* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download Guidelines for the Pharmacological Treatment of Antisocial and
Bipolar II disorder wikipedia , lookup
Excoriation disorder wikipedia , lookup
Separation anxiety disorder wikipedia , lookup
Antipsychotic wikipedia , lookup
Depersonalization disorder wikipedia , lookup
Panic disorder wikipedia , lookup
Borderline personality disorder wikipedia , lookup
Schizoid personality disorder wikipedia , lookup
Asperger syndrome wikipedia , lookup
Mental disorder wikipedia , lookup
Classification of mental disorders wikipedia , lookup
Schizoaffective disorder wikipedia , lookup
Spectrum disorder wikipedia , lookup
Child psychopathology wikipedia , lookup
Moral treatment wikipedia , lookup
Personality disorder wikipedia , lookup
History of psychiatric institutions wikipedia , lookup
History of mental disorders wikipedia , lookup
Conversion disorder wikipedia , lookup
Diagnostic and Statistical Manual of Mental Disorders wikipedia , lookup
Conduct disorder wikipedia , lookup
Generalized anxiety disorder wikipedia , lookup
Emergency psychiatry wikipedia , lookup
Abnormal psychology wikipedia , lookup
Pyotr Gannushkin wikipedia , lookup
History of psychiatry wikipedia , lookup
Dissociative identity disorder wikipedia , lookup
Controversy surrounding psychiatry wikipedia , lookup
SH CP 189 Guidelines for the Pharmacological Treatment of Antisocial and Borderline Personality Disorder Version 2 Summary: Advice and guidelines on the use of medication in the treatment of personality disorders Keywords (minimum of 5): (To assist policy search engine) Antisocial, borderline, personality disorder, pharmacological treatment, BPD, ASPD Target Audience: Mental health staff working with patients with a personality disorder Next Review Date: March 2020 Approved & Ratified by: Medicines Management Committee Date issued: March 2017 Author: Dr Gwen Adshead, Consultant Forensic Psychiatrist, Rebecca Henry, Principal Pharmacist Specialised Services Sponsor: Dr Lesley Stevens – Medical Director Date of meeting: 15 March 2017 1 Guidelines for the pharmacological treatment of antisocial and borderline personality disorder Version: 2 March 2017 Version Control Change Record Date Author Version Page Reason for Change Dec 2016 Dr Gwen Adshead and Rebecca Henry 2 4-6 Dec 2016 Dr Gwen Adshead and Rebecca Henry Dr Gwen Adshead and Rebecca Henry 2 7 Text changed to flow charts to improve clarity. Suggested treatment table added to improve clarity. “Additional points” section expands on flow charts and incorporates text from previous version, to improve clarity. New references 5-10 included from updated literature search 2 1 Co-badged with Solent NHS Trust to work collaboratively. Dec 2016 Reviewers/contributors Name Dr Amanda Taylor Dr Catherine Sherwin Stephen Bleakley Mental Health Drugs and Therapeutics Forum Medicines Management Committee Dr Gwen Adshead Rebecca Henry Position Version Reviewed & Date Clinical Director Specialised Mental Health Services Specialist Registrar forensic Psychiatry Deputy Chief Pharmacist Trust wide representation V1, Dec 2015 Trust wide representation Consultant forensic psychiatrist Principal pharmacist specialised services V1 Jan 2016 V2 Dec 2016 V2 Dec 2016 V1, Dec 2015 V1, Dec 2015 V1 Dec 2015 2 Guidelines for the pharmacological treatment of antisocial and borderline personality disorder Version: 2 March 2017 CONTENTS Page 1. Guidelines for Antisocial Personality Disorder, ASPD 4 2. Guidelines for Borderline Personality Disorder, BPD 5 3. Suggested Treatments based on symptoms 6 4. References 7 3 Guidelines for the pharmacological treatment of antisocial and borderline personality disorder Version: 2 March 2017 GUIDELINES FOR THE PHARMACOLOGICAL TREATMENT OF ANTISOCIAL PERSONALITY DISORDER (ASPD) Pharmacological interventions should not be routinely used for the treatment of antisocial personality disorder or associated behaviours of aggression, anger and impulsivity. If the MDT is of the opinion that a pharmacological intervention is necessary, the following protocol should be followed: Accurate Diagnosis Treat co-morbid conditions eg: depression, anxiety, PTSD, psychosis, insomnia, mood disorders, drug/alcohol addictions. See relevant Trust Guidelines Behavioural interventions, cognitive behavioural therapy Adjunctive medications; Discuss in MDT; need clear and collaborative goals to manage specific symptoms. Inform the patient that the medication(s) is/are being prescribed off license. Consider risks vs benefits, including misuse, toxicity and overdose risks. Document rationale and care plan. Doses should remain within BNF limits Consider prescribing a second generation antipsychotic or benzodiazepine, in the short term, to control arousal levels to enable the patient to engage with the treating team Regular review, at least every 3 months, including physical health and compliance, poor compliance is common. Stop ineffective medications 4 Guidelines for the pharmacological treatment of antisocial and borderline personality disorder Version: 2 March 2017 GUIDELINES FOR PHARMACOLOGICAL TREATMENT OF BORDERLINE PERSONALITY DISORDER (BPD) Current NICE guidelines CG78 recommend that drug treatment should not be used specifically for borderline personality disorder or for the individual symptoms or behaviour associated with the disorder 1. However, there are situations where clinicians may need to use pharmacological interventions with BPD patients. This may be in outpatient settings including crisis teams or in inpatient (including forensic) settings. There is little evidence available for the psychopharmacological treatment of these patients as there are few RCTs so the following protocol is based on the limited evidence available2. Pharmacological treatments should not be a substitute for psychological interventions. The reason for the use of pharmacological intervention must be properly recorded and reviewed at regular intervals. Accurate Diagnosis Treat co-morbid conditions eg: depression, anxiety, PTSD, psychosis, insomnia, mood disorders, drug/alcohol addictions. Patients may be more resistant to treatment. See relevant Trust Guidelines Psychosocial treatments; Cognitive Behavioural Therapy, Dialectical Behavioural Therapy, Mentalisation Based Therapy, Schema Focused Therapy Adjunctive medications; Discuss in MDT; need clear and collaborative goals to manage specific symptoms. Time limited, crisis management should be for one week only. Inform the patient that the medication(s) is/are being prescribed off license. Consider risks vs benefits, including toxicity and overdose risks. Document rationale and care plan. Regular review, at least every 3 months, including physical health and compliance, poor compliance is common. Stop ineffective medications 5 Guidelines for the pharmacological treatment of antisocial and borderline personality disorder Version: 2 March 2017 Suggested treatment based on symptoms experienced in both ASPD and BPD Anger Suicidal behaviour Anxiety Topiramate Affective dysregulation Lamotrigine Valproate Haloperidol Cognitive perceptual disturbances Flupentixol Olanzapine Quetiapine Aripiprazole Low Dose Clozapine Impulse control Aggression Self-directed aggression Social professional relationships Additional points Clinicians may find it helpful to remember that people can have more than one personality disorder i.e. a patient may have elements of BPD and ASPD. Consider overdose risk, side effects including sedation and weight gain, compliance. Insomnia, consider sleep hygiene, hypnotic or antihistamine for 1 week. Clozapine greatest improvement first 6 months, mean dose <300mg/day, weight gain same as schizophrenia but glucose intolerance is less common. All treatments should be prescribed within BNF limits. Avoid prescribing more than one medication at a time, where possible. Caution with prescribing mood stabilisers (such as sodium valproate or lamotrigine) in women of childbearing age (See SPC). In crisis situations consider the cautious use of sedative medication, as part of an overall treatment plan but this should be reviewed after one week. Short term prescribing in crises should attempt to use drugs with low side effect profile, minimal potential for misuse and relatively safe in overdose. The Maudsley prescribing guidelines recommend promethazine for BPD3 but in practice benzodiazepines (lorazepam or diazepam) are often used although prescribers should be aware of the risks of disinhibition, excessive sedation, tolerance and addiction. There is limited evidence for the use of Carbamazepine, but it can be considered in patients who have been non responsive to other medications. SSRIs are not recommended, if there is no evidence of depression. There is little evidence available for the psychopharmacological treatment of these patients as there are few RCTs so the protocol is based on the limited evidence available. Ensure that all patients are referred for psychological treatments. 6 Guidelines for the pharmacological treatment of antisocial and borderline personality disorder Version: 2 March 2017 Note: These guidelines reflect the latest evidence and have been developed by specialists from both primary and secondary care. Clinicians are expected to consider the recommendations made in these guidelines but they do not override individual clinical judgements in consultation with the patient, carer or guardian. References: 1. National Institute for Health and Care Excellence (NICE) Borderline personality disorder: recognition and management. Nice guideline CG78, January 2009. Available at: www.nice.org.uk 2. Leib K et al. Pharmacotherapy for Borderline Personality Disorder: Cochrane systemic review of randomised trials. The British Journal of Psychiatry 2009 ;196: 4-12 3. Taylor D et al . The Maudsley Guidelines 12th edition. John Wiley Ltd, Chichester: 2015 4. Frogley C et al. A Case Series of Clozapine for Borderline Personality Disorder. Annals of Clinical Psychiatry 2013; 25: 125-134 5. Treatment of personality disorder, Anthony Bateman et al, Lancet, vol 385, Feb 21, 2015 6. World Federation of societies of biological psychiatry (WFSBP) guidelines for the biological treatment of personality disorders, Herpertz et al, The World Journal of Biological Psychiatry, 2007; 8(4): 212-244. 7. Treatment of personality disorder, Anthony W Bateman, John Gunderson, Roger Mulder, The Lancet,Vol 385 February 21, 2015 8. Challenging behaviour and learning disabilities: prevention and interventions for people with learning disabilities whose behaviour challenges. National Institute of Health and Care Excellence. Accessed via www.nice.org.uk (12/1/17) 9. SHFT Guidelines for Insomnia, Depression, Psychosis, BPAD, Lithium, Physical health monitoring, Anxiety, Rapid Tranquilisation. 10. Argent SE, Hill SA. The novel use of clozapine in an adolescent with borderline personality disorder. Therapeutic Advances in Psychopharmacology 2014; vol 4, is 4: 1-7 7 Guidelines for the pharmacological treatment of antisocial and borderline personality disorder Version: 2 March 2017