Professor Peter Tyrer explains why borderline personality disorder can be challenging to manage, and highlights the importance of a multidisciplinary team in providing care

Why should GPs be interested in yet another guideline for a condition that many consider to be at the fringes of practice? The answer is simple: this is a condition that impinges dramatically on the work of every healthcare professional, and its immediate management is the responsibility of all. The condition comes under the grouping of personality disorders, which are alleged to be long-term stable conditions. However, borderline personality disorder is more a set of behaviours, which can range from undetectable to full expression, and it is these behaviours that constitute the condition. Borderline personality disorder comprises a heterogeneous mix of criteria that give a clear idea of the extent of the problem (see Table 1).1 When these behaviours are manifest in a GP’s surgery, it is impossible for anyone to be indifferent to them.

Table 1: Diagnostic criteria for borderline personality disorder

The presence of any five of the nine criteria is sufficient for a diagnosis:

  1. Frantic efforts to avoid real or imagined abandonment (not including suicidal or self-injuring behavior covered in criterion 5).
  2. A pattern of unstable and intense interpersonal relationships, characterised by alternating between extremes of idealisation 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 (e.g. promiscuous sex, eating disorders, binge eating, substance abuse, reckless driving) not including suicidal or self-injuring behavior covered in criterion 5.
  5. Recurrent suicidal behavior, gestures, threats, or self-injuring behavior, such as cutting, interfering with the healing of scars (excoriation), or picking at oneself.
  6. Affective instability due to a marked reactivity of mood (e.g. intense episodic dysphoria, irritability, or anxiety, usually lasting a few hours and only rarely more than a few days).
  7. Chronic feelings of emptiness and worthlessness.
  8. Inappropriate anger or difficulty controlling anger (e.g. frequent displays of temper, constant anger, recurrent physical fights).
  9. Transient, stress-related, paranoid ideation, delusions, or severe dissociative symptoms.
Reproduced with permission from the Diagnostic and Statistical Manual of Mental Disorders, text Revision, fourth edition, (copyright 2000). American Psychiatric Association.

Definition of borderline personality disorder

It is not difficult to see why people with borderline personality disorder impinge on GPs’ time, as most of their presenting features tend to be dramatic and associated with crisis. The problem with crisis management is that it is not always the best method for managing the condition long term.

The fundamental problem in patients with borderline personality disorder is a pattern of emotional instability that prevents them from stepping back and being able to weather adversity. Life for the person with borderline personality disorder is a rollercoaster of relatively short periods of optimism and self confidence interspersed with intense episodes of severe depression, which are very frequently associated with:2

  • self-harm
  • great irritability and anxiety
  • great uncertainty about who they are and where they are going in life
  • the inability to avoid being trapped within their own emotions with impulsive and often harmful behaviours.

Every GP knows patients with borderline personality disorder, although they may not always recognise it as such. The disorder is often co-morbid with other psychiatric conditions, such as depression, anxiety, and bipolar disorder, and its symptoms are often confused with these.2 The difference between borderline personality disorder and the other psychiatric conditions is that the onset of symptoms is sudden and unanticipated, and the distress caused by many of them leads people to seek urgent help.3

Challenges associated with the management of borderline personality disorder

Patients with borderline personality disorder present at GP surgeries, accident and emergency departments, and emergency psychiatric clinics. Urgent treatment is demanded of the GP and also seems to be appropriate. However, when patients present in a highly suicidal state, it is very difficult to make a full assessment in a few minutes and give appropriate treatment unless the patient has presented many times previously, and the GP understands the background to the problem. It is, therefore, very common for patients to receive prescriptions for psychotropic drugs because these are most likely to confer some symptomatic relief immediately. Unfortunately, one of the other manifestations of the disorder, the inability to cope with rejection, makes it difficult for patients on medication to stop treatment. If, therefore, the patient returns after getting some apparent benefit from medication, but feels additional medication is needed, there is a tendency to psychotropic polypharmacy. The patient is reluctant to reduce any medication that might be of value. The same applies to relationships with therapists; patients become attached to the GP who first recognised their disorder and, whether or not treatment is beneficial or further help is needed, there is reluctance to change to an alternative therapist.4

In a worst-case scenario, a GP may have seen a patient with borderline personality disorder over a long period of time, and have prescribed many pharmacological interventions as well as psychosocial counselling, but not referred the patient to specialists. By the time the patient is referred to secondary care, the GP is frustrated and the patient is likely to be on an unhealthy mix of drugs with potentially serious adverse effects.

Treatment

The NICE guideline on Borderline personality disorder treatment and management should help all healthcare professionals avoid six problems often encountered in current practice (see Table 2). The guideline has two central messages:2,4

  • short-term use of sedative medication should be used in a crisis only
  • if other treatments (mainly psychological) are to be given, they should be administered using a structured team approach, i.e. one in which the members work closely together and prevent ‘splitting’ (the tendency for patients to become attached to particular team members, segregating them from others whom they believe to be less able).

The guideline is explicit about the use of medication. Thus, drug treatment is not recommended specifically for borderline personality disorder or for the individual symptoms or behaviour associated with the disorder, and antipsychotic drugs should not be used for the medium- and long-term treatment of borderline personality disorder. It also recommends that brief psychological interventions (of less than 3 months’ duration) are not used specifically for borderline personality disorder or for the individual symptoms of the disorder, outside a service that:

  • has an explicit and integrated theoretical approach
  • can provide structured care
  • has provision for therapist supervision.

This suggests that it would be unwise for GPs to take on any specific psychological treatment for patients with borderline personality disorder unless they have had specific training.

