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Personality disorders

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What is covered

This interactive flowchart combines information from two guidelines on the assessment and management of people with antisocial personality disorder and people with borderline personality disorder.

Antisocial personality disorder

People with antisocial personality disorder exhibit traits of impulsivity, high negative emotionality, low conscientiousness and associated behaviours including irresponsible and exploitative behaviour, recklessness and deceitfulness. This is manifest in unstable interpersonal relationships, disregard for the consequences of one's behaviour, a failure to learn from experience, egocentricity and a disregard for the feelings of others. The condition is associated with a wide range of interpersonal and social disturbance.
This interactive flowchart makes recommendations for the treatment, management and prevention of antisocial personality disorder in primary, secondary and tertiary healthcare. These recommendations are concerned with the treatment of people with antisocial personality disorder across a wide range of services including those provided within mental health services, substance misuse services, social care and the criminal justice system.
This interactive flowchart includes recommendations that target a range of populations:
  • treatment and management of adults with a diagnosis of antisocial personality disorder in the NHS and prison system (including Dangerous and Severe Personality Disorder)
  • preventative interventions with children and adolescents at significant risk of developing antisocial personality disorder
  • treatment and management of common comorbidities in people with antisocial personality disorder as far as these conditions affect the treatment of antisocial personality disorder.

Borderline personality disorder

Borderline personality disorder is characterised by significant instability of interpersonal relationships, self-image and mood, and impulsive behaviour. There is a pattern of sometimes rapid fluctuation from periods of confidence to despair, with fear of abandonment and rejection, and a strong tendency towards suicidal thinking and self-harm. Transient psychotic symptoms, including brief delusions and hallucinations, may also be present. It is also associated with substantial impairment of social, psychological and occupational functioning and quality of life. People with borderline personality disorder are particularly at risk of suicide.
Its course is variable and although many people recover over time, some people may continue to experience social and interpersonal difficulties. This interactive flowchart contains recommendations for the treatment and management of borderline personality disorder in adults and young people (under the age of 18) in primary, secondary and tertiary care. It also covers the treatment and management of people diagnosed with emotionally unstable personality disorder based on ICD-10 criteria.

Updates

Updates to this interactive flowchart

10 June 2015 Personality disorders: borderline and antisocial (NICE quality standard 88) added.

Person-centred care

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 prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

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 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.

Short Text

Everything NICE has said on assessing and managing antisocial and borderline personality disorders in an interactive flowchart

What is covered

This interactive flowchart combines information from two guidelines on the assessment and management of people with antisocial personality disorder and people with borderline personality disorder.

Antisocial personality disorder

People with antisocial personality disorder exhibit traits of impulsivity, high negative emotionality, low conscientiousness and associated behaviours including irresponsible and exploitative behaviour, recklessness and deceitfulness. This is manifest in unstable interpersonal relationships, disregard for the consequences of one's behaviour, a failure to learn from experience, egocentricity and a disregard for the feelings of others. The condition is associated with a wide range of interpersonal and social disturbance.
This interactive flowchart makes recommendations for the treatment, management and prevention of antisocial personality disorder in primary, secondary and tertiary healthcare. These recommendations are concerned with the treatment of people with antisocial personality disorder across a wide range of services including those provided within mental health services, substance misuse services, social care and the criminal justice system.
This interactive flowchart includes recommendations that target a range of populations:
  • treatment and management of adults with a diagnosis of antisocial personality disorder in the NHS and prison system (including Dangerous and Severe Personality Disorder)
  • preventative interventions with children and adolescents at significant risk of developing antisocial personality disorder
  • treatment and management of common comorbidities in people with antisocial personality disorder as far as these conditions affect the treatment of antisocial personality disorder.

