorded. Strongly Agree 4 Strongly Disagree Conflicts of interest were disclosed to the Steering Committee.

74 66 APA Guidelines (Reviewer 2) Scope and Purpose The overall objective(s) of the guideline is (are) specifically described. Strongly Agree 4 Strongly Disagree The guideline states that it offers treatment recommendations based on available evidence and clinical consensus to help psychiatrists develop plans for the care of adult patients with borderline personality disorder. It notes that it is designed to be used as a guideline only, and not as a standard of medical care. The clinical question(s) covered by the guideline is (are) specifically described. Strongly Agree 3 Strongly Disagree The clinical questions are not specifically described however they can be inferred from the specific recommendations provided in the guideline (ie, initial assessment, psychiatric management, principles of treatment selection, specific treatment strategies, special features influencing treatment and risk management issues). The patients to whom the guideline is meant to apply are specifically described. Strongly Agree 3 Strongly Disagree The guideline states that it is primarily aimed at adults with borderline personality disorder. Stakeholder Involvement The guideline development group includes individuals from all the relevant professional groups. Strongly Agree 3 Strongly Disagree

75 67 The guideline states that the initial draft was carried out by a work group that included psychiatrists with clinical and research expertise in borderline personality, that subsequent drafts were informed by comments from 16 organisations and 60 individuals and that the final draft was approved by the APA Assembly and Board of Trustees. In addition to psychiatry organisations, other organisations that provided comments came from the following disciplines: ophthalmology, obstetrics and gynaecology, radiology, occupational therapy, nursing and psychology. The patients views and preferences have been sought. Strongly Agree 1 Strongly Disagree There is no indication that patient views and preferences were sought. The target users of the guideline are clearly defined. Strongly Agree 4 Strongly Disagree The guideline states that it is for the use of psychiatrists. The guideline has been piloted among target users. Strongly Agree 1 Strongly Disagree There is no indication that the guideline has been piloted among psychiatrists. Rigour of development Systematic methods were used to search for evidence. Strongly Agree 4 Strongly Disagree Specific search strategies (both databases searched and terms used) have been described. The guideline also notes that less formal searches were conducted by APA staff and individual members of the work group. The criteria for selecting the evidence are clearly described. Strongly Agree 1 Strongly Disagree

76 68 No criteria for selecting the relevant studies from the literature search results are described. The methods used for formulating the recommendations are clearly described. Strongly Agree 2 Strongly Disagree The section describing the development process states that the recommendations are based on the best available data and clinical consensus however the specific methods of formulating the recommendations are not described. The health benefits, side effects and risks have been considered in formulating the recommendations. Strongly Agree 4 Strongly Disagree For each therapy assessed, the efficacy and side effects have been described and considered. There is an explicit link between the recommendations and the supporting evidence. Strongly Agree 4 Strongly Disagree Specific evidence has been referenced for each of the recommendations, and it is clear what level of evidence recommendations have been based on. The guideline has been externally reviewed by experts prior to its publication. Strongly Agree 4 Strongly Disagree As noted previously, the initial draft was carried out by a work group that included psychiatrists with clinical and research expertise in borderline personality, that subsequent drafts were informed by comments from 16 organisations and 60 individuals and that the final draft was approved by the APA Assembly and Board of Trustees. A procedure for updating the guideline is provided. Strongly Agree 3 Strongly Disagree

77 69 The development process section of the guideline states that one of the key features of the APA Guideline Development Process is planned revision at regular intervals. It should be noted that since the latest version of the guideline (2001), a guideline watch has been published (2005) which updates some of the evidence and recommendations included in the original guideline. Clarity and presentation The recommendations are specific and unambiguous. Strongly Agree 3 Strongly Disagree The recommendations are specific and are grouped under headings regarding specific issue in the management of borderline personality disorder. The level of evidence associated with each recommendation is provided. The different options for management of the condition are clearly presented. Strongly Agree 4 Strongly Disagree Different management options are clearly presented within the recommendations, with background information also provided. Key recommendations are easily identifiable. Strongly Agree 4 Strongly Disagree Key recommendations are easily identifiable in the Executive Summary of Recommendations section. Each recommendation is supported with a level of evidence raging from (I) recommended with substantial clinical confidence to (III) may be recommended on the basis of individual circumstances. The guideline is supported with tools for application. Strongly Agree 4 Strongly Disagree The guideline is supported by a Treating Borderline Personality Disorder Quick Reference Guide which includes management algorithms. It states that the Quick reference Guide should be used in conjunction with the full text of the practice guideline.

