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CONSULTATION DRAFT August 2010

Borderline Personality Disorder /Complex Trauma


Integrated Care Pathway

For use by all professionals working in Mental Health Services and Partner Agencies, for all people with a diagnosis of Borderline Personality Disorder/Complex Trauma in Lanarkshire

Prepared by: Reviewed by: Endorsed by: Responsible Person: Previous Version/Date: Version Number/Date: Review Date:

Borderline Personality Disorder ICP Development Group Mental Health ICP Steering Group Mental Health Service Improvement Board Karen Robertson, Associate Director of Nursing, Mental Health and Learning Disabilities N/A Consultation Draft August 2010 N/A

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Contents
Page
1. Introduction .......................................................................................... 4 1.1 Rationale for Developing the ICP.......................................................5 1.2 How to use the Complex Trauma/Borderline Personality Disorder ICP........................................................................5 1.3 Patient Journey .....................................................................................6 2. Management in Primary Care............................................................ 7 2.1 Recognition and Management in Primary Care .............................7 2.2 Crisis Management in Primary Care...................................................7 2.3 Referral to Community Mental Health Services ...............................8 3. Management in Secondary Care...................................................... 9 3.1 Assessment, Diagnosis and Care Planning .......................................9 3.2 Risk Assessment and Management ...................................................9 3.3 Psychological Treatment .....................................................................10 3.4 Management of Crises.........................................................................11 3.5 Discharge to Primary Care ..................................................................11 4. Medication ........................................................................................... 12 4.1 Notes on the Prescribing of Psychotropic Medicine in BPD ...........12 4.2 Algorithm for Prescribing of Psychotropic Medication in BPD .......14 5. Training and Support ........................................................................... 15 5.1 General Training Requirements ..........................................................15 5.2 Specialist Training Initiatives.................................................................16 6. Service Development.......................................................................... 17 6.1 Potential Service Models......................................................................17 7. ICP Monitoring...................................................................................... 18 Appendices.............................................................................................. 19 References................................................................................................ 32 Glossary/Abbreviations .......................................................................... 33

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1. Introduction
The group developing this Borderline Personality Disorder/Complex Trauma (BPD/CT) ICP recognised that this patient group represents a particular challenge, differing significantly in many ways from that posed by the other groups being addressed by the ICP initiative. This is due to various factors, including:

the relatively recent recognition and acceptance of this diagnosis, around which there still exists some ambivalence and at times resistance, the fact that effective treatments (essentially psychosocial) for this group have only in recent years begun to emerge and are still at an early stage in terms of an evidence base, finally and, perhaps above all, the fact that the diagnosis represents in many ways an indication of clinical severity and complexity with considerable so-called comorbidity the rule rather than the exception. (It has been calculated that there are 128 different ways in which a patients symptoms may meet formal criteria for this disorder - without even considering levels of severity which are recognised to vary considerably.) This is manifest in the many different ways in which this group may present to many different services. Such patients may present for example, to Community Mental Health Teams (CMHTs), Accident and Emergency, services such as psychology or psychotherapy, substance misuse, eating disorders or for survivors of abuse. This inevitably makes care planning and delivery problematic. An additional challenge in offering appropriate care and treatment to such patients is that a key aspect of their difficulties lies in the relational and interpersonal domain. These may not only make the personal lives of patients difficult but can often, as is well recognised, complicate and undermine attempts to deliver care and also constitute a source of stress for professionals, especially if attempting to work alone over long periods of time with such patients. An additional complication in formulating appropriate care pathways for patients with this diagnosis lies in the changing ways on which it is conceptualised with increasing recognition (see NICE 2009) that these disorders do not simply constitute fixed personality traits which cannot be altered, but rather represent, broadly speaking, a group of disorders with common roots in complex developmental trauma and/or deprivation, in the possible context of some neurobiological vulnerability (for example around impaired impulse control). One consequence of this is that it is virtually certain that in forthcoming American and WHO classifications this diagnosis will no longer exist in its present form which will further complicate attempts to construct a care pathway around a clear diagnostic category. A further consequence of this complex and evolving situation (which was confirmed by feedback from a local survey), is that very few staff, whether generic or specialist will have received any formal training in the recognition or treatment and management of such disorders. This further contributes to the stress staff experience in attempting at present to do so. It is also recognised that unlike other major diagnostic categories (e.g. depression, psychosis and dementia) very few services either locally or nationally hitherto have specialist practitioners or formal services addressing this group. A final major challenge is that, whilst encouraging treatment approaches are being developed, the number of patients with what is increasingly considered at least a
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partially treatable disorder is very large indeed. Typical estimates of the prevalence of this diagnosis would be about 2-3% in the general population, about 20% in Outpatient /Tier 2 populations, and about 40% for in-patient or many Tier 3 type services.

