limitations of treatment for borderline and histrionic PD

Group 2: Discuss the limitations of treatment for borderline and histrionic PD and what can be done from a psychopharmacological perspective.

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2018 surv2018 surveillance of personalityeillance of personality
disorders (NICE guidelines CG77 anddisorders (NICE guidelines CG77 and
CG78)CG78)

Surveillance report

Published: 19 July 2018
nice.org.uk

© NICE 2018. All rights reserved. Subject to Notice of rights (https://www.nice.org.uk/terms-and-conditions#notice-of-
rights).

http://nice.org.uk

ContentsContents

Surveillance decision ……………………………………………………………………………………………………………………………….. 3

Reasons for the decision …………………………………………………………………………………………………………………………………….. 3

Overview of 2018 surveillance methods……………………………………………………………………………………………… 5

Evidence considered in surveillance …………………………………………………………………………………………………………………. 6

Ongoing research………………………………………………………………………………………………………………………………………………….. 6

Intelligence gathered during surveillance………………………………………………………………………………………………………… 7

Overall decision …………………………………………………………………………………………………………………………………………………….. 14

2018 surveillance of personality disorders (NICE guidelines CG77 and CG78)

© NICE 2018. All rights reserved. Subject to Notice of rights (https://www.nice.org.uk/terms-and-
conditions#notice-of-rights).

Page 2 of
14

SurvSurveillance decisioneillance decision

We will not update the following guidelines on personality disorders:

Antisocial personality disorder: prevention and management (2009) NICE guideline CG77

Borderline personality disorder: recognition and management (2009) NICE guideline CG78

Reasons for the decision

An advance preview of the new version 11 of the International Classification of Diseases (ICD-11)

was released in June 2018. It will be presented at the World Health Assembly in May 2019 for

adoption by member states. This version introduces substantial changes in the way personality

disorder is classified. It removes all categories of personality disorder and replaces them with a

single dimensional scale of personality disorder severity. Trait domain qualifiers may be applied to

describe the personality characteristics that are most prominent, but do not count as diagnoses in

their own right.

Given the pending changes in ICD-11 to personality disorder classification, we will not update the

NICE guidelines on antisocial personality disorder and borderline personality disorder at this time.

We will perform an exceptional surveillance review of these guidelines in 2021, in order to gauge

the reaction of the community to ICD-11 and consider any potential impact before deciding

whether to update NICE’s personality disorder

guidelines.

In the current surveillance of the 2 guidelines, new evidence identified either supported

recommendations or was insufficient to propose an update. Specific considerations for the

individual guidelines are stated below.

Antisocial personality disorderAntisocial personality disorder

The surveillance process for NICE guideline CG77 followed the static list review process therefore

no formal evidence searches were done. Most evidence came from topic experts and is discussed in

the views of topic experts section of this report.

Borderline personality disorderBorderline personality disorder

Evidence supporting current recommendations was found for: patient experience; recognition of

borderline personality disorder; borderline personality disorder in young people; and general

psychotherapies.

2018 surveillance of personality disorders (NICE guidelines CG77 and CG78)
© NICE 2018. All rights reserved. Subject to Notice of rights (https://www.nice.org.uk/terms-and-
conditions#notice-of-rights).

Page 3 of
14

http://www.nice.org.uk/guidance/cg77

http://www.nice.org.uk/guidance/cg78

https://icd.who.int/browse11/l-m/en

Evidence was found for the following areas within the guideline scope but outside current

recommendations, that was insufficient to update the guideline or showed no benefit: screening

instruments; dialectical behaviour therapy (other than for women who self-harm);

psychoeducation; transference-focused psychotherapy; mentalisation; motive-oriented

therapeutic relationship; interpersonal psychotherapy; cognitive therapy; cognitive behavioural

therapy; schema-focused therapy; and drug treatment.

For further details and a summary of all evidence identified in surveillance, see appendix A.