78 70 Applicability The potential organisational barriers in applying the recommendations have been discussed. Strongly Agree 3 Strongly Disagree Specific implementations issues are noted for each of the management strategies assessed. The potential cost implications of applying the recommendations have been considered. Strongly Agree 3 Strongly Disagree The cost-effectiveness of each of the management strategies assessed has been addressed. The guideline presents key review criteria for monitoring and/or audit purposes. Strongly Agree 1 Strongly Disagree The guideline does not present key review criteria for monitoring and/or audit purposes. Editorial independence The guideline is editorially independent from the funding body. Strongly Agree 3 Strongly Disagree The guideline states that the development of the APA practice guidelines is not financially supported by any commercial organisation. Conflicts of interest of guideline development members have been recorded. Strongly Agree 3 Strongly Disagree The guideline states that it is possible that some contributors may have received some income related to treatments discussed in the guideline. Contributors are asked to disclose any potential conflict of interest. Potential conflicts of interest are not provided in the guideline.

79 71 WFSBP Guidelines (Reviewer 1) Scope and Purpose The overall objective(s) of the guideline is (are) specifically described. Strongly Agree 3 Strongly Disagree While the objectives of the CPG are clearly stated, specific health outcomes are not included in the list of guideline aims. The clinical question(s) covered by the guideline is (are) specifically described. Strongly Agree 2 Strongly Disagree The CPG categorises advice by therapeutic class and then provides a summary of evidence relating to clinical efficacy and safety. Specific questions (e.g. should patients with affective dysregulation receive SSRIs?) are not asked. The patients to whom the guideline is meant to apply are specifically described. Strongly Agree 1 Strongly Disagree The CPG is targeted at patients with personality disorders, with a chapter dedicated to patients with BPD. Further specifications to define the target patient population are not provided. This may be because the CPGs are intended to be used in a broad range of patients with BPD (e.g. across all ages, comorbidities etc.) however this point should probably be stated more explicitly. Stakeholder Involvement The guideline development group includes individuals from all the relevant professional groups. Strongly Agree 2 Strongly Disagree The guidelines were developed by the authors and arrived at by consensus with a Task Force on Personality Disorders consisting of 23 international researchers and clinicians. Further information about the composition, discipline and relevant expertise of the guideline development group is not provided. Whether there was input from other disciplines outside of psychiatry (e.g. allied health) is also not specified. The patients views and preferences have been sought. Strongly Agree 1 Strongly Disagree

80 72 Based on the description of Methods used, information from patient interviews or literature reviews of patients experiences was not collected. The target users of the guideline are clearly defined. Strongly Agree 3 Strongly Disagree The target users are defined as all physicians seeing and treating patients with personality disorders. Whether the guidelines are useful to practitioners in other health professions is not made clear. The guideline has been piloted among target users. Strongly Agree 1 Strongly Disagree Whether the pilot was piloted among the target users prior to publication was not specified Rigour of development Systematic methods were used to search for evidence. Strongly Agree 3 Strongly Disagree The data used for the development of this CPG were collected via a systematic search of the literature, which is described in detail in the Methods section of the report. The exact search terms used in the searches are not provided. The criteria for selecting the evidence are clearly described. Strongly Agree 3 Strongly Disagree Eligible studies were selected based on methodological quality, the use of valid instruments and study-size. Details of specific inclusion/exclusion criteria are not provided. The methods used for formulating the recommendations are clearly described. Strongly Agree 1 Strongly Disagree The methods used for translating evidence into clinical recommendations are not described. The health benefits, side effects and risks have been considered in formulating the recommendations. Strongly Agree 2 Strongly Disagree

81 73 While the side-effects of treatments are discussed under Comparative efficacy and tolerability, however it does not appear that these factors were taken into consideration in the formulation of recommendations. There is an explicit link between the recommendations and the supporting evidence. Strongly Agree 3 Strongly Disagree The summaries of evidence are referenced appropriately. The recommendations themselves, however, are not directly linked to a list of references. The guideline has been externally reviewed by experts prior to its publication. Strongly Agree 3 Strongly Disagree Prior to publication the CPGs were externally reviewed by task force members, the Chairman of the WFSBP Committee on Scientific Publications, the Presidents of those national societies of biological psychiatry that belong to the WFSBP, and the WFSBP Executive Committee members. The CPGs were therefore reviewed by experts; however it is questionable whether these reviewers can be classified as external. A procedure for updating the guideline is provided. Strongly Agree 1 Strongly Disagree A procedure for updating the CPGs is not provided. Clarity and presentation The recommendations are specific and unambiguous. Strongly Agree 2 Strongly Disagree Recommendations are relatively non-specific, and are for the most part summaries of the level of evidence available for different treatment rather than explicit descriptions of appropriate management strategies. The different options for management of the condition are clearly presented. Strongly Agree 3 Strongly Disagree Options for treatment are discussed under separate headings for antidepressants, neuroleptics, mood stabilisers, other pharmacological approaches and psychotherapy.