1.1 Rationale for developing the ICP The ICP was developed from the NHS QIS standards for mental health integrated care pathways, which specify both generic and BPD-specific care standards and in this case also suggests principles of management to promote good care of people with this diagnosis. It has been put together by a local development group consisting of NHS staff, service users and carers, local authorities, voluntary organisations and the independent sector (see Appendix 1 BPD/CT ICP development group members). In Lanarkshire various terms are used to describe the people who use mental health services which include, clients, patients and service users and to simplify this we have used the single term patients in both the Generic ICP and this conditionspecific ICP. Within NHS Lanarkshires mental health service, there is currently no specialist service provision for this group which means that they are absorbed into the generic system, usually at times of crisis. The implementation of the generic and condition-specific ICP standards should enable us to provide appropriate care and treatment for people with this diagnosis, incorporating evidence based effective treatment approaches, examining and acting upon the training needs of staff working with these people and generally raising awareness of the condition. 1.2 How to use the Lanarkshire Borderline Personality Disorder/Complex Trauma ICP The Generic ICP will automatically be used for people accessing mental health services in Lanarkshire (with the exception of those people with depression who do not require specialist assessment and treatment in which case only the condition-specific ICP for depression will be used). For all others the Generic ICP will apply and if appropriate, this condition specific ICP for Borderline Personality Disorder/ Complex Trauma will also be used as required. This ICP is designed to be used for any person over the age of 16 who presents with a primary diagnosis of borderline personality disorder/complex trauma (additionally, people with learning disabilities can access services via the Lanarkshire Learning Disabilities Service). For young people aged 16 or under services can be accessed through the Lanarkshire Child and Adolescent Mental Health Service. These ICPs are based on a stepped model of care as described in the Lanarkshire Mental Health Strategy. They encompass a culture and values which aim to enable person-centred recovery and strengths-based focus with a move towards positive management of individual risk, maximising choice and access to evidence-based interventions (see Appendix 2, Guidance and Policy Base). The ICP is intended to provide a standard model of good care based on the current evidence base and expert opinion. It is important to note that the ICP is a guide to good care but it should never replace sound professional judgement. The professionals assessment and judgement will always override the advice of the tool where this is necessary. The ICP is part of the patient record and as with all such records, it will be private and confidential with access governed by the usual rules of confidentiality. By using this ICP we will be able to produce data about the care and interventions provided to people in Lanarkshire with borderline personality disorder/complex trauma. This information (variance data), will allow us to compare the actual care and interventions given with those planned in the ICP and enable us to identify areas where the ICP should be modified to improve the quality of care provided. The variance information will also identify resource issues, gaps in service availability and future staff training and supervision requirements.
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1.3 Patient Journey for People with Borderline Personality Disorder/Complex Trauma
To communicate the findings of this ICP we have created a series of flow charts which show the major levels of therapeutic activity (boxes) connected by a series of relationships (arrows), but we are aware that not every potential activity or relationship can be covered in a diagram. In the interests of simplicity we have only included the current major pathways. The accompanying narrative gives further detail of each tier of the patient journey. Fuller guidance on the management of Borderline Personality Disorder/Complex Trauma can be found in the current NICE guideline:
http://www.nice.org.uk/nicem edia/pdf/Borderline%20person ality%20disorder%20full%20gui deline-published.pdf

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2. Management in Primary Care


The principles for the recognition and management of borderline personality disorder/complex trauma in primary care are based on the guidelines from NICE (2009 - full version and quick reference guide). Key priorities from the guideline surrounding treatment for this patient group are reproduced for reference in Appendix 3. They include consideration of access to services, autonomy and choice, developing an optimistic and trusting relationship, managing endings and transitions, assessment, care planning in CMHTs, role of psychological treatment, role of drug treatment, and the role of specialist personality disorder services. 2.1 Recognition and Management in Primary Care Consider referral to community mental health services for people who present with a history of probably complex psychological trauma with a range of problems which can include: Frequent intense and unmanageable feelings which lead to desperate coping behaviours which may include: self harm, substance abuse or abnormal eating behaviours Overt anxiety or depression Intrusive memories/flashbacks relating to previous traumatic experiences Instability and uncertainty about personal identity and sense of self Anxieties about abandonment and desperate attempts to seek help, or alternatively outbursts of angry and unmanageable feelings Difficulty in interpersonal relationships, including with health service staff, due to the above underlying problems. GPs may also consider the use of screening tools such as the Personality Structure Questionnaire (PSQ) (Appendix 4) and/or CORE (Appendix 5) as part of the assessment and referral process. (Scores above a cut-off point of 28 on the PSQ suggest BPD/CT type problems and a clinical score of above 20 on the CORE suggests 'moderate to severe problems.) Guidelines for recognition and management in Primary Care (NICE) http://www.gpnotebook.co.uk/simplepage.cfm?ID=-1281753086 2.2 Crisis Management in Primary Care Assess current level of risk, using the Lanarkshire Suicide Assessment and Treatment Pathway if appropriate. Ask about previous episodes and effective management strategies used Help manage anxiety by enhancing coping skills and focusing on current problems Encourage the person to identify manageable changes to enable them to deal with the current problems Offer a follow-up appointment at an agreed time.
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2.3 Referral to Community Mental Health Services Consider referral when: Levels of distress and/or risk of harm to self or others are increasing Levels of distress and/or risk of harm to self or others have not subsided despite attempts to reduce anxiety and improve coping skills The person requests further help from specialist services.

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3. Management in Secondary Care


3.1 Assessment, Diagnosis and Care Planning Effective recognition and assessment procedures should be in place for this group of disorders at Tier 2 level consistent with the emphasis in general on developing common and effective screening and assessment procedures. This will enable collaborative and informed decisions to be made about recommending types of intervention (if any) which are appropriate either at Tier 2 level or about referral for more specialist and possibly intensive treatment. It is recognised that specialised or research-based instruments (such as the SCID 2) would not be appropriate at this point but brief screening instruments such as the PSQ and/or a broad psychological screening instrument such as the CORE (Evans et al.) should be considered. The latter measures overall psychological distress and disturbance as well as risk and is increasingly used by many services and can serve as an indication of severity and complexity (both of these instruments are in the public domain and are copy-left). It may also be that a set of clinical prompts such as incorporated in our Staff Questionnaire (Appendix 6) may be equally or more useful in initially screening for this group of disorders. However it is recognised that broader brush instruments such as HONOS are not adequately sensitive in screening for psychological disorders or for monitoring their progress. These assessments would complement the broader clinical and risk assessment procedures being recommended by the generic ICP. For patients being considered for formal specialist treatment more rigorous assessment should include use of a specific instrument such as the Personality Disorder Questionnaire (PDQ) (Hyler et al). 3.2 Risk Assessment and Management This should be undertaken as per NHS Lanarkshire Generic ICP and in addition: Agree explicitly with the person the risks being assessed and develop collaborative risk management plans that: address both long term and more immediate risks relate to the overall long-term treatment strategy take account of changes in personal relationships, including therapeutic relationship. Manage risks with a multidisciplinary team with good supervision arrangements, being particularly cautious evaluating the risk if the person is not well known to the team or if there have been frequent suicidal crises. To assess suicide risk use the Lanarkshire Suicide Assessment and Treatment Pathway. o o o Regularly review (at least annually) the team members tolerance and sensitivity to people who pose a risk to themselves and others.