Borderline personality disorder

Borderline personality disorder is characterised by significant instability of interpersonal relationships, self-image and mood, and impulsive behaviour. There is a pattern of sometimes rapid fluctuation from periods of confidence to despair, with fear of abandonment and rejection, and a strong tendency towards suicidal thinking and self-harm. Transient psychotic symptoms, including brief delusions and hallucinations, may also be present. It is also associated with substantial impairment of social, psychological and occupational functioning and quality of life. People with borderline personality disorder are particularly at risk of suicide.
Its course is variable and although many people recover over time, some people may continue to experience social and interpersonal difficulties. This interactive flowchart contains recommendations for the treatment and management of borderline personality disorder in adults and young people (under the age of 18) in primary, secondary and tertiary care. It also covers the treatment and management of people diagnosed with emotionally unstable personality disorder based on ICD-10 criteria.

Updates

Updates to this interactive flowchart

10 June 2015 Personality disorders: borderline and antisocial (NICE quality standard 88) added.

Sources

NICE guidance and other sources used to create this interactive flowchart.
Antisocial personality disorder: prevention and management (2009 updated 2013) NICE guideline CG77
Personality disorders: borderline and antisocial (2015) NICE quality standard 88
Hypersexuality: fluoxetine (2015) NICE Evidence summary ESUOM46

Quality standards

Personality disorders: borderline and antisocial

These quality statements are taken from the personality disorders: borderline and antisocial quality standard. The quality standard defines clinical best practice for personality disorders: borderline and antisocial and should be read in full.

Quality statements

Structured clinical assessment

This quality statement is taken from the personality disorders: borderline and antisocial quality standard. The quality standard defines clinical best practice in personality disorders: borderline and antisocial care and should be read in full.

Quality statement

Mental health professionals use a structured clinical assessment to diagnose borderline or antisocial personality disorder.

Rationale

Borderline and antisocial personality disorders are complex and difficult to diagnose. Even when borderline or antisocial personality disorder is identified, significant comorbidities are frequently not detected. People often need support that goes beyond healthcare and this makes care planning complex. Carrying out a structured assessment using recognised tools is essential to identify a range of symptoms, make an accurate diagnosis and recognise comorbidities.

Quality measures

Structure
Evidence of local arrangements to ensure that mental health professionals use a structured clinical assessment to diagnose borderline or antisocial personality disorder.
Data source: Local data collection.
Process
Proportion of people with a diagnosis of borderline or antisocial personality disorder who had the diagnosis made by a mental health professional using a structured clinical assessment.
Numerator – the number in the denominator who had the diagnosis made by a mental health professional using a structured clinical assessment.
Denominator – the number of people with a diagnosis of borderline or antisocial personality disorder.
Data source: Local data collection.

What the quality statement means for service providers, mental health professionals, and commissioners

Service providers (mental health trusts) ensure that mental health professionals are trained and competent to carry out a structured clinical assessment to diagnose borderline or antisocial personality disorder.
Mental health professionals carry out and document a structured clinical assessment to diagnose borderline or antisocial personality disorder.
Commissioners (clinical commissioning groups, NHS England local area teams) ensure that they commission services with mental health professionals who are trained and competent to carry out and document a structured clinical assessment to diagnose borderline or antisocial personality disorder.

What the quality statement means for service users and carers

People with possible borderline or antisocial personality disorder have a structured assessment by a specialist in mental health before they are given a diagnosis. The results of the assessment are written in their records. This means that the diagnosis is accurate and that their needs and other health problems are identified from the outset.

Source guidance

Definitions of terms used in this quality statement

Structured clinical assessment
Structured clinical assessment should be undertaken using a standardised and validated tool. The main tools available for diagnosing borderline and antisocial personality disorders include:
  • Diagnostic Interview for DSM–IV Personality Disorders (DIPD–IV)
  • Structured Clinical Interview for DSM–IV Personality Disorders (SCID–II)
  • Structured Interview for DSM–IV Personality (SIDP–IV)
  • International Personality Disorder Examination (IPDE)
  • Personality Assessment Schedule (PAS)
  • Standardised Assessment of Personality (SAP).
[Adapted from Borderline personality disorder (the full guideline CG78), Antisocial personality disorder (the full guideline CG77)].

Equality and diversity considerations

People with borderline or antisocial personality disorder frequently experience a range of comorbid conditions. These may be physical as well as mental health problems. Those working with people with borderline or antisocial personality disorder should always assess all of their needs and offer support accordingly. Diagnosis of borderline or antisocial personality disorder should never exclude people from receiving the help they need.