82 74 Key recommendations are easily identifiable. Strongly Agree 2 Strongly Disagree The key recommendations appear under the same headings as the summaries of clinical efficacy. The recommendations are difficult to identify without reading the evidence summaries that precede them. The guideline is supported with tools for application. Strongly Agree 1 Strongly Disagree The CPG is not accompanied by tools for implementation. Applicability The potential organisational barriers in applying the recommendations have been discussed. Strongly Agree 1 Strongly Disagree Settings for delivery and associated organisational barriers are not discussed. The potential cost implications of applying the recommendations have been considered. Strongly Agree 1 Strongly Disagree Cost implications of the recommendations and the cost-effectiveness BPD treatments are not discussed. The guideline presents key review criteria for monitoring and/or audit purposes. Strongly Agree 1 Strongly Disagree Means of measuring adherence to the CPG are not presented. Editorial independence The guideline is editorially independent from the funding body. Strongly Agree 3 Strongly Disagree

83 75 While it is possible that some contributors received income related to treatments discussed in the CPG, a number of mechanisms (described in the report) were instituted in order to minimise bias resulting from conflict of interest. The development of the CPG was not financially supported by any commercial organisation. There is however, no explicit statement that the view or interests of the funding body have not influenced the final recommendations. Conflicts of interest of guideline development members have been recorded. Strongly Agree 4 Strongly Disagree Task force members were asked to disclose potential conflicts of interest that could bias their contribution.

84 76 WFSBP Guidelines (Reviewer 2) Scope and Purpose The overall objective(s) of the guideline is (are) specifically described. Strongly Agree 4 Strongly Disagree The goal of the WFSBP guideline is to provide an update of contemporary knowledge of personality disorders (including borderline) and evidence-based recommendations for their treatment. It is noted that the guideline is specifically concerned with biological, pharmacological treatment of patients, and that psychotherapeutic treatments are covered only briefly. The clinical question(s) covered by the guideline is (are) specifically described. Strongly Agree 1 Strongly Disagree No clinical questions are specifically described. The search strategy notes that searches were conducted using terms for pharmacotherapy; however, these are not defined in the methods section. The patients to whom the guideline is meant to apply are specifically described. Strongly Agree 1 Strongly Disagree The guideline states that it is for individuals with personality disorders, with borderline as well as schizotypal and anxious/avoidant types being considered separately. There is no other specific information specified although separate information is provided on the treatment of adolescents. Stakeholder Involvement The guideline development group includes individuals from all the relevant professional groups. Strongly Agree 2 Strongly Disagree The guideline states that it was developed by the authors and arrived at by consensus with a Task Force of 23 international researchers and clinicians. No specific details on the make up of this Task Force are provided so it is difficult to determine whether all relevant professional groups were involved, or whether any patient groups were represented. The patients views and preferences have been sought. Strongly Agree 1 Strongly Disagree

85 77 There is nothing in the guidelines to indicate that patient views and preferences have been sought. The target users of the guideline are clearly defined. Strongly Agree 3 Strongly Disagree The guidelines state that they are intended for use in clinical practice for all physicians seeing and treating patients with personality disorders. The guideline has been piloted among target users. Strongly Agree 1 Strongly Disagree There is no indication that the guideline has been piloted among target users. Rigour of development Systematic methods were used to search for evidence. Strongly Agree 3 Strongly Disagree The guideline states that a literature search of the Medline database was undertaken, however the full search strategy has not been provided. In addition, a number of other sources of data are cited. The criteria for selecting the evidence are clearly described. Strongly Agree 3 Strongly Disagree RCTs were preferentially included and other studies were only included where there was insufficient RCT evidence. Specific inclusion/exclusion criteria are listed including the exclusion of studies with mixed samples of personality disorders, used specific diagnostic methods, applied valid measurements of diagnosis and change and included at least 10 subjects. The methods used for formulating the recommendations are clearly described. Strongly Agree 1 Strongly Disagree The specific methods for formulating the recommendations are not stated.