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3.3 Psychological Treatment The NICE guideline stresses that formal treatment should ideally be delivered in the form of clear, coherent, structured, longer term (typically 1-3 years) programmes and that very short term (less than three months), low intensity (less than twice weekly input) are not effective or appropriate for such disorders. The appropriately-nuanced NICE guideline reviewed a range of brand name models of treatment and concluded that certain common overarching principles of multidisciplinary, intensive treatment approaches are undoubtedly most critical. These include the criteria that: any model should be clear and coherent to staff and patients, be well structured and be collaborative and proactive in style. Ideally treatment programmes should address the whole range of symptoms and problems characteristic of these disorders although it is recognised that at present no one model does so fully. NICE stresses that emphasising apparent differences between different brand name approaches may be more misleading than helpful. (In addition it is widely accepted in delivering psychological treatments that common factors [such as quality of therapeutic alliance and therapist competence] will be as, if not more, important than brand name allegiances although it is stressed that adhering to a clear model is also important for effectiveness for any therapist or service.) However in the future it is likely that these different emphases and strengths will be more clearly teased out and evaluated (through dismantling studies) and that ultimately a range of types of intervention (ranging from those directed at more behavioural problems through to those of a more interpersonal and relational nature) will need, variably, to be employed in more personalised treatment packages. In addition, the recently published Matrix document from the Scottish Government, (although it does not provide a systematic review of BPD specifically) provides health boards with a comprehensive review of the evidence base for psychological therapies and guidance as to how these should be delivered (Appendix 7, MATRIX Evidence Base). There is evidence for the (differential) efficacy of various models which may be considered. These include:
Dialectical behaviour therapy (DBT) long term* intensive team based approach Mentalisation individual therapy usually employed within a team approach Schema-focussed CBT (S-CBT) long term intensive individual therapy Transference focussed analytic therapy (T-PA) long term intensive individual therapy Cognitive analytic therapy (CAT) medium term individual and/or team based approach STEPPS programme CBT based systemically-informed long term group approach Therapeutic community (TC) long term large group psychosocial approach *Long term describes treatment programmes in general lasting over one year

Exactly which approach is used as a basis for any treatment service will depend partly on local expertise and resources and also should ideally be responsive to informed patient preference. The provision of these and other therapies identified in the NHS Lanarkshire ICPs is being managed through the Psychological Therapies Strategy Implementation Plan which will determine the therapies that will be available across Lanarkshire and agree future development timescales.
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[The survey undertaken by the working group suggests that] there is a limited and patchy expertise available in some of these models at present in NHS Lanarkshire (notably S-CBT, T-PA, CAT, and very patchily DBT, STEPPS and TC approaches). Evidence also generally suggests the superiority and preferability of a multidisciplinary team-based model of treatment provision (including possibly adjunctive therapies such as mindfulness training or creative therapies) rather than one offered solely by individual practitioners. Such an approach is also, importantly, less stressful for practitioners. Regular supportive supervision for practitioners working with this patient group should be offered and is recognised to be of fundamental importance. Finally, it is generally accepted that social rehabilitation plays an important role in outcome for such patients and should play an active part in any treatment approach. 3.4 Management of Crises These require high levels of support and frequent review in secondary care settings. A new model for alternatives to admission/crisis support is being developed in Lanarkshire. This model should support prevention management and recovery from periods of crisis and will be carried out on a partnership basis. The model follows the journey of care for people in Lanarkshire known to mental health services and new referrals. Good practice includes: Ideally prior creation of advance directive/crisis card stating joint plans and patient preferences for treatment/management in cases of crisis or detention under the Mental Health Act. Assessment as per the Generic ICP, including the Lanarkshire Suicide Assessment and Treatment Pathway if appropriate. Review of any co-morbid conditions, e.g. depression, acute anxiety, psychosis, and any need for direct treatment of these. This may require judicious use of short term medication (see medication algorithm and notes section). Availability of advice and support from more specialist colleagues through a forum or specialist team. Take into account all other alternative options for support, i.e. family and community, before consideration of brief crisis/respite hospital admission bearing in mind these may be counter-productive. Arrange follow-up for monitoring purposes as per Lanarkshire alternative to admission/crisis support model. 3.5 Discharge to Primary Care When discharging: The process should be discussed and negotiated beforehand with the person and also family or carers whenever possible. A care plan should be agreed which specifies steps to take to manage distress, how to cope with future crises and how to re-engage with any specialist treatment programme if ongoing and with community mental health services if needed. Support the person in their journey towards recovery. To assist with the process a number of support methods and tools are available (should the person wish to choose them) which include, Advance Statement, My RAP, etc. (see Appendix 8, Information and Resources). Discharge arrangements as per Generic ICP.
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4. Medication
4.1 Notes on the Prescribing of psychotropic medication in borderline personality Disorder/complex trauma This section is intended as guidance on the problematic issue of prescribing for the severe and complex group of disorders currently described as borderline personality disorder/complex trauma - particularly in the light of recent rigorous systematic reviews conducted and reported in the current NICE guideline (2009). What has emerged clearly from that review is that, whilst there is encouraging emerging evidence for the efficacy of psychological and psychosocial treatments for BPD/CT, there is currently NO good evidence to support any prescribing of psychotropic medication for BPD/CT as such. These findings have emerged despite previously reported preliminary and very limited evidence for judicious prescribing in BPD/CT for different symptoms such as affect dysregulation, impulsive/aggressive episodes or fleeting psychotic symptoms. What is more the NICE review and others strongly highlight the dangers of so doing given the well-recognised pressures experienced by psychiatrists and staff teams when treating this patient group to offer some form of help - but also the problems associated with long-term dependency and habituation as well as possible misuse in subsequent self-harm attempts or as a means of numbing during periods of distress. Such misuse may then effectively become part of the clinical problem. It is noted that typically patients finish up unwittingly being offered a polypharmacy which becomes at times effectively a therapeutic counsel of despair. This may then be very hard to reduce or discontinue. It is further noted that certain drugs (e.g. benzodiazepines) may result in paradoxical dyscontrol or disinhibition syndromes which is particularly problematic in patients prone to impulsive self harm. In addition, most patients diagnosed with BPD are young women of child bearing age (see NICE guideline on Ante Natal and Post Natal Mental Health 2007) and many drugs up to now commonly prescribed for BPD/CT (e.g. benzodiazepines, neuroleptics, mood stabilisers, anti-depressants) may have harmful effects on the foetus. However one of the recognised problems with this patient group is so called comorbidity - although it has been argued that this is simply a reflection of the complexity and severity of the diagnosis. This may include acute anxiety, acute psychotic episodes, depression (often of a more empty existential type given the typically high levels of affect seen in BPD/CT) as well as problems such as anorexia, binge-eating or substance misuse. It is recognised that clearly defined co-morbid conditions may need to be treated in their own right as appropriate and this may include use of psychotropic medication. It is stressed however that these should be used only after a careful risk-benefit analysis of the issues involved in prescribing around BPD/CT. Such prescribing should be ideally only ever be undertaken on a time-limited basis although clearly this may not be possible for some conditions such as depression or psychosis.