Psychological therapies – borderline personality disorder

This quality statement is taken from the personality disorders: borderline and antisocial quality standard. The quality standard defines clinical best practice in personality disorders: borderline and antisocial care and should be read in full.

Quality statement

People with borderline personality disorder are offered psychological therapies and are involved in choosing the type, duration and intensity of therapy.

Rationale

The NICE guideline on borderline personality disorder recommends psychological therapies for managing and treating the disorder. Because of the variety of symptoms and the variation in needs, flexible approaches that are responsive to the needs of each person with personality disorder are important. Involving people with borderline personality disorder in decisions regarding their own care is key for their engagement with treatment.

Quality measures

Structure
a) Evidence of local arrangements to ensure that psychological therapies are available to people with borderline personality disorder.
Data source: Local data collection.
b) Evidence of local arrangements to ensure that people with borderline personality disorder are involved in choosing the type, duration and intensity of psychological therapies that they receive.
Data source: Local data collection.
Process
a) Proportion of people with borderline personality disorder who received psychological therapies.
Numerator – the number in the denominator who received psychological therapies.
Denominator – the number of people with borderline personality disorder.
Data source: Local data collection.
b) Proportion of people with borderline personality disorder who chose the type, duration and intensity of psychological therapy they received.
Numerator – the number in the denominator who chose the type, duration and intensity of psychological therapy they received.
Denominator – the number of people with borderline personality disorder who received psychological therapies.
Data source: Local data collection.
Outcome
Evidence from experience surveys and feedback that service users feel actively involved in shared decision-making.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals, and commissioners

Service providers (mental health trusts) offer people with borderline personality disorder psychological therapies that are defined by the service user in terms of type, duration and intensity.
Healthcare professionals offer people with borderline personality disorder psychological therapies that are defined by the service user in terms of type, duration and intensity.
Commissioners (clinical commissioning groups, NHS England local area teams) commission services that have sufficient resources to provide psychological therapies for people with borderline personality disorder that are defined by the service user in terms of type, duration and intensity.

What the quality statement means for service users and carers

People with borderline personality disorder are offered psychological therapies that help them manage their condition. They can choose the type, the length of the sessions, treatment and frequency of the therapy they receive.

Source guidance

Equality and diversity considerations

Adults within the prison population who present with symptoms of borderline personality disorder should have equitable access to services received by people in the community.
Specialist mental health services should ensure that culturally appropriate psychological interventions are provided to people from diverse ethnic and cultural backgrounds and that interventions address cultural and ethnic differences in beliefs regarding biological, social and family influences on mental states and functioning.

Psychological therapies – antisocial personality disorder

This quality statement is taken from the personality disorders: borderline and antisocial quality standard. The quality standard defines clinical best practice in personality disorders: borderline and antisocial care and should be read in full.

Quality statement

People with antisocial personality disorder are offered group-based cognitive and behavioural therapies and are involved in choosing the duration and intensity of the therapy.

Rationale

The NICE guideline on antisocial personality disorder recommends psychological therapies for managing and treating the symptoms and behaviours associated with antisocial personality disorder. Group-based cognitive and behavioural therapies help to address problems such as impulsivity, interpersonal difficulties, and antisocial behaviour, and can help to reduce offending behaviours. Because of the variety of symptoms and the variation in needs, flexible approaches that are responsive to the needs of each person with the disorder are important. Involving people with antisocial personality disorder in decisions about their own care is key for their engagement with treatment.

Quality measures

Structure
a) Evidence of local arrangements to ensure that group-based cognitive and behavioural therapies are available to people with antisocial personality disorder.
Data source: Local data collection.
b) Evidence of local arrangements to ensure that people with antisocial personality disorder are involved in choosing the duration and intensity of group-based cognitive and behavioural therapy that they receive.
Data source: Local data collection.
Process
a) Proportion of people with antisocial personality disorder who received group-based cognitive and behavioural therapy.
Numerator – the number in the denominator who received group-based cognitive and behavioural therapy.
Denominator – the number of people with antisocial personality disorder.
Data source