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Download 4a NICE Guidelines – BPD
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NICE Guidelines – BPD 2009 Dr David Whitty Poole CMHT December 2016 NICE - BPD The Disorder – Diagnosis, Epidemiology, Mx Pychological Rx Pharmacological Rx * Crisis Mx Organization of Services Young people with BPD Diagnosis Persistant 1. pervasive pattern of:- Unstable Mood 2.Unstable Relationships 3.Unstable sense of Self 4.Impulsivity Diagnosis Personality Commonly used term, hard to define. Those aspects of a person’s behaviour, thinking and emotional reactions which are enduring and predictable through a wide range of circumstances. No generally accepted model as all have pros/cons (trait, categorical and structural models) Personality development is influenced by genetic and environmental factors. Important bearing on response to physical illness and vulnerability to psychiatric disorder. Assessment Hard to make an objective assessment on the basis of one interview (e.g. aggressive with peers, subdued with authority figures). Behaviour may reflect illness, not personality, or admixture of both. Instruments include Millon Clinical Multiaxial Inventory III (MCMI-III) and Structured Clinical Interview for DSMIV (SCID-II) ICD-10 Diagnostic Criteria 6 general criteria, and specific criteria for 8 PDs i)Enduring pattern of inner experience and behaviour, which deviates markedly from the expectations of individual’s culture, manifested in two or more areas: cognition, affectivity, interpersonal functioning, impulse control ii)Enduring pattern is inflexible and pervasive across a broad range of personal and social settings iii)Behaviour causes personal distress or adverse impact on social environment iv)Deviation is stable and long-standing, since adolescence v)Cannot be explained by another mental disorder vi)Not due to organic disease or drugs Diagnosis Borderline Personality Disorder Diagnostic Criteria (5/9) 1)Frantic efforts to avoid real or imagined abandonment. 2)Pattern of unstable and intense interpersonal relationships, characterized by alternating between extremes of idealization and devaluation. 3)Identity disturbance: markedly and persistently unstable self-image or sense of self. 4)Impulsivity, in at least two areas that are potentially self-damaging (spending, sex, drugs,reckless driving, binge eating). 5)Recurrent suicidal behaviour, gestures, or threats, or self-mutilating behaviour. 6)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) 7)Chronic feelings of empiness. 8)Inappropriate, intense anger or difficulty controlling anger (eg frequent displays of temper, constant anger, recurrent physical fights) 9)Transient, stress-related paranoid ideation or severe dissociative symptoms. Diagnosis SCID-II – Structured Clinical Interview for DSMIV Axis II Personality Disorders Epidemiology Although borderline personality disorder is a condition that is thought to occur globally (Pinto et al., 2000), there has been little epidemiological research into the disorder outside the Western world. Only three methodologically rigorous surveys have examined the community prevalence of borderline personality disorder. the median prevalence of borderline personality disorder across the three studies being 0.7%. Epidemiology In primary care, the prevalence of borderline personality disorder ranges from 4 to 6% of primary attenders. Compared with those without personality disorder, people with borderline personality disorder are more likely to visit their GP frequently and to report psychosocial impairment. In spite of this, borderline personality disorder appears to be under-recognised by GPs. Epidemiology In mental healthcare settings, the prevalence of all personality disorder subtypes is high, with many studies reporting a figure in excess of 50% of the sampled population. Borderline personality disorder is generally the most prevalent category of personality disorder in non-forensic mental healthcare settings. In community samples the prevalence of the disorder is roughly equal male to female, whereas in services there is a clear preponderance of women, who are more likely to seek treatment. It follows that the majority of people diagnosed with personality disorder, most of whom will have borderline personality disorder, will be women. Assessment When assessing a person with possible borderline personality disorder in community mental health services, fully assess: psychosocial and occupational functioning, coping strategies, strengths and vulnerabilities comorbid mental disorders and social problems the need for psychological treatment, social care and support, and occupational rehabilitation or development the needs of any dependent children Psychology 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 above characteristics Psychology For women with borderline personality disorder for whom reducing recurrent selfharm is a priority, consider a comprehensive dialectical behaviour therapy programme. DBT Dialectical behavioral therapy (DBT) is a psychological method developed by Marsha Linehan to treat persons with BPD. There are two essential parts of the treatment, and without either of these parts the therapy is not considered "DBT adherent." 1.An individual component in which the therapist and client discuss issues that come up during the week, recorded on diary cards and follow a treatment target hierarchy. During the individual therapy, the therapist and client work towards improving skill use. Often, skills group is discussed and obstacles to acting skillfully are addressed. 2.The group, which ordinarily meets once weekly for two to two-and-a-half hours, learns to use specific skills that are broken down into four modules: core mindfulness skills, emotion regulation skills, interpersonal effectiveness skills, and distress tolerance skills The DBT hierarchy 1. Decreasing suicidal and self-harm behaviour 2. Decreasing behaviours that undermine or interfere with therapy 3. Decreasing behaviours which interfere with your quality-of-life; often behaviour which lead to crisis 4. Increasing other required skills 5. Decreasing post-traumatic stress 6. Increasing respect for self 7. Achieving other individual goals Pharmacology 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). Pharmacology 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. 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 Pharmacology RESEARCH RECOMMENDATION Mood stabilisers for people with borderline personality disorder What is the effectiveness and cost effectiveness of mood stabilisers on the symptoms of borderline personality disorder? This should be answered by a randomised placebo-controlled trial, which should include the medium to long-term impact of such treatment. The study should be sufficiently powered to investigate both the effects and side effects of this treatment. Why this is important There is little evidence of the effectiveness of pharmacological treatments for people with personality disorder. However, there have been encouraging findings from smallscale studies of mood stabilisers such as topiramate and lamotrigine, which indicates the need for further research. Emotional instability is a key feature of borderline personality disorder and the effect of these treatments on mood and other key features of this disorder should be studied. The findings of such a study would support the development of future recommendations on the role of pharmacological interventions in the treatment of borderline personality disorder. Pharmacology LABILE Study Lamotrigine versus inert placebo in the treatment of borderline personality disorder: a randomized controlled trial and economic evaluation 252 pts, 12 months, publication due March 2017 Cochrane Review 2010 Pharmacological interventions for borderline personality disorder The available evidence indicates some beneficial effects with secondgeneration antipsychotics, mood stabilisers, and dietary supplementation by omega-3 fatty acids. However, these are mostly based on single study effect estimates. Antidepressants are not widely supported for BPD treatment, but may be helpful in the presence of comorbid conditions. Total BPD severity was not significantly influenced by any drug. No promising results are available for the core BPD symptoms of chronic feelings of emptiness, identity disturbance and abandonment. Conclusions have to be drawn carefully in the light of several limitations of the RCT evidence that constrain applicability to everyday clinical settings (among others, patients’ characteristics and duration of interventions and observation periods). Crisis Management 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. Thanks for listening