86 78 The health benefits, side effects and risks have been considered in formulating the recommendations. Strongly Agree 2 Strongly Disagree The comparative efficacy and tolerability is discussed for each of the assessed specific classes of treatment (ie, antidepressants, neuroleptics and mood stabilisers) however it does not appear to be a linked to any specific recommendation. There is an explicit link between the recommendations and the supporting evidence. Strongly Agree 2 Strongly Disagree The supporting evidence has been described but there is no clear ling between it and any specific recommendations. The guideline has been externally reviewed by experts prior to its publication. Strongly Agree 4 Strongly Disagree The second draft of the guidelines was sent to all Presidents of the various societies of biological psychiatry that belong to the WFSBP for their comments. A procedure for updating the guideline is provided. Strongly Agree 1 Strongly Disagree No procedure for updating the guideline is reported. Clarity and presentation The recommendations are specific and unambiguous. Strongly Agree 2 Strongly Disagree The recommendations are not clearly listed but are included within a number of paragraphs discussing the findings of the review. The different options for management of the condition are clearly presented. Strongly Agree 3 Strongly Disagree

87 79 The evidence for different treatment options are summarised. The recommendations also suggest which treatments may be best for different aspects of the disorder. Key recommendations are easily identifiable. Strongly Agree 2 Strongly Disagree As noted previously, the recommendations are not clearly listed but are included within a number of paragraphs discussing the findings of the review. The guideline is supported with tools for application. Strongly Agree 1 Strongly Disagree There is no indication that the guideline is supported with tools for applications. Applicability The potential organisational barriers in applying the recommendations have been discussed. Strongly Agree 1 Strongly Disagree There is no indication that the potential organisational barriers in applying the recommendations have not been discussed. The potential cost implications of applying the recommendations have been considered. Strongly Agree 1 Strongly Disagree There is no indication that the potential cost implications of applying the recommendations have been discussed. The guideline presents key review criteria for monitoring and/or audit purposes. Strongly Agree 1 Strongly Disagree The guideline does not present key review criteria for monitoring and/or audit purposes. Editorial independence The guideline is editorially independent from the funding body. Strongly Agree 3 Strongly Disagree

88 80 The guideline was not financially supported by any commercial organisation. Conflicts of interest of guideline development members have been recorded. Strongly Agree 3 Strongly Disagree The guideline notes that some task force members may have received income related to treatments discussed in the guideline and that members are asked to disclose potential conflicts of interest. These conflicts of interest are not listed in the guideline.

89 81 Appendix C: Extraction of Recommendations NICE Guidelines The numbering system for the NICE recommendations is identical to that used in the original NICE guideline publication. 1.1 General principles for working with people with borderline personality disorder Access to services People with borderline personality disorder should not be excluded from any health or social care service because of their diagnosis or because they have selfharmed 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 CAMHS Ensure that people with borderline personality disorder from black and minority ethnic groups have equal access to culturally appropriate services based on clinical need When language is a barrier to accessing or engaging with services for people with borderline personality disorder, provide them with: Information in their preferred language and in an accessible format Psychological or other interventions in their preferred language Independent interpreters Borderline personality disorder and learning disabilities When a person with a mild learning disability presents with symptoms and behaviour that suggest borderline personality disorder, assessment and diagnosis should take place in consultation with a specialist in learning disabilities services 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. If they show behaviour and

90 82 symptoms that suggest borderline personality disorder, refer for assessment and treatment by a specialist in learning disabilities services Autonomy and choice Work in partnership with people with borderline 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 Developing an optimistic and trusting relationship 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 build a trusting relationship, work in an open, engaging and nonjudgemental manner, and be consistent and reliable 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 Involving families or carers 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 Principles for assessment When assessing a person with borderline personality disorder: explain clearly the process of assessment use non-technical language whenever possible

91 83 explain the diagnosis and the use and meaning of the term borderline personality disorder offer post-assessment support, particularly if sensitive issues, such as childhood trauma, have been discussed Managing endings and supporting transitions 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: time the transfer to suit the young person, even if it takes place after they have reached the age of 18 years 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 Managing self-harm and attempted suicide Follow the recommendations in Self-harm (NICE clinical guideline 16) to manage episodes of self-harm or attempted suicide Training, supervision and support 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 ) Mental health professionals working with people with borderline personality disorder should have routine access to supervision and staff support.

92 Recognition and management in primary care Recognition of borderline personality disorder 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 Crisis management in primary care 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 Referral to community mental health services 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 1.3 Assessment and management by community mental health services Assessment Community mental health services (community mental health teams, related community-based services, and tier 2/3 services in 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

93 85 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 Care planning 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 and management 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

94 86 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) Psychological treatment 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 For women with borderline personality disorder for whom reducing recurrent self-harm is a priority, consider a comprehensive dialectical behaviour therapy programme.