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If any psychotropic medication is prescribed however for BPD/CT itself in the absence of any other clear formally-diagnosed disorder, prescribers should be aware that this represents off label use of drugs which should ideally only be undertaken with the informed (and preferably written) consent of the patient as per routine BNF guidance. It would be anticipated however that the implementation of improved (psychosocial) treatments for this group of patients would result in much less pressure to prescribe and a corresponding reduction ultimately in levels of so doing. Finally, it should be noted that whilst disorders such a severe depression (actually quite rare in overt BPD/CT) may need to be considered and treated in their own right, treatments such as ECT in the context of BPD/CT are recognised to be greatly compromised in their efficacy and are not generally recommended. In particular there is no evidence for the use of ECT for BPD/CT in itself (APA 2001; NICE 2009).

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4.2 Treatment algorithm for prescribing of psychotropic medication in borderline personality disorder/complex trauma If there is a clear diagnosis of BPD/CT offer psychologically informed management and support and consider referral for specialist psychosocial treatment approaches. If there is a clearly defined acute or chronic co-morbid condition consider other forms of appropriate, specifically-targeted treatments following careful risk-benefit analysis of prescribing in the context of BPD/CT and in conjunction with informed consent from patient or relative if appropriate (e.g. in context of treatment under a section of the Mental Health Act).
Management of Co-morbidities Management of Crises Management of Insomnia

Review diagnosis and comorbid condition Review previous and current treatments

If major psychosis, dependence on alcohol or class A drugs or severe eating disorder, refer to or seek advice from appropriate service

If co-morbid condition follow the NICE/SIGN clinical guideline for co-morbid condition

Consider short term drug treatments: Choose drugs with low side effect profile: - Low addictive properties - Minimum potential for misuse - Relative safety in overdose Use minimum effective dose Prescribe fewer tablets more frequently if significant risk of overdose Agree with person: target symptoms, monitoring arrangements, anticipated duration of treatment Agree plan for adherence with person Discontinue a drug after a trial period if target symptoms do not improve Consider alternative treatments including psychological treatments if target symptoms do not improve or level of risk does not diminish

Provide general advice on sleep hygiene

Short term management: Use zaleplon, zolpidem and zopiclone as per NICE guidance 77 Consider sedative antihistamines

Ref: NICE Clinical Guideline 78 January 2009

Review and Follow-up: Review drug treatment Plan to stop treatment within 1 month Review of psychological treatments including role in overall treatment strategy If drug cannot be stopped within 1 month review regularly

ICP Standard 26a: The care record shows that a treatment algorithm for drug choices based on best practice is followed.
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5. Training and Support


5.1 General Training Requirements All clinical staff should be familiar with the use of basic screening and assessment procedures and tools. A brief training package (possibly half a day long) offering an update on the recognition and principles of treatment for BPD/CT should be offered and rolled out to all staff on an ongoing basis given the continuing rapid evolution of understandings and treatment approaches in this area. All generic and specialist staff who may be expected to work with and manage this group of patients should have these basic skills as well as basic psychological treatment skills across a range of modalities ranging from the behavioural and cognitive through to the interpersonal and relational in line with the types of treatment packages recommended by recent systematic reviews notably the one from NICE (2009). Service user and carer organisations both locally (e.g. Lanarkshire Links, SAMH) and nationally (e.g. Emergence) should be involved on an ongoing basis in planning, developing, monitoring and evaluation of services. Feedback from Lanarkshire Links with regard to the ICP development process suggested a need to focus on various issues notably staff training. Key issues included: Involving service users and carers:
Problems of not having a diagnosis

Important areas to measure:


Consistent approach Standards Time delays reduce gaps in

therefore not being part of this particular pathway More information Make user and carer feel more valued and listened to including our experience and opinions Show how our opinions and experience can make a difference Encourage and enable involvement Keep it relaxed and informal Outline the benefits

provision Relevant staff training Recognise that everyone recovers at a different rate Interventions to avoid long hospital admissions Other agency involvement Community based treatment
(Lanarkshire Links Summer Meeting 17th June 2009)

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5.2 Specialist Training Initiatives In light of questionnaire feedback and working group impressions there appears to be a pressing need for a brief (?mandatory) training package (? day in length) which covers: awareness, understanding and recognition of this group of disorders, principles of treatment for all mental health professionals in NHS Lanarkshire (?and other agencies, e.g. Social Services, non-statutory agencies). This should ideally be formulated and delivered by a group of trainers (ideally in conjunction with an outside educational organisation(s)) who would come from a small (?virtual) specialist team in line with most current guidance. There is a need for a substantial number of colleagues with specialist training in appropriate treatment modalities (e.g. schema based CBT, DBT, CAT, Mentalisation and so forth). This should continue to be addressed in conjunction with initiatives implemented by the IAPT approach. Trained practitioners should be available to assess and offer treatment to this patient group both in various secondary care teams and also in any specialist BPD/CT team. Some training initiatives may require external resources whilst others could be developed and rolled out essentially in house and make use of currently existing expertise.

