Borderline personality disorder

NICE Pathways bring together everything NICE says on a topic in an interactive

flowchart. NICE Pathways are interactive and designed to be used online.

They are updated regularly as new NICE guidance is published. To view the latest
version of this NICE Pathway see:

http://pathways.nice.org.uk/pathways/personality-disorders
NICE Pathway last updated: 10 August 2018

This document contains a single flowchart and uses numbering to link the boxes to the
associated recommendations.

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1 Borderline personality disorder in children, young people and adults

No additional information

2 Recognition of borderline personality disorder in primary care

If a person presents in primary care who has repeatedly self-harmed or shown persistent risk-
taking behaviour or marked emotional instability, consider referring them to community mental
health services for assessment for borderline personality disorder.

If the person is younger than 18 years, refer them to CAMHS for assessment.

3 Referral to community mental health services

Consider referring a person with diagnosed or suspected borderline personality disorder who is
in crisis to a community mental health service when:

their levels of distress and/or the risk of harm to self or others are increasing
their levels of distress and/or the risk of harm to self or others have not subsided despite
attempts to reduce anxiety and improve coping skills
they request further help from specialist services.

4 Inpatient services

Before considering admission to an acute psychiatric inpatient unit for a person with borderline
personality disorder, first refer them to a crisis resolution and home treatment team or other
locally available alternative to admission.

Only consider admission to an acute psychiatric inpatient unit for:

the management of crises involving significant risk to self or others that cannot be managed
within other services, or
detention under the Mental Health Act (for any reason).

When considering inpatient care, actively involve the person in the decision and:

ensure the decision is based on an explicit, joint understanding of the potential benefits and
likely harm that may result from admission

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 Borderline personality disorder NICE Pathways

agree the length and purpose of the admission in advance

ensure that when, in extreme circumstances, compulsory treatment is used, management
on a voluntary basis is resumed at the earliest opportunity.

Arrange a formal CPA review for people who have been admitted twice or more in the previous
6 months.

5 Crisis management

When a person with an established diagnosis of borderline personality disorder presents to

primary care in a crisis:

assess the current level of risk to self or others

ask about previous episodes and effective management strategies used in the past
help to manage their anxiety by enhancing coping skills and helping them to focus on the
current problems
encourage them to identify manageable changes that will enable them to deal with the
current problems
offer a follow-up appointment at an agreed time.

6 Assessment of people with borderline personality disorder by

community mental health services

See Personality disorders / Assessment of people with borderline personality disorder by

community mental health services

7 Management of borderline personality disorder by community mental

health services

See Personality disorders / Management of borderline personality disorder by community

mental health services

8 See what NICE says on transition from children's to adults' services

See Transition from children's to adults' services

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Borderline personality disorder NICE Pathways

Glossary

Anger control

usually offered to children who are aggressive at school, anger control includes a number of
cognitive and behavioural techniques similar to cognitive problem-solving skills training

Brief strategic family therapy

an intervention that is systemic in focus and is influenced by other approaches such as

structural/systemic family therapy. The main elements include engaging and supporting the
family, identifying maladaptive family interactions and seeking to promote new and more
adaptive family interactions

CAMHS

child and adolescent mental health service

Cognitive problem-solving skills training

an intervention that aims to reduce children's conduct problems by teaching them different
responses to interpersonal situations. Using cognitive and behavioural techniques with the child,
the training has a focus on thought processes.

The training includes:

teaching a step-by-step approach to solving interpersonal problems

structured tasks such as games and stories to aid the development of skills
combining a variety of approaches including modelling and practice, role-playing and
reinforcement
CPA

Care Programme Approach

Functional family therapy

family-based intervention that is behavioural in focus. The main elements include engagement
and motivation of the family in treatment, problem-solving and behaviour change through
parent-training and communication-training

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Borderline personality disorder NICE Pathways

Multidimensional treatment foster care

using strategies from family therapy and behaviour therapy to intervene directly in systems and
processes related to antisocial behaviour (for example, parental discipline, family affective
relations, peer associations and school performances) for children or young people in foster
care and other out-of-home placements

Multisystemic therapy

using strategies from family therapy and behaviour therapy to intervene directly in systems and
processes related to antisocial behaviour (for example, parental discipline, family affective
relations, peer associations and school performances) for children or young people

Parent-training programme

an intervention that aims to teach the principles of child behaviour management, to increase
parental competence and confidence in raising children and to improve the parent/carer-child
relationship by using good communication and positive attention to aid the child's development

Self-talk

the internal conversation a person has with themselves in response to a situation. Using or
changing self-talk is a part of anger control training

Social problem-solving skills training

a specialist form of cognitive problem-solving training that aims to:

modify and expand the child's interpersonal appraisal processes through developing a more
sophisticated understanding of beliefs and desires in others
improve the child's capacity to regulate his or her own emotional responses

Sources

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

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Borderline personality disorder NICE Pathways

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful
consideration of the evidence available. When exercising their judgement, professionals and
practitioners are expected to take this guideline fully into account, alongside the individual
needs, preferences and values of their patients or the people using their service. It is not
mandatory to apply the recommendations, and the guideline does not override the responsibility
to make decisions appropriate to the circumstances of the individual, in consultation with them
and their families and carers or guardian.

Local commissioners and providers of healthcare have a responsibility to enable the guideline
to be applied when individual professionals and people using services wish to use it. They
should do so in the context of local and national priorities for funding and developing services,
and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to
advance equality of opportunity and to reduce health inequalities. Nothing in this guideline
should be interpreted in a way that would be inconsistent with complying with those duties.

Commissioners and providers have a responsibility to promote an environmentally sustainable

health and care system and should assess and reduce the environmental impact of
implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after
careful consideration of the evidence available. When exercising their judgement, health
professionals are expected to take these recommendations fully into account, alongside the
individual needs, preferences and values of their patients. The application of the
recommendations in this interactive flowchart is at the discretion of health professionals and
their individual patients and do not override the responsibility of healthcare professionals to
make decisions appropriate to the circumstances of the individual patient, in consultation with
the patient and/or their carer or guardian.

Commissioners and/or providers have a responsibility to provide the funding required to enable
the recommendations to be applied when individual health professionals and their patients wish
to use it, in accordance with the NHS Constitution. They should do so in light of their duties to

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Borderline personality disorder NICE Pathways

have due regard to the need to eliminate unlawful discrimination, to advance equality of
opportunity and to reduce health inequalities.

Commissioners and providers have a responsibility to promote an environmentally sustainable

health and care system and should assess and reduce the environmental impact of
implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures

guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after
careful consideration of the evidence available. When exercising their judgement, healthcare
professionals are expected to take these recommendations fully into account. However, the
interactive flowchart does not override the individual responsibility of healthcare professionals to
make decisions appropriate to the circumstances of the individual patient, in consultation with
the patient and/or guardian or carer.

Commissioners and/or providers have a responsibility to implement the recommendations, in

their local context, in light of their duties to have due regard to the need to eliminate unlawful
discrimination, advance equality of opportunity, and foster good relations. Nothing in this
interactive flowchart should be interpreted in a way that would be inconsistent with compliance
with those duties.

Commissioners and providers have a responsibility to promote an environmentally sustainable

health and care system and should assess and reduce the environmental impact of
implementing NICE recommendations wherever possible.

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