95 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 The role of drug treatment 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) 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. The duration of treatment should be agreed with them, but should be no longer than 1 week (see section 1.3.7) 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 The management of comorbidities 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

96 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 When treating a comorbid condition in people with borderline personality disorder, follow the NICE clinical guideline for the comorbid condition The management of crises The following principles and guidance on the management of crises apply to secondary care and specialist services for personality disorder. They may also be of use to GPs with a special interest in the management of borderline personality disorder within primary care. Principles and general management of crises When a person with borderline personality disorder presents during a crisis, consult the crisis plan and: maintain a calm and non-threatening attitude try to understand the crisis from the person s point of view explore the person s reasons for distress use empathic open questioning, including validating statements, to identify the onset and the course of the current problems seek to stimulate reflection about solutions avoid minimising the person s stated reasons for the crisis refrain from offering solutions before receiving full clarification of the problems explore other options before considering admission to a crisis unit or inpatient admission offer appropriate follow-up within a time frame agreed with the person Drug treatment during crises Short-term use of drug treatments may be helpful for people with borderline personality disorder during a crisis Before starting short-term drug treatments for people with borderline personality disorder during a crisis (see recommendation ):

97 89 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 short-term drug treatment for people with borderline personality disorder in a crisis: 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 with the person a plan for adherence discontinue a drug after a trial period if the target symptoms do not improve consider alternative treatments, including psychological treatments, if target symptoms do not improve or the level of risk does not diminish arrange an appointment to review the overall care plan, including pharmacological and other treatments, after the crisis has subsided Follow-up after a crisis After a crisis has resolved or subsided, ensure that crisis plans, and if necessary the overall care plan, are updated as soon as possible to reflect current concerns and identify which treatment strategies have proved helpful. This should be done in conjunction with the person with borderline personality disorder and their family or carers if possible, and should include: a review of the crisis and its antecedents, taking into account environmental, personal and relationship factors a review of drug treatment, including benefits, side effects, any safety concerns and role in the overall treatment strategy a plan to stop drug treatment begun during a crisis, usually within 1 week a review of psychological treatments, including their role in the overall treatment strategy and their possible role in precipitating the crisis If drug treatment started during a crisis cannot be stopped within 1 week, there should be a regular review of the drug to monitor effectiveness, side effects,

98 90 misuse and dependency. The frequency of the review should be agreed with the person and recorded in the overall care plan The management of insomnia 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 Guidance on the use of zaleplon, zolpidem and zopiclone for the short-term management of insomnia (NICE technology appraisal guidance 77). However, be aware of the potential for misuse of many of the drugs used for insomnia and consider other drugs such as sedative antihistamines Discharge to primary care 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 reengage with community mental health services if needed. Inform the GP. 1.4 Inpatient services Before considering admission to an acute psychiatric inpatient unit for a person with borderline personality disorder, first refer them to a crisis resolution and home treatment team or other locally available alternative to admission Only consider people with borderline personality disorder for admission to an acute psychiatric inpatient unit for: the management of crises involving significant risk to self or others that cannot be managed within other services, or detention under the Mental Health Act (for any reason) When considering inpatient care for a person with borderline personality disorder, actively involve them in the decision and: ensure the decision is based on an explicit, joint understanding of the potential benefits and likely harm that may result from admission agree the length and purpose of the admission in advance ensure that when, in extreme circumstances, compulsory treatment is used, management on a voluntary basis is resumed at the earliest opportunity Arrange a formal CPA review for people with borderline personality disorder who have been admitted twice or more in the previous 6 months.

99 NHS trusts providing CAMHS should ensure that young people with severe borderline personality disorder have access to tier 4 specialist services if required, which may include: inpatient treatment tailored to the needs of young people with borderline personality disorder specialist outpatient programmes home treatment teams 1.5 Organisation and planning of services The role of specialist personality disorder services within trusts 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 ) 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).

100 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.