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6. Service Development
6.1 Potential Service Models In order to implement these initiatives and to continue to support, train and supervise staff and offer in-depth assessment and more intensive treatments (in line with recent reviews such as NICE 2009) for the large number of patients falling into this diagnostic group there should ideally exist a multidisciplinary psychological treatment team offering treatment for such disorders in each locality. The composition and role of such a team would be comparable to that embodied in other tertiary level specialist services. Ideally this team would have access to a small number of in-patient beds to deal with the need for intermittent crisis admissions although these should be greatly diminished overall by the existence of such a team. Given the large numbers of patients with such disorders (as with any Tier 3 type service) only a small number of more severe cases would be directly treated but such a team would nonetheless represent an important referral, assessment, and treatment option for generic workers in services in other Tiers.

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7. ICP Monitoring
Monitoring of the service provided to each person will take place using: Variance Analysis questions to be agreed in conjunction with ICP development groups and national QIS ICP programme team. Aspects of the ICP which would require monitoring would include, e.g. number of patients identified and diagnosed, numbers of crisis plans formulated, numbers of admissions, prescribing levels, episodes of deliberate self harm, suicide rates and overall treatment outcomes. Staff, Patient and Carer Surveys to be developed in conjunction with ICP development groups, national QIS public involvement group, etc.

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Appendices
Appendix 1: Complex Trauma/Borderline Personality Disorder ICP Development Group Members
Gordon Barclay, ST5, NHS Lanarkshire Stuart Baxter, Nurse Specialist, Crisis Resolution and Home Treatment Service, NHS Lanarkshire Martin Benes, Consultant Psychiatrist, NHS Lanarkshire Caroline Brown, Clinical Governance Co-ordinator (Mental Health), NHS Lanarkshire Avril Cleary, Community Psychiatric Nurse Team Leader, NHS Lanarkshire Norma Cruickshank, Nurse Consultant Psychological Interventions, NHS Lanarkshire Eileen Dickson, Charge Nurse, NHS Lanarkshire Jackie Donaghey, Senior Social Worker, North Lanarkshire Council Shay Griffin, Consultant Psychiatrist, NHS Lanarkshire Pauline Hanlon, Senior Nurse Clinical and Professional Practice (Mental Health), NHS Lanarkshire Alison Howley, Forensic Community Psychiatric Nurse, NHS Lanarkshire Ian Kerr, Consultant Psychiatrist and Psychotherapist, NHS Lanarkshire (Chair) Scott Lees, Community Psychiatric Nurse, NHS Lanarkshire Caroline Lennon, Psychotherapy Nurse Practitioner, NHS Lanarkshire ICP Team: Patricia Kent, ICP Manager Janis Dickson, Mental Health ICP Project Assistant Ana Lopez, Consultant Psychiatrist, NHS Lanarkshire Roy McGregor, Nurse Therapist, NHS Lanarkshire Dorothy McMonagle, Charge Nurse, NHS Lanarkshire Claire Nelson, Consultant Psychiatrist, NHS Lanarkshire Debra O'Neill, Chartered Clinical Psychologist, NHS Lanarkshire Loraine Ratter, Community Psychiatric Nurse, NHS Lanarkshire Gwen Scott, Team Leader, Rutherglen Community Mental Health Team, South Lanarkshire Council Lisa Marie Smith, Community Psychiatric Nurse, NHS Lanarkshire Derek Thomson, Community Psychiatric Nurse, NHS Lanarkshire Hermione Thornhill, Clinical Psychologist, NHS Lanarkshire Brenda Vincent, Service Manager, Equals Advocacy Partnership Caroline Watson, Ward Manager, NHS Lanarkshire Alison Wilson, Psychiatric Assessment Team Co-ordinator, NHS Lanarkshire

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Appendix 2: Guidance and Policy to support Values

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Appendix 3: NICE Quick Reference Guide (pages 4 6)

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Appendix 4: Personality Structure Questionnaire (PSQ) IMPORTANTPLEASE READ THIS FIRST. This questionnaire is about aspects of your personality. People vary in all sorts of ways. Some people feel themselves to be constant and all of a piece. Other people are quite variable and find themselves shifting between two or more distinct states of mind. Most people are in the middle between these two extremes. A state of mind is recognized by a typical mood, or a typical way of relating to other people. In some states people feel in control and in others more out of control. States of mind can change quickly or may last for days. Sometimes changes in state of mind happen because of a change of circumstances or an event of some kind. There are two statements per question. Please indicate which description applies to you most closely. Please complete all 8 questions and cross one box per question only like this .
1 Very True 1 2 My sense of myself is always the same. The various people in my life see me in much the same way. I have a stable and unchanging view of myself. I have no sense of opposed sides to my nature. 2 True 3 May or may not be true 4 True 5 Very True How I act or feel is constantly changing. The various people in my life have different views of me as if I were not the same person. I am so different at times that I wonder who I really am. I feel I am split between two (or more) ways of being, sharply different from each other. My mind can change abruptly in ways which can make me feel unreal or out of control. I am often confused by my mood changes which seem either unprovoked or out of scale with what provoked them. I get into states in which I lose control and do harm to myself and/or others. I get into states in which I say or do things which I later deeply regret. Thank you for completing this questionnaire

My mood and sense of self seldom change suddenly.

My mood changes are understandable.

I never lose control.

I never regret what I have said or done.

Copyright 2009 John Wiley & Sons, Ltd.