According to epidemiological figures, nearly seven in every 1000 patients on a GP’s register will have borderline personality disorder at any one time.4 The condition is more common in late adolescence or early adult life, although it is often not formally diagnosed before the age of 18 years.2 It is, therefore, not appropriate for every patient to be referred for intensive psychological treatment. For those with less serious disorders it can be of great help to discuss the diagnosis with the patient and the circumstances in which a referral might be needed. It would be better not to attempt any specific treatment, but instead offer support and understanding.

For the most severe forms of borderline personality disorder, a structured long-term (at least 6 months but usually longer) form of management, such as dialectical behaviour therapy, mentalisation-based treatment, cognitive analytical therapy, or modified cognitive behaviour therapy, is given.4 These treatments share more features than differences, and the structured planned team approach is perhaps the most important aspect of this. However, it is only those who have recurrent episodes of serious self-harm or who repeatedly present to emergency psychiatric facilities who are normally referred for these treatments.4 Most other patients with borderline personality disorder can be seen and treated by mental health teams in the community where the GPs are increasingly supported by other personnel attached to personality disorder services.2

Table 2: How following the NICE guideline can help to improve care of those with borderline personality disorder

NICE guideline recommendation What tends to happen now How the guideline should improve care
Avoid polypharmacy whenever possible Polypharmacy is common as there is unwillingness to stop existing drug treatment By reducing unnecessary and potentially dangerous polypharmacy
Short-term treatment aims should be developed by multidisciplinary teams Some GPs attempt to provide care on their own, which can be counterproductive Referral to team-based structured care is more likely to lead to successful outcomes
Borderline personality disorder is often confused with other psychiatric conditions Borderline personality disorder may be mistaken for bipolar disorder, schizophrenia, depression, and anxiety, and treated inappropriately By reducing unnecessary drug treatment
Refer to community mental health and specialist personality disorder services when needed Referrals are made but borderline personality disorder is not often mentioned on referral If borderline personality disorder is recognised earlier, more appropriate assessment and treatment is likely
Develop a simple crisis plan Each crisis is dealt with on an ad hoc basis Problems may be anticipated if a crisis plan is developed
Transition from one service to another may evoke strong emotions Feelings of abandonment can lead to suicidal behaviour and other crises By reducing suicidal behaviour

Services

In England, it is now recommended that all PCTs should have a personality disorder service.4 There are now some 20 such services across the country and, even in the present economic circumstances, these are still expected to expand.5 It is important that GPs acknowledge that they can be a very important part of a multidisciplinary team delivering structured planned treatment programmes.

Implementation of the guideline

With the recommended management outlined, patients with borderline personality disorder are likely to benefit from a better outcome than previously realised, with little stigma attached to the diagnosis. Good management results in a favourable prognosis, with over 80% of patients losing the diagnosis over time, and few relapsing subsequently.6 Implementation of the NICE guideline should further improve future outcomes for patients with borderline personality disorder. The main barrier to implementation will come from the absence of teams with specialist knowledge of borderline personality disorder in some parts of the country, but even this is being addressed.

Summary

One impact of this guideline is that borderline personality disorder will now be better recognised. Although it may be thought that people with this condition might shy away from any discussion of their diagnosis, this is now less true than it used to be as the disorder is gradually becoming destigmatised.

For GPs, the key aspects of the NICE guideline are early recognition and focused referral. If services for borderline personality disorder exist in the area, they should be used. If no specific services are present, a referral to a community mental healthcare team with reference to the possibility of borderline personality disorder will alert the team to the need for careful assessment. It is also likely that GPs will become involved in the network of services for an individual patient, not to a major degree, but as a cohesive part of a complex treatment plan.

NICE implementation tools

NICE has developed the following tools to support implementation of its guideline on Borderline personality disorder: treatment and management. They are now available to download from the NICE website: www.nice.org.uk

Costing tools

National cost reports and local cost templates for the guideline have been produced:

  • costing reports are estimates of the national cost impact arising from implementation based on assumptions about current practice, and predictions of how it might change following implementation of the guideline.

Slide set

The slides are aimed at supporting organisations to raise awareness of the guideline and resulting implementation issues at a local level, and can be edited to cater for local audiences. This information does not supersede or replace the guidance itself.

Audit support

This has been developed to support the implementation of the NICE guideline on borderline personality disorder. The aim is to help NHS organisations with a baseline assessment and to assist with the audit process, thereby helping to ensure that practice is in line with the NICE recommendations. The audit support is based on the key recommendations of the guidance and includes criteria and data collection tools.

  1. American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 4th Revision. Washington: American Psychiatric Association, 2004.
  2. National Institute for Health and Care Excellence. Borderline personality disorder: treatment and management. Clinical Guideline 78. London: NICE, 2009. Available at: www.nice.org.uk/guidance/CG78
  3. Gross R, Olfson M, Gameroff M et al. Borderline personality disorder in primary care. Archives of Internal Medicine 2002; 162 (1): 53–60.
  4. National Collaborating Centre for Mental Health. Borderline personality disorder: treatment and management. Clinical Guideline 78. London: NICE, 2009. Available at: www.nice.org.uk/guidance/CG78
  5. Personality disorder website. www.personalitydisorder.org.uk/index.php (accessed 25 June).
  6. Zanarini M, Frankenburg F, Hennen J, Silk K. The longitudinal course of borderline psychopathology: 6-year prospective follow-up of the phenomenology of borderline personality disorder. Am J Psych 2003; 160 (2): 274–283. G