101 93 APA Guidelines Recommendations in the APA guideline were not numbered in the original reports, so a numbering system has been applied post hoc. The initial assessment [Page 9, C.1, R1] The psychiatrist first performs an initial assessment of the patient to determine the treatment setting [I]. [Page 9, C.1, R2] Because suicidal ideation and suicide attempts are common, safety issues should be given priority, and a thorough safety evaluation should be done. This evaluation, as well as consideration of other clinical factors, will determine the necessary treatment setting (e.g., outpatient or inpatient). A more comprehensive evaluation of the patient should then be completed [I]. [Page 9, C.1, R3] It is important at the outset of treatment to establish a clear and explicit treatment framework [I], which includes establishing agreement with the patient about the treatment goals. Psychiatric management [Page 9, C.2, R1] Psychiatric management forms the foundation of treatment for all patients. The primary treatment for BPD is psychotherapy, complemented by symptom-targeted pharmacotherapy [I]. [Page 9, C.2, R2] In addition, psychiatric management consists of a broad array of ongoing activities and interventions that should be instituted by the psychiatrist for all patients with BPD [I]. [Page 9, C.2, R3] Regardless of the specific primary and adjunctive treatment modalities selected, it is important to continue providing psychiatric management throughout the course of treatment. The components of psychiatric management for patients with BPD include responding to crises and monitoring the patient's safety, establishing and maintaining a therapeutic framework and alliance, providing education about BPD and its treatment, coordination treatment provided by multiple clinicians, monitoring the patient's progress, and reassessing the effectiveness of the treatment plan. The psychiatrist must also be aware of and manage potential problems involving splitting and boundaries. Principles of treatment selection Type [Page 10, C.3a, R1] Certain types of psychotherapy (as well as other psychosocial modalities) and certain psychotropic medications are effective in the treatment of BPD [I]. [Page 10, C.3a, R2] Although it has not been empirically established that one approach is more effective than another, clinical experience suggests that most patients with BPD will need extended psychotherapy to attain and maintain lasting improvement in their personality, interpersonal problems, and overall functioning [II]. [Page 10, C.3a, R3] Pharmacotherapy often has an important adjunctive role, especially for diminution of symptoms such as affective instability, impulsivity, psychotic-like symptoms, and self-destructive behaviour [I]. [Page 10, C.3a, R4] No studies have compared a combination of psychotherapy and pharmacotherapy to either treatment alone, but clinical experience indicates that many patients will benefit most from a combination of these treatments [II]. Focus [Page 10, C.3b, R1] Treatment planning should address BPD as well as comorbid axis I and axis II disorders, with priority established according to risk or predominant symptoms [I].

102 94 Flexibility [Page 10, C.3c, R1] Because comorbid disorders are often present and each patient s history is unique, and because of the heterogeneous nature of BPD, the treatment plan needs to be flexible, adapted to the needs of the individual patient [I]. Flexibility is also needed to respond to the changing characteristics of patients over time. Role of patient preference [Page 10, C.3d, R1] Treatment should be a collaborative process between patient and clinician(s), and patient preference is an important factor to consider when developing an individual treatment plan [I]. Multiple- versus single-clinician treatment [Page 10, C.3e, R1] Treatment by a single clinician and treatment by more than one clinician are both viable approaches [II]. [Page 10, C.3e, R2] Treatment by multiple clinicians has potential advantages but may become fragmented; good collaboration among treatment team members and clarity of roles are essential [I]. Specific treatment strategies Psychotherapy [Page 10, C.4a, R1] Two psychotherapeutic approaches have been shown in randomized controlled trials to have efficacy: psychoanalytic/psychodynamic therapy and dialectical behaviour therapy [I]. The treatment provided in these trials has 3 key features: weekly meetings with an individual therapist, one or more weekly group sessions, and meetings of therapists for consultation/supervision. No results are available from direct comparisons of these two approaches to suggest which patients may respond better to which type of treatment. Although brief therapy for BPD has not been systematically examined, studies of more extended treatment suggest that substantial improvement may not occur until after approximately 1 year of psychotherapeutic intervention has been provided; many patients require even longer treatment. [Page 11, C.4a, R2] Clinical experience suggests that there are a number of common features that help guide the psychotherapist, regardless of the specific type of therapy used [I]. These features include building a strong therapeutic alliance and monitoring self-destructive and suicidal behaviours. Some therapists create a hierarchy of priorities to consider in the treatment (e.g., first focusing on suicidal behaviour). Other valuable interventions include validating the patient s suffering and experiences as well as helping the patient take responsibility for his or her actions. Because patients with BPD may exhibit a broad array of strengths and weaknesses, flexibility is a crucial aspect of effective therapy. Other components of effective therapy for patients with BPD include managing feelings (in both patient and therapist), promoting reflection rather than impulsive action, diminishing the patient s tendency to engage in splitting, and setting limits on any self-destructive behaviour. [Page 11, C.4a, R3] Individual psychodynamic psychotherapy without concomitant group therapy or other partial hospital modalities has some empirical support [II]. [Page 11, C.4a, R4] The literature on group therapy or group skills training for patients with BPD is limited but indicates that this treatment may be helpful [II]. Group approaches are usually used in combination with individual therapy and other types of treatment. [Page 11, C.4a, R5] The published literature on couples therapy is limited but suggests that it may be a useful and, at times, essential adjunctive treatment modality. However, it is not recommended as the only