Clin. Psychol. Psychother. 16, 77-81 (2009) DOI: 10.1002/cpp

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Appendix 5: Clinical Outcomes in Routine Evaluation (CORE)

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Appendix 6: Lanarkshire Staff Questionnaire


Borderline Personality Disorder Integrated Care Pathway (ICP) Background Questionnaire for Staff As part of the work of the Borderline Personality Disorder ICP workgroup, which will aim to implement objectives of the ICPs overall and specifically to improve services for this patient group, we are initially attempting to obtain a background picture of both the prevalence of this disorder locally and of views of colleagues about their confidence and abilities in working with them. Addressing this patient group is probably significantly more problematic than for many others, partly given the complex nature of their presentations, but also due to changing views and understandings of their origins and nature as well as the emergence of encouraging treatment methods for them over the past decade or so. Broadly speaking, it is now much better understood that this group of patients who present with often a range of complex and hard-to-help difficulties have common origins in, usually, childhood and developmental histories of serious deprivation, emotional trauma and at times overt abuse. This has often occurred in the context of dysfunctional family dynamics and of adverse and sometimes traumatic life events. The range of problems associated with this sort of disorder (broadly described as borderline personality disorder although this label is contentious and not always helpful) is very wide. These may include: i) Frequent intense and unmanageable feelings which lead to desperate coping behaviours which may include, e.g. self harm, substance abuse or abnormal eating behaviours ii) Overt anxiety or depression iii) Intrusive memories / flashbacks relating to previous traumatic experiences iv) Instability and uncertainty about personal identity and sense of self v) Anxieties about abandonment and desperate attempts to seek help, or alternatively outbursts of angry and unmanageable feelings vi) These may then lead to difficulty in interpersonal relationships, including with health service staff This picture is recognised to start emerging already in late childhood or adolescence. Clearly, given this range of difficulties (often referred to as co-morbidity), such patients frequently present to very different services, both in primary and secondary care, including for example, services for survivors of abuse, eating disorder services, substance abuse services, therapy services or more generic secondary care services due to behaviour such as self-harm or symptoms such as anxiety and depression. More recent reviews and guidelines have stressed the partial effectiveness at least of newer treatment approaches and have clearly stated that these should be routinely available to such patients. The consensus in such guidelines is that whatever model is being used, it should be clear and coherent to those involved, including patients, and should inform more intensive and multi-disciplinary team-based specialist services which should ideally exist for the more severe and complex and hard-to-help cases. As part of our attempt to inform further development of Mental Health and other services in Lanarkshire, we would be grateful if you could answer the following questions about: The frequency with which you consider that you encounter such cases in your workload ideally identifying them through initials and date of birth The extent to which you might feel confident or otherwise about understanding and working with such patients

Please note that the questionnaire feedback is entirely confidential.


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Borderline Personality Disorder Integrated Care Pathway Development Mental Health Services

Borderline Personality Disorder ICP Background Questionnaire


Thank you for taking the time to complete this questionnaire. (Please continue on another sheet if necessary.) Background Details: Name: Professional Role: Work Setting:

Qualifications:

Any specialist training in Psychological Treatments:

Prevalence

1. Given the outline description of this patient group on Page 2, could you please try to indicate approximately what percentage of your current workload such patients might represent? 2. In terms of actual numbers, how many would this be?

3. Can you please identify these cases by Initials and Date of Birth so that we can cross reference them in terms of contact elsewhere from other staff and services and also the principal and any other diagnoses which have been given to these patients? No. 1 2 3 4 5 6 7 8 9 10 Any other comments: Initials Date of Birth Principal Diagnosis Other Diagnoses

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Borderline Personality Disorder Integrated Care Pathway Development Mental Health Services

Borderline Personality Disorder ICP Background Questionnaire


Thank you for taking the time to complete this questionnaire. (Please continue on another sheet if necessary.) Name (optional): Professional Role (optional):

Your views on working with this patient group:

(please put a cross in the box as appropriate)


Strongly Agree Agree Unsure Disagree Strongly Disagree

1. I feel confident about recognising this patient group and about my clinical understanding of it. 2. I feel confident about my skills in trying to work with this patient group. 3. I currently feel rather anxious and uncertain about working with this patient group. 4. I feel confident about obtaining advice and support in working with this patient group. 5. I would welcome any further basic training initiatives to help with my attempts to work with this patient group. 6. I feel confident about knowing where to refer on for more focused and intensive treatment of this patient group. 7. I would welcome the support of a specialist service for this patient group. 8. I feel that attempts to help this patient group are often complicated by other nonpsychiatric factors (e.g. lack of social support). 9. I feel that the use of the term borderline personality disorder is often inappropriate and unhelpful in working with such patients. 10. I feel that attempts to work with such patients are often undermined and complicated by pejorative and hostile reactions which they may elicit from health professionals. Any other comments:

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borderline personality disorder/complex trauma integrated care pathway

Appendix 7: MATRIX Evidence Base

MATRIX Borderline Personality Disorder Evidence Base


Level of Severity Level of service Intensity of intervention What intervention? Recommendation

Severe

Secondary/ Specialist Outpatient

High

CBT for personality disorders Individual therapy (30 sessions over 1 year) Schema Focused CBT Twice weekly over 3 years STEPPS -Systems Training for Emotional Predictability and Problem Solving (CBT approach) 20 group sessions group + usual treatment Transference-focused psychotherapy (twice weekly sessions plus weekly supportive treatment over one year) Dialectical Behaviour Therapy (DBT) Involves group + individual therapy + telephone support (Several times per week over one year)

A2 A3 A6

A4

A1

Severe

Secondary/ Specialist Partial Day Hospital

High Multi-modal

Mentalization based Day Hospital (Several times per week over 3 years)

A5

Lessons learned from the evaluation of pilot services in England suggests that due to the complexity of personality disorder most services should offer more than one type of intervention (Crawford et al, 2007)7.

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MATRIX BORDERLINE PERSONALITY DISORDER REFERENCES 1. Linehan, M.M. et al., (2006) Two-Year Randomized Controlled Trial and Follow-up of Dialectical Behavior Therapy vs Therapy by Experts for Suicidal Behaviors and Borderline Personality Disorder. Archives of General Psychiatry 63, 757-766. 2. Davidson K, Norrie J, Tyrer P, Gumley A, Tata P, Murray H, Palmer S (2006) The effectiveness of cognitive behaviour therapy for borderline personality disorder: results from the borderline personality disorder study of cognitive therapy (BOSCOT) trial. Journal of Personality Disorder 20, 450465 3. Giesen-Bloo J, van Dyck R, Spinhoven P, van Tilburg W, Dirksen C, van Asselt T, Kremers I, Nadort M, Arntz, A. (2006) Outpatient psychotherapy for borderline personality disorder: randomized trial of schema-focused therapy vs transference-focused psychotherapy. Archives of General Psychiatry, 63, 649658 4. Clarkin J.F., Levy K.N., Lenzenweger M.F., Kernberg O.F. (2007) Evaluating three treatments for borderline personality disorder: a multiwave study. American Journal of Psychiatry, 164, 922928 5. Bateman A, Fonagy P (1999) The effectiveness of partial hospitalization in the treatment of borderline personality disorder: a randomized controlled trial. American Journal of Psychiatry, 156, 15631569 6. Blum N, St. John D, Pfohl B, Stuart S, McCormick B, Allen J, Arndt S, Black D (2008) Systems Training for Emotional Predictability and Problem Solving (STEPPS) for Outpatients With Borderline Personality Disorder: A Randomized Controlled Trial and 1-Year Follow-Up. American Journal of Psychiatry, 165, 468478 7. Crawford, M & Rutter, D (2007) Lessons learned from an evaluation of dedicated community based services for people with personality disorder. Mental Health Review Journal, 12, 55-61.