Page 4 of
14

https://www.nice.org.uk/guidance/cg77/evidence/appendix-a-summary-of-evidence-from-surveillance-pdf-4906490078

OvOverview of 2018 surverview of 2018 surveillance methodseillance methods

NICE’s surveillance team checked whether recommendations in the following guidelines remain up

to date:

Antisocial personality disorder (NICE guideline CG77).

Borderline personality disorder (NICE guideline CG78).

The surveillance process consisted of:

Initial feedback from topic experts via a questionnaire.

A search for new or updated Cochrane reviews and national policy.

A search for ongoing research.

Examining related NICE guidance and quality standards.

Examining the NICE event tracker for relevant ongoing and published events.

Literature searches to identify relevant evidence for borderline personality

disorder.

Assessing the new evidence against current recommendations and deciding whether or not to

update sections of the guideline, or the whole guideline.

Consulting on the decision with stakeholders.

Considering comments received during consultation and making any necessary changes to the

decision.

For further details about the process and the possible update decisions that are available, see

ensuring that published guidelines are current and accurate in developing NICE guidelines: the

manual.

Page 5 of
14

http://www.nice.org.uk/guidance/cg77

http://www.nice.org.uk/guidance/cg78

https://www.nice.org.uk/process/pmg20/chapter/ensuring-that-published-guidelines-are-current-and-accurate

Evidence considered in surveillance

Search and selection strSearch and selection strategyategy

Antisocial personality disorAntisocial personality disorderder

This topic was a static list review and therefore, in accordance with the static list review process,

literature searches were not conducted. However, we considered 18 studies identified by previous

surveillance.

BorBorderline personality disorderline personality disorderder

We searched for new evidence related to the whole guideline.

We found 19 studies in a search for randomised controlled trials and systematic reviews published

between 1 October 2014 and 7 March 2018.

We also included:

1 relevant study identified by topic experts

2 studies identified through comments received after publication of the guideline

29 studies identified by previous surveillance.

From all sources, we considered 51 studies to be relevant to the guideline.

See appendix A: summary of evidence from surveillance for details of all evidence considered, and

references.

Ongoing research

We checked for relevant ongoing research. Of the studies identified, 3 studies relating to antisocial

personality disorder and 4 studies relating to borderline personality disorder were assessed as

having the potential to change recommendations; therefore we plan to regularly check whether

these studies have published results, and evaluate the impact of the results on current

recommendations as quickly as possible. These studies are:

Page 6 of
14

https://www.nice.org.uk/guidance/cg77/evidence/appendix-a-summary-of-evidence-from-surveillance-pdf-4906490078

Antisocial personality disorderAntisocial personality disorder

A small randomised controlled trial on schema mindfulness training versus COMET (correcting

a dysfunctional self-image using counter-conditioning) for patients with a personality disorder

(also relevant to borderline personality disorder).

Dialectical behavior therapy for men with borderline personality disorder and antisocial

behavior (also relevant to borderline personality disorder).

Mentalization-based therapy (MBT) for individuals with antisocial personality disorder.

Borderline personality disorderBorderline personality disorder

Group schema therapy for borderline personality disorder*.

*Studies have the same title but are separate.

Intelligence gathered during surveillance

Views of topic eViews of topic expertsxperts

We sent questionnaires to 16 topic experts and received 7 responses for antisocial personality

disorder and 6 for borderline personality disorder. The topic experts either:

participated in the guideline committee who developed the guideline, or

were recruited to the NICE Centre for Guidelines Expert Advisers Panel to represent their

specialty.

Topic experts were asked some specific questions about evidence and information identified during

the surveillance reviews of the personality disorders guidelines:

Some evidence was identified suggesting instruments for assessing personality disorders can

increase personality disorder diagnoses. However experts had mixed opinions on these tools,

with some noting the risk of false positives.

Experts noted that although the new Diagnostic and Statistical Manual of Mental Disorders

(DSM-5) has been published, it essentially retains the personality disorder classification

structure of the previous version 4 and therefore is unlikely to affect the guidelines.