103 95 form of treatment for patients with borderline personality disorder [II]. [Page 11, C.4a, R6] While data on family therapy are also limited, they suggest that a psycho-educational approach may be beneficial [II]. [Page 11, C.4a, R7] Published clinical reports differ in their recommendations about the appropriateness of family therapy and family involvement in the treatment; family therapy is not recommended as the only form of treatment for patients with BPD [II]. Pharmacotherapy and other somatic treatments (i) Treatment of affective dysregulation symptoms [Page 11, C.4b, R1] Patients with BPD displaying this dimension (affective dysregulation) exhibit mood lability, rejection sensitivity, inappropriate intense anger, depressive mood crashes, or outbursts of temper. These symptoms should be treated initially with a selective serotonin reuptake inhibitor (SSRI) or related antidepressant such as venlafaxine [I]. [Page 11, C.4b, R2] Studies of tricyclic antidepressants have produced inconsistent results. When affective dysregulation appears as anxiety, treatment with an SSRI may be insufficient, and addition of a benzodiazepine should be considered, although research on these medications in patients with BPD is limited, and their use carries some potential risk [III]. [Page 11, C.4b, R3] When affective dysregulation appears as disinhibited anger that coexists with other affective symptoms, SSRIs are also the treatment of choice [II]. [Page 11, C.4b, R4] Clinical experience suggests that for patients with severe behavioural dyscontrol, low-dose neuroleptics can be added to the regimen for rapid response and improvement of affective symptoms [II]. [Page 11, C.4b, R5] Although the efficacy of monoamine oxidase inhibitors (MAOIs) for affective dysregulation in patients with BPD has strong empirical support, MAOIs are not a first-line treatment because of the risk of serious side effects and the difficulties with adherence to required dietary restrictions [I]. [Page 11, C.4b, R6] Mood stabilizers (lithium, valproate, carbamazepine) are another second-line (or adjunctive) treatment for affective dysregulation, although studies of these approaches are limited [II]. [Page 11, C.4b, R7] There is a paucity of data on the efficacy of electroconvulsive therapy (ECT) for treatment of affective dysregulation symptoms in patients with border line personality disorder. Clinical experience suggests that while ECT may sometimes be indicated for patients with comorbid severe axis I depression that is resistant to pharmacotherapy; affective features of BPD are unlikely to respond to ECT [II]. (ii) Treatment of impulsive-behavioural dyscontrol symptoms [Page 12, C.4b, R8] Patients with BPD displaying this dimension exhibit impulsive aggression, self-mutilation, or self-damaging behaviour (e.g., promiscuous sex, substance abuse, reckless spending). SSRIs are the initial treatment of choice [I]. [Page 12, C.4b, R9] When behavioural dyscontrol poses a serious threat to the patient s safety, it may be necessary to add a low-dose neuroleptic to the SSRI [II]. [Page 12, C.4b, R10] Clinical experience suggests that partial efficacy of an SSRI may be enhanced by adding lithium [II]. [Page 12, C.4b, R11] If an SSRI is ineffective, switching to an MAOI may be considered [II]. [Page 12, C.4b, R12] Use of valproate or carbamazepine may also be considered for impulse control, although there are few studies of these treatments for impulsive aggression in patients with BPD [II]. [Page 12, C.4b, R13] Preliminary evidence suggests that atypical neuroleptics may have some efficacy for impulsivity in patients with BPD [II]. (iii) Treatment of cognitive-perceptual symptoms [Page 12, C.4b, R14] Patients with BPD displaying this dimension exhibit suspiciousness, referential thinking, paranoid ideation, illusions, derealization, depersonalization, or hallucination-like symptoms. Low-dose neuroleptics are the treatment of choice for these

104 96 symptoms [I]. [Page 12, C.4b, R15] These medications (neuroleptics) may improve not only psychotic-like symptoms but also depressed mood, impulsivity, and anger/hostility. If response is suboptimal, the dose should be increased to a range suitable for treating axis I disorders [II]. Special features influencing treatment [Page 12, C.5, R1] Treatment planning and implementation should reflect consideration of the following characteristics: comorbidity with axis I and other axis II disorders, problematic substance use, violent behaviour and antisocial traits, chronic self-destructive behaviour, trauma and post-traumatic stress disorder (PTSD), dissociative features, psychosocial stressors, gender, age, and cultural factors [I]. Risk management issues [Page 12, C.6, R1] Attention to risk management issues is important [I]. Risk management considerations include the need for collaboration and communication with any other treating clinicians as well as the need for careful and adequate documentation. Any problems with transference and counter-transference should be attended to, and consultation with a colleague should be considered for unusually high-risk patients. Standard guidelines for terminating treatment should be followed in all cases. Psycho-education about the disorder is often appropriate and helpful. Other clinical features requiring particular consideration of risk management issues are the risk of suicide, the potential for boundary violations, and the potential for angry, impulsive, or violent behaviour.