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Appendix 8: Information and Resources

Information and Resources


Reading: Borderline Personality Disorder Demystified: An Essential Guide for Understanding and Living with BPD, Robert Friedel Stop Walking on Eggshells: Taking your Life Back when Someone you Care About has Borderline Personality Disorder, Paul T Mason The Borderline Personality Disorder Survival Guide: Everything you need to know about living with BPD, Alex Chapman Websites: Scottish Personality Disorder Network: http://www.scottishpersonalitydisorder.org/ Elament - an online mental health and wellbeing information website: http://www.lanarkshirementalhealth.org.uk/ For information on suitable drugs and their uses: http://www.choiceandmedication.org.uk/ My RAP - a self management tool developed by a multi-agency group in Lanarkshire to support people in their recovery, available at: http://www.lanarkshirementalhealth.org.uk/News/myrapavailable Scottish Recovery Network - an affiliation of individuals and organisations with a common interest in recovery, which also aims to share information and ideas: http://www.scottishrecovery.net/ Lanarkshire Links an organisation for mental health service users and carers in Lanarkshire: http://www.lanarkshirelinks.org.uk/ Information Leaflets: What is Borderline Personality Disorder? available from the Scottish Personality Disorder Network website: http://www.abdn.ac.uk/~wmm075/uploads/files/leaflet.pdf Patient Information Leaflets - can be accessed via NHS Lanarkshire Intranet Pharmacy Mental Health pages

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References
1. Bedford A, Davies F, Tibbles J (2009) The Personality Structure Questionnaire (PSQ): A Cross-Validation with a Large Clinical Sample. Clinical Psychology and Psychotherapy 16, 77-81. Published online at Wiley InterScience (www.interscience.wiley.com). 2. Evans, C., Connell, Barkham, M., Margison, F., McGrath, G., Mellor-Clark, J. and Audin, K. (2002). Towards a standardised brief outcome measure: psychometric properties and utility of the CORE-OM. British Journal of Psychiatry, 180, 51-60. 3. See also www.coreims.co.uk 4. Hyler SE, Skodol AE, Kellman HD, Oldham J and Rosnick L. (1990). The validity of the Personality Diagnostic Questionnaire: A comparison with two structured interviews. American Journal of Psychiatry, 147, 1043-1048. 5. Mental Health in Scotland: A guide to delivering evidence-based psychological therapies in Scotland The Matrix, Scottish Executive, 2008. 6. National Institute for Clinical Effectiveness (NICE) (2009). Borderline Personality Disorder: Treatment and Management. National Clinical Practice Guideline No 78, London. 7. Standards for Integrated Care Pathways for Mental Health, NHS Quality Improvement Scotland, December 2007.

Borderline Personality Disorder References from more recent literature


1. Bateman, A S. and Fonagy, P. (2009). Randomized Controlled Trial of Outpatient Mentalisation Based Treatment Versus Structured Clinical Management. American Journal of Psychiatry, 166, 1355-1364. (shows effectiveness of intensive mentalisation package with partial superiority over psychologically-informed, coherent, proactive psychiatric care package.) 2. Chanen, A.M., Jackson, H. McCutcheon, L. K., Jovev, M., Dudgeon, P., Yuen, H.P., Germano, D., Nistico, H., McDougall, Weinstein, C., Clarkson, V. and McGorry P.D. (2008). Early intervention for adolescents with borderline personality disorder using cognitive analytic therapy: randomised controlled trial. British Journal of Psychiatry, 193, 477-484. (shows effectiveness of 24 session CAT with partial superiority over psychologically-informed, coherent, proactive psychiatric care package). 3. Chanen, A.M., Jackson, H. McCutcheon, L. K., Jovev, M., Dudgeon, P., Yuen, H.P., Germano, D., Nistico, H., McDougall, Weinstein, C., Clarkson, V. and McGorry P.D. (2009). Early Intervention for adolescent with borderline personality disorder: quasiexperimental comparison with treatment as usual. Australian and New Zealand Journal of Psychiatry, 43, 397-408. (shows effectiveness of 24 session CAT with partial superiority over psychologically-informed, coherent, proactive psychiatric care package, with both showing marked superiority over historic treatment as usual.) 4. Doering, S., Horz, S., Rentrop, M., Fisher-Kern, M. et al. (2010). Transferencefocused psychotherapy v. treatment by community psychotherapists for borderline personality disorder: randomised control trial. British Journal of Psychiatry, 196, 389-395. (shows effectiveness of twice-weekly modified psychoanalytic transference focussed therapy (for one year) for borderline symptomatology, social function and personality organisation compared to control group receiving non-specific therapy by experienced community therapists. 5. McMain, S.F., Links, P.S., Gnam, W.H., Guimond, T., Cardish, R.J., Korman, L., and Streiner, D.L. (2009). A Randomized Trial of Dialectical Behavior Therapy Versus General Psychiatric Management for Borderline Personality Disorder. American Journal of Psychiatry, 166, 1365-1374. (shows effectiveness of intensive DBT package but with no superiority over psychologically-informed, coherent, proactive psychiatric care package.)
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Glossary/Abbreviations
Cognitive Analytic Therapy (CAT) Cognitive Analytic Therapy is a relational approach which involves a therapist and a client working together to look at what has hindered changes in the past, in order to understand better how to move forward in the present. CAT focuses its attention on discovering how problems have evolved and how the procedures devised to cope with them may be ineffective. It is designed to enable clients to gain an understanding of how the difficulties they experience may be made worse by their habitual coping mechanisms. Problems are understood in the light of clients' inter personal and social histories and life experiences. The focus is on recognising how these coping procedures originated and how they can be adapted and improved. Then, mobilising the clients' own strengths and resources, plans are developed to bring about change. Promoting integration of the self is a major additional focus in working with BPD/CT This umbrella term describes those therapies which share the central idea that thoughts generate emotions and behaviour(s) and that negatively biased thinking generates unhelpful emotions and unhelpful behaviour(s); from which emotional disorders may arise. Such therapies focus on monitoring thoughts, beliefs and behaviours in the here and now in order to help people evaluate how helpful or unhelpful they are. Therapist and client/patient work collaboratively to achieve explicitly agreed goals in a time limited fashion. Psychiatric Diagnoses are categorized by the Diagnostic and Statistical Manual of Mental Disorders. The manual is published by the American Psychiatric Association and covers all mental health disorders for both children and adults. It also lists known causes of these disorders, statistics in terms of gender, age at onset, and prognosis as well as some research concerning the optimal treatment approaches. Dialectical Behaviour Therapy is an innovative method of treatment that has been developed specifically to treat this people in a way which is optimistic and which preserves the morale of the therapist. The core strategies in DBT are 'validation' and 'problem solving'. Attempts to facilitate change are surrounded by interventions that validate the patient's behaviour and responses as understandable in relation to their current life situation, and that show an understanding of their difficulties and suffering. This is a procedure sometimes used to treat severe depression and other conditions in which an electric current is briefly applied to the brain. ECT is only offered if other kinds of treatments have not helped to relieve depression. In 1993 the UK Department of Health commissioned the Royal College of Psychiatrists Research Unit to develop scales to measure the health and social functioning of people with severe mental illness. The initial aim was to provide a means of recording progress towards the Health of the Nation target to improve significantly the health and social functioning of mentally ill people. Development and testing over three years resulted in an instrument with 12 items measuring behaviour, impairment, symptoms and social functioning (Wing, Curtis & Beevor, 1996). The scales are completed after routine clinical assessments in any setting and have a variety of uses for clinicians, researchers and administrators, in particular health care commissioners and providers. The scales were developed using stringent testing for acceptability, usability, sensitivity, reliability and validity.