Page 7 of
14

https://www.isrctn.com/ISRCTN23894653

https://www.isrctn.com/ISRCTN23976022

https://www.isrctn.com/ISRCTN32309003

https://www.isrctn.com/ISRCTN76381242

http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=2392

Experts suggested that the new ICD-11 could have an impact on the guidelines, but they noted

that it may be appropriate to gauge the community’s reaction before any update is considered.

Other areas of interest noted by topic experts included:

The NHS and National Offender Management Service (which is now Her Majesty’s Prison and

Probation Service) have a joint responsibility for this population.

The Dangerous and Severe Personality Disorder (DSPD) Programme, in place when NICE

guideline CG77 was developed, has been replaced by the Offender Personality Disorder (OPD)

Pathway.

NICE has now published a guideline on mental health of adults in contact with the criminal justice

system which includes recommendations on organisation of services for commissioners and

providers of criminal justice services and healthcare services. Adding a link to this guideline in NICE

guidelines CG77 and CG78 will go towards addressing some of the issues raised by topic experts.

Implementation of the guidelineImplementation of the guideline

Topic experts raised the issue that many people with diagnosable borderline personality disorder

receive help, support and sometimes treatment in non-health settings, where there may be little

awareness of relevant NICE guidelines. This information has been passed to the NICE field team.

Views of stakViews of stakeholderseholders

Stakeholders are consulted on all surveillance decisions except if the whole guideline will be

updated and replaced. Because this surveillance decision was to not update the guidelines, we

consulted on the decision.

Antisocial personality disorAntisocial personality disorderder

Overall, 7 stakeholders commented (3 royal colleges, 2 NHS trusts, a government department, and

a charity): 1 agreed with the decision; 2 disagreed with the decision;

4 did not provide an answer.

The following issues were raised in disagreement with the proposal not to update.

A stakeholder stated that treatment recommendations in NICE guideline CG77 are overly focused

on the prison population. The evidence base for treatment outside the criminal justice system is

limited, and NICE guideline CG77 does acknowledge that ‘…the focus of several interventions is

offending behaviour’. However some treatment recommendations do include mental health

Page 8 of
14

http://www.nice.org.uk/guidance/ng66

https://www.nice.org.uk/about/what-we-do/into-practice/nice-field-team

services settings. A NICE research recommendation was made to attempt to address the lack of

evidence in this area: ‘4.2 Group-based cognitive and behavioural interventions for populations

outside criminal justice settings’.

A stakeholder noted issues with the construct and labelling of personality disorder (the same

comment was also made about borderline personality disorder). However, any decision on changes

to the guideline in this area will be best made once NICE and the wider community have had chance

to review and respond to ICD-11, which introduces substantial changes in the classification of

personality disorders and could have major implications for NICE guidelines CG77 and CG78.

A stakeholder was concerned that the decision not to update the guideline could lead to failures to

fund adequately in these areas (the same comment was also made about borderline personality

disorder). However, the guideline retains the status of NICE guidance whether it is updated or not.

No reduction in funding as a result of the decision not to update it at this time is anticipated.

A stakeholder stated that the focus is predominantly on men in NICE guideline CG77 and women in

NICE guideline CG78 (the same comment was also made about borderline personality disorder).

However, the guideline scopes do not specify any particular focus on men or women, and only

1 recommendation in each guideline is specific to a particular sex.

BorBorderline personality disorderline personality disorderder

Overall, 8 stakeholders commented (3 royal colleges, 2 NHS trusts, a government department, a

charity, and a non-profit organisation): 2 agreed with the decision; 2 disagreed with the decision;

4 did not provide an answer.

The following issues were raised in disagreement with the decision not to update.

