1. Borderline Personality Disorder 9 June 2016

2. Diagnostic Criteria for Personality Disorder. Markedly disharmonious attitudes and behavior, generally involving several areas of functioning; e.g. affectivity, arousal, impulse control, ways of perceiving and thinking, and style of relating to others; The abnormal behavior pattern is enduring, of long standing, and not limited to episodes of mental illness; The abnormal behavior pattern is pervasive and clearly maladaptive to a broad range of personal and social situations; The above manifestations always appear during childhood or adolescence and continue into adulthood; The disorder leads to considerable personal distress but this may only become apparent late in its course; The disorder is usually, but not invariably, associated with significant problems in occupational and social performance.

3. Epidemiology 5-10% of the adult population in the community suffer from a personality disorder. More common in younger age groups Equal sex distribution (unequal for some subtypes e.g. dissocial more common in males)

4. Specific Personality Disorders (F60.0) Paranoid personality disorder (F60.1) Schizoid personality disorder (F60.2) Dissocial personality disorder (F60.3) Emotionally unstable personality disorder Impulsive/Borderline personality disorder (F60.4) Histrionic personality disorder (F60.5) Anankastic personality disorder (F60.6) Anxious (avoidant) personality disorder (F60.7) Dependent personality disorder (F60.8) Other specific personality disorders (F60.9) Personality disorder not otherwise specified

5. Emotionally unstable personality disorder Personality disorder in which there is a marked tendency to act impulsively without consideration of the consequences, together with affective instability. Two subtypes: Impulsive type: predominant characteristics are emotional instability and lack of impulse control. Outbursts of violence or threatening behaviour are common, particularly in response to criticism by others. Borderline type: characterized in addition by disturbances in self-image, aims, and internal preferences, by chronic feelings of emptiness, by intense and unstable interpersonal relationships, and by a tendency to self- destructive behaviour, including suicide gestures and attempts.

6. Prevalence of Borderline PD 0.5 -0.7% of subjects in household surveys In mental healthcare settings borderline personality disorder is the most common type of personality disorder. Although the sex distribution is equal, women are more likely to present for treatment. 10% of psychiatric out-patients 20% of psychiatric inpatients

7. Impact Studies of clinical populations have shown that people with borderline personality disorder experience significantly greater impairment in their work, social relationships and leisure compared with those with depression People with borderline personality disorder may engage in a variety of destructive and impulsive behaviours including self-harm, eating problems and excessive use of alcohol and illicit substances. 65-80% engage in non-suicidal self-injury 60-70% attempting suicide at some point in their life

8. Aetiology Genetics: twin studies suggest that the heritability factor for borderline personality disorder is 0.69 Psychosocial factors: neglect and emotional under- involvement and/or abuse by caregivers; mother perceived as distant or overprotective, and their relationship with her as conflictual, while the father is perceived as less involved and more distant; insecure attachments to care-givers; physical and sexual abuse occurring in the context of an unstable, non-nurturing family environment

9. Mechanism Neurotransmitters with serotonin mainly implicated in the regulation of impulses, aggression and affect Neurobiology: evidence of structural and functional deficit in brain areas central to affect regulation, attention and self-control, and executive function have been described in borderline personality disorder including the amygdala, hippocampus and orbitofrontal regions

10. Diagnosis Most frequently made following an unstructured clinical assessment (often without obtaining a collateral history from an informant). However agreement among clinicians’ diagnoses of personality disorder has been shown to be poor. Reliability of diagnosis improved by use of standardised interview schedules. No single schedule identified as the gold standard, only moderate correlation between different schedules, few clinicians are trained in the use of such instruments; time consuming.

11. Course Symptoms develop in adolescence and persist into adulthood Between 50-80% of patients will improve sufficiently to no longer meet the criteria for borderline personality disorder 10 years after first diagnosis (evidence suggests that a significant proportion of improvement is spontaneous and accompanied by greater maturity and self- reflection rather than secondary to treatment). 10% commit suicide

12. Co-morbidity Considerable overlap with other personality disorders (particularly Cluster B: histrionic, narcissistic and antisocial) Lifetime prevalence of at least one comorbid mental illness approaches 100% for this group (particularly depression, anxiety (PTSD) and substance misuse)

13. Pharmacological treatment Many of the symptoms of borderline personality disorder (including affective instability, transient stress-related psychotic symptoms, suicidal and self-harming behaviours, and impulsivity) are similar in quality to those of many types of mental illness and could intuitively be expected to respond to drug treatment No psychotropic drug is specifically licensed for the management of borderline personality disorder. Psychiatric medications commonly prescribed and often in combination (75% of patients with borderline personality disorder are prescribed combinations of drugs at some point) Such treatment is often initiated during periods of crisis and the placebo response rate in this context is high (50%); the crisis is usually time limited and can be expected to resolve itself irrespective of drug treatment.

14. Evidence base for pharmacological treatment ……….is weak Few studies. Wide variations in populations studied Large number of outcomes reported by each individual study Lack of standard outcome rating scales within the research field

15. Summary of evidence for pharmacological treatments Some evidence (largely based on single studies) that pharmacological treatments can help to reduce specific symptoms including anger, anxiety, depression symptoms, hostility and impulsivity. It is far from clear if the above effects are the consequence of treating comorbid disorders. There is no evidence that pharmacological treatments alter the fundamental nature of the disorder in either the short or longer term.

16. NICE guidance 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 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.

17. NICE (pharmacological management of crises) 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 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. 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.

18. Psychological treatment Specific therapies for borderline personality disorder developed through modification of existing techniques (CBT, CAT, IPT). Dialectical Behaviour Therapy (DBT) a specific intervention for borderline personality disorder per se. Most psychological therapy offered to people with borderline personality disorder in the NHS are generic or eclectic and do not use a specific method.

19. Evidence base for psychological therapies …………..is relatively poor few studies low numbers of patients and therefore low power multiple outcomes with few in common between studies and a heterogeneous diagnostic system that makes it hard to target a specific treatment on patients with specific sets of symptoms because the trials may be too ‘all inclusive’.

20. Summary of evidence for psychological treatments The state of knowledge about the current psychological treatments available is in a development phase rather than one of consolidation. Conclusions are, therefore, provisional and more and better-designed studies need to be undertaken before stronger recommendations can be made. Some evidence that psychological therapy programs, specifically DBT and MBT, are effective in reducing suicide attempts and self-harm, anger, aggression and depression.

21. NICE guidance When providing psychological treatment for people with borderline personality disorder 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. 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 above. Although the frequency of psychotherapy sessions should be adapted to the person’s needs and context of living, twice-weekly sessions may be considered. For women with borderline personality disorder for whom reducing recurrent self-harm is a priority, consider a comprehensive dialectical behaviour therapy program.

22. Recommendations Recognise transference/countertransference. (Avoid playing the role unconsciously given to us by the patient ) Empathise (try to understand the crisis from the person’s point of view; avoid minimising the person’s stated reasons for the crisis; refrain from offering solutions before receiving full clarification of the problems) Avoid focusing on symptom management and instead explore the reasons for the person’s distress and help them reflect on possible solutions. Avoid making the situation worse! Provide practical help/sign-posting Actively treat co-morbidities Educate the patient about mood instability Inform the patient about good long-term prognosis

23. Recommendations