Cognitive Behavioural Therapies (CBT)

Diagnostic and Statistical Manual of Mental Disorders (DSM IV) Dialectical Behaviour Therapy (DBT)

Electroconvulsive Therapy (ECT) Health of the Nation Outcomes Scale or HONOS 65+

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Mentalisation NHS Quality Improvement Scotland (QIS)

National Institute for Clinical Excellence (NICE)

Personality Structure Questionnaire (PSQ)

Schema Focussed CBT (S-CBT)

Scottish Intercollegiate Guidelines Network (SIGN) Systems Training for Emotional Predictability and Problem Solving (STEPPS) Therapeutic Community Approaches (TCs) Transference Focussed Analytic Therapy (T-PA)

Mentalisation based therapy is a type of psychotherapy that focuses on a persons ability to mentalise, or recognize thoughts, feelings, wishes, and desires, and see how these internal states are linked to behaviour. NHS Quality Improvement Scotland was established as a Special Health Board by the Scottish Executive in 2003, in order to act as the lead organisation in improving the quality of healthcare delivered by NHS Scotland. By 'improve', they mean the improving of the experiences of patient/clients and the outcomes of their treatment while in the care of NHS Scotland. They work to achieve these goals through an analysis of scientific evidence, by listening to the needs and preferences of patient/clients and carers, as well as the experiences of healthcare professionals. Web address: www.nhshealthquality.org NICE is part of the NHS. It is the independent organisation responsible for providing national guidance on treatments and care for those using the NHS in England and Wales. Its guidance is for healthcare professionals and patient/clients and their carers, to help them make decisions about treatment and healthcare. NICE guidance and recommendations are prepared by independent groups that include healthcare professionals working in the NHS and people who are familiar with the issues affecting patient/clients and carers. Website address: www.nice.org.uk The PSQ was devised to measure deficits in personality integrity, and represents an assessment measure of the multiple self-states model of cognitive analytic therapy which has however been validated for broader use. This conceptualizes disturbances in personality, with a gradation from healthy identity development to the extreme of a dissociative identity disorder. The PSQ consists of eight bipolar self-rated items for which there is a range of possible responses scoring from 1 to 5 with higher scores (over 28) indicating greater identity disturbance. Schema therapy (also called schema-focused therapy) is an integrative approach based on cognitive-behavioural or skills-based techniques along with object relations and gestalt approaches. It directly targets deeper aspects of emotion, personality and schemas (fundamental ways of categorising and reacting to the world). The treatment also focuses on the relationship with the therapist (including a process of "limited re-parenting"), daily life outside of therapy and traumatic childhood experiences. SIGN was established in 1993 by the Academy of Royal Colleges and Faculties in Scotland. Its objective is to improve the quality of healthcare for patients in Scotland by reducing variation in practice and outcome, through the dissemination of national clinical guidelines containing recommendations for effective practice based on current evidence. For further information contact: www.sign.ac.uk This cognitive-behavioural, skills training approach is based on a systems approach to treatment of individuals with Borderline Personality Disorder originally developed by Bartels and Crotty (1992). Therapeutic community is a term applied to a participative, group-based approach to long-term mental illness, personality disorders and drug addiction. The approach is usually residential with the clients and therapists living together, is based on milieu therapy principles and includes group psychotherapy as well as practical activities. Transference-focused psychotherapy is a modified psychoanalytic psychotherapy based on Dr. Otto Kernberg's object relations model. It begins with a treatment contract, which helps contain acting-out behaviours and sets a frame for discussing deviations from the contract. The treatment emphasises analysis of transference to help the person integrate disparate representations of the self and others in order to develop better affective control. A deviation from an activity set out in an ICP.
borderline personality disorder/complex trauma integrated care pathway

Variance
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