A stakeholder commented that NICE guideline CG78 does not recommend any pharmacological

treatments, but many people are taking these and an update is needed to emphasise not

prescribing. As noted by the stakeholder, NICE guideline CG78 makes an explicit recommendation

that drug treatment should not be used specifically for borderline personality disorder or for the

individual symptoms or behaviour associated with the disorder. Implementation of the guideline,

which includes the monitoring of ‘do not do’ recommendations, is outside the remit of surveillance

reviews. However concerns about the use of drugs in this population will be passed on to our

implementation team.

Page 9 of
14

https://www.nice.org.uk/guidance/cg77/chapter/4-Research-recommendations#group-based-cognitive-and-behavioural-interventions-for-populations-outside-criminal-justice

A stakeholder noted there are still no NICE-recommended, evidence-based treatments or

managements, and that NICE should consider lobbying for urgently needed research. The

surveillance review identified several studies on management strategies for borderline personality

disorder but it was felt that there was not enough evidence to indicate any need to update the

guideline. NICE is able to suggest areas for research through its research recommendations. NICE

guideline CG78 has 4 research recommendations about management of borderline personality

disorder.

A stakeholder indicated a need to address that personality disorders affect men, women and

ethnicities differently. NICE guideline CG78 does acknowledge differences among these groups,

for example a recommendation is made about a specific approach to management in women.

Additionally, the guideline recommends that people from black and minority ethnic groups have

equal access to culturally appropriate services based on clinical need.

Additional consultation questionsAdditional consultation questions

Additionally, stakeholders were asked for their views on whether or not they anticipated ICD-11

classification would be adopted in the UK, and if they felt that would impact on the guidelines. Of

the 5 stakeholders responding, 4 felt it would be adopted and 3 felt it would impact on the

guidelines.

The majority of stakeholders responding yes to these questions lends support to the decision not to

update the guidelines at this time, but to perform a further surveillance review in 2021 to gauge the

reaction of the community to ICD-11 and examine any potential impact on NICE guidelines CG77

and 78.

See appendix B for full details of stakeholders’ comments and our responses.

See ensuring that published guidelines are current and accurate in developing NICE guidelines: the

manual for more details on our consultation processes.

EqualitiesEqualities

No equalities issues were identified during the surveillance process.

Editorial amendmentsEditorial amendments

During surveillance of the guideline we identified the following points in the guideline that should

be amended.

Page 10 of
14

https://www.nice.org.uk/guidance/cg78/chapter/4-Research-recommendations

https://www.nice.org.uk/guidance/cg77/evidence/appendix-b-stakeholder-consultation-comments-table-pdf-4906490079

https://www.nice.org.uk/process/pmg20/chapter/ensuring-that-published-guidelines-are-current-and-accurate

Antisocial personality disorAntisocial personality disorderder

In the full version of NICE guideline CG77, page 139/140: recommendation 5.4.24.1 on

multisystemic therapy will be deleted because the corresponding recommendation (1.2.7.6) in

the short guideline has been deleted (now replaced by recommendation 1.5.13 in NICE’s

guideline on antisocial behaviour and conduct disorders in children and young people).

The person-centred care section of the short version of NICE guideline CG77 will be replaced

with the following box in line with newer NICE guidelines:

People have the right to be involved in discussions and make informed decisions about their

care, as described in your care.

Making decisions using NICE guidelines explains how we use words to show the strength (or

certainty) of our recommendations, and has information about professional guidelines,

standards and laws (including on consent and mental capacity), and safeguarding.

Footnote 2 in recommendation 1.6.3.1 contains a hyperlink to ‘The Essential Shared

Capabilities’. This link goes to the wrong page; this is the correct link to the Essential Shared

Capabilities).

The following cross-referrals will be added to NICE guideline CG77:

From recommendation 1.1.2.2: ‘Staff providing interventions for people with antisocial

personality disorder with learning or physical disabilities or acquired cognitive

impairments…’: a link will be added to NICE’s guideline on mental health problems in

people with learning disabilities: prevention, assessment and

management.

From recommendation 1.2.9.1 ‘Health and social care services should consider referring

vulnerable young people with a history of conduct disorder or contact with youth

offending schemes, or those who have been receiving interventions for conduct and

related disorders, to appropriate adult services for continuing assessment and/or

treatment’: a link will be added to NICE’s guideline on transition from children’s to

adults’ services for young people using health or social care services.

From recommendation 1.3.3.1 ‘Services should develop a comprehensive risk

management plan for people with antisocial personality disorder who are considered to

be of high risk…’, and recommendation 1.4.3.1 ‘Pharmacological interventions should

not be routinely used for the treatment of antisocial personality disorder or associated

behaviours of aggression, anger and impulsivity’: a link will be added to NICE’s guideline

on violence and aggression: short-term management in mental health, health and

Page 11 of
14

https://www.nice.org.uk/guidance/cg77/evidence/full-guideline-pdf-242104429

http://www.nice.org.uk/guidance/cg158

https://www.nice.org.uk/guidance/cg77/chapter/Person-centred-care

http://www.nice.org.uk/about/nice-communities/public-involvement/your-care

http://www.nice.org.uk/about/what-we-do/our-programmes/nice-guidance/nice-guidelines/making-decisions-using-nice-guidelines

http://webarchive.nationalarchives.gov.uk/20121102194625/http:/www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4087169

http://www.nice.org.uk/guidance/ng54

http://www.nice.org.uk/guidance/ng43

http://www.nice.org.uk/guidance/ng10

community settings (from recommendation 1.4.3.1, the link will be to the specific

recommendations in NICE guideline NG10 about rapid tranquilisation).

From recommendation 1.6.1.1 ‘Provision of services for people with antisocial

personality disorder ….’: a link will be added to NICE’s guideline on mental health of

adults in

contact with the criminal justice system.

In recommendations 1.4.1.1, 1.4.3.2 and 1.4.4.1 (which state that comorbid disorders

should be treated in line with recommendations in the relevant NICE guideline, and

provide a link to an outdated and incomplete list of related NICE guidance in section 6),

the link to section 6 will be replaced with: see the NICE mental health and behavioural

conditions

topic page, or search the NICE find guidance page.

In recommendation 1.5.1.2 ‘For people who meet criteria for psychopathy or DSPD,

offer treatment for any comorbid disorders in line with existing NICE guidance…’, the

following text will be added: See the NICE mental health and behavioural conditions

topic page, or search the NICE find guidance page.

Research recommendations 4.3 effectiveness of multisystemic therapy versus functional

family therapy and 4.4 interventions for infants at high risk of developing conduct disorders

will be deleted because these areas are now covered by recommendations in NICE’s guideline

on antisocial behaviour and conduct disorders in children and young people: recognition and

management.
BorBorderline personality disorderline personality disorderder

The person-centred care section of the short version of NICE guideline CG78 will be replaced

with the following box in line with newer NICE guidelines:
People have the right to be involved in discussions and make informed decisions about their
care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or
certainty) of our recommendations, and has information about professional guidelines,
standards and laws (including on consent and mental capacity), and safeguarding.

In footnote 2 to recommendation 1.3.1.2, the hyperlink to the SCIE research briefing

‘Experiences of children and young people caring for a parent with a mental health problem’ is

broken and will be fixed. This is the correct link to the SCIE research briefing on the experience

of children and young people caring for a parent with a mental health problem.

Page 12 of
14

http://www.nice.org.uk/guidance/ng10

http://www.nice.org.uk/guidance/ng66

https://www.nice.org.uk/guidance/cg77/chapter/6-Related-NICE-guidance

https://www.nice.org.uk/guidance/conditions-and-diseases/mental-health-and-behavioural-conditions

https://www.nice.org.uk/guidance

https://www.nice.org.uk/guidance/conditions-and-diseases/mental-health-and-behavioural-conditions

https://www.nice.org.uk/guidance

https://www.nice.org.uk/guidance/cg77/chapter/4-Research-recommendations

http://www.nice.org.uk/guidance/cg158

https://www.nice.org.uk/guidance/cg78/chapter/Person-centred-care

http://www.nice.org.uk/about/nice-communities/public-involvement/your-care

http://www.nice.org.uk/about/what-we-do/our-programmes/nice-guidance/nice-guidelines/making-decisions-using-nice-guidelines

https://www.scie.org.uk/publications/briefings/briefing24/

The hyperlink in recommendation 1.3.8.2 to NICE technology appraisal guidance 77 is broken

and will be fixed. This is the correct link to NICE technology appraisal guidance 77.

The following cross-referrals will be added to the guideline:

From recommendation 1.1.2.4 ‘People with a moderate or severe learning disability

should not normally be diagnosed with borderline personality disorder…’: a link will be

added to NICE’s guideline on mental health problems in people with learning

disabilities: prevention, assessment and management.

From recommendation 1.1.7.2 ‘CAMHS and adult healthcare professionals should work

collaboratively to minimise any potential negative effect of transferring young people

from CAMHS to adult services…’: a link will be added to the NICE topic overview page

for service transition.

The wording of recommendation 1.1.8.1 ‘Follow the recommendations in ‘Self-harm’

(NICE clinical guideline 16) to manage episodes of self-harm or attempted suicide’ will

be changed to ‘Follow the recommendations in NICE’s guidelines on self-harm in over

8s: short-term management and prevention of recurrence and self-harm in over 8s:

long-term management to manage episodes of self-harm or attempted suicide’.

The wording of recommendation 1.3.6.4 will be changed from: ‘When treating a

comorbid condition in people with borderline personality disorder, follow the NICE

clinical guideline for the comorbid condition’ to: ‘When treating a comorbid condition in

people with borderline personality disorder, follow the NICE clinical guideline for the

comorbid condition (see the NICE mental health and behavioural conditions topic page,

or search the NICE find guidance page)’.

From recommendation 1.3.7.1 ‘When a person with borderline personality disorder

presents during a crisis…’: a link will be added to NICE’s guideline on violence and

aggression: short-term management in mental health, health and community settings.

From recommendation 1.5.1.1: ‘…develop systems of communication and protocols for

information sharing among different services, including those in forensic settings, and

collaborate with all relevant agencies within the local community including health,

mental health and social services, the criminal justice system, CAMHS and relevant

voluntary services’: a link will be added to NICE’s guideline on mental health of adults in

contact with the criminal justice system.
2018 surveillance of personality disorders (NICE guidelines CG77 and CG78)
© NICE 2018. All rights reserved. Subject to Notice of rights (https://www.nice.org.uk/terms-and-
conditions#notice-of-rights).

Page 13 of
14

http://www.nice.org.uk/guidance/ta77

http://www.nice.org.uk/guidance/ng54

https://www.nice.org.uk/guidance/service-delivery–organisation-and-staffing/service-transition

http://www.nice.org.uk/guidance/cg16

http://www.nice.org.uk/guidance/cg133

https://www.nice.org.uk/guidance/conditions-and-diseases/mental-health-and-behavioural-conditions

https://www.nice.org.uk/guidance

http://www.nice.org.uk/guidance/ng10

http://www.nice.org.uk/guidance/ng66

Overall decision

After considering all evidence and other intelligence and the impact on current recommendations,

we decided that no update is necessary to NICE guidelines CG77 or CG78.

ISBN: 978-1-4731-3015-9

Page 14 of
14

Overview of 2018 surveillance methods
Evidence considered in surveillance
Search and selection strategy
Antisocial personality disorder
Borderline personality disorder

Ongoing research
Antisocial personality disorder
Borderline personality disorder
Intelligence gathered during surveillance
Views of topic experts
Implementation of the guideline
Views of stakeholders
Antisocial personality disorder
Borderline personality disorder
Additional consultation questions
Equalities
Editorial amendments
Antisocial personality disorder
Borderline personality disorder

Overall decision

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limitations of treatment for borderline and histrionic PD

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