105 97 WFSBP Guidelines Recommendations in the WFSBP guideline were not numbered in the original reports, so a numbering system has been applied post hoc. [Page 214, C1, L1] In BPD, there are a limited number of randomized controlled trials (RCTs) of only moderate quality, with small sample sizes and short-term observation periods. No class of pharmacological agents appears to improve BPD psychopathology in general although the majority of studies have incorporated measurements of global functioning in addition to targeting special aspects of psychopathology. Medication suggestions will rather be given considering the dominating symptomatology of the individual patient. [Page 214, C1, L11] There is moderate evidence for the efficacy of atypical neuroleptics and second-generation antipsychotics on cognitive-perceptual symptoms and impulsive behavioural dyscontrol, including anger in personality disorders. These medications appear to work at lower doses than in schizophrenia. [Page 214, C1, L16] Selective serotonin reuptake inhibitors (SSRIs) are best shown to influence emotional dysregulation such as depressive mood, anxiety and mood swings and these effects appear to extend the improvement of comorbid conditions of mood and anxiety disorders. However, there is no evidence that SSRIs are effective for common symptoms such as emotional experiences of emptiness, loneliness, boredom or chronic dysphoria. In addition, there is no conclusive evidence that antidepressants reduce impulsive, aggressive or self-harming behaviours in BPD. [Page 214, C1, L27] SSRIs have shown a benefit for impulsive aggression in BPD patients with a comorbid condition of intermittent explosive disorder revised (IED); however, data from BPD samples without IED present inconsistent results. Although one study showed a superior effect of olanzapine monotherapy compared to fluoxetine alone on impulsive aggression, further studies are needed to test whether in the case of dominance of impulsivity and (auto) aggression, atypical neuroleptics may be recommended as first line treatment. [Page 214, C1, L38] If not sufficiently helpful (neuroleptics), mood stabilizers may be indicated such as divalproex sodium, topiramate, or lamotrigine, which have been shown to be effective for impulsive, aggressive behaviour in some controlled trials. However, sample sizes of studies on mood stabilizers are small in general and there is no data at all that indicates their efficacy in the long term. [Page 214, C2, L1] Because adherence to medication is not high in BPD, patients may be particularly vulnerable to even mild adverse effects. Correspondingly, classical neuroleptics are not indicated, all the more so as there is little evidence that classical neuroleptics reduce anxiety, depression, anger or improve global functioning in BPD.

106 98 [Page 214, C2, L7] Finally, BPD individuals need safe drugs that have few risks in the case of overdose and parasuicidal gestures, meaning that irreversible MAOIs and lithium, despite some evidence of efficacy, are not likely to find broad application in BPD. [Page 214, C2, L12] No reliable comment can be provided on the length of pharmacological treatment, which may also vary as a function of the targeted domain of psychopathology. However, it may be recommended that a drug should be tried for at least 3 months with a sufficient baseline assessment of psychopathology, clearly defined targets of therapy and cessation of the drug if there is no benefit. [Page 214, C2, L20] To conclude, no medication has been registered for personality disorders, and there is no evidence for a benefit of polypharmacy in these patients. Although there is some evidence for differential effects on psychopathology, classes of psychotropic agents act on a rather broad spectrum of symptoms and there is no database to suggest the combination of several drugs with respect to different targets. [Page 214, C2, L28] Patients with BPD should be informed that there is no strong evidence base for the prescription of any drug. However, the off-label use of psychotropic agents may help individuals with BPD to improve affective symptoms and impulsivity. [Page 214, C2, L32] A pharmacological treatment might also be indicated in severe conditions to support psychosocial interventions or even to make them possible although there is not much of an evidence-base on when/how to combine pharmacotherapy/psychotherapy. [Page 214, C2, L37] Since pharmacotherapy will be part of a multimodal treatment programme including individual and/or group psychotherapy, psychotherapeutic specialists on these disorders should usually be involved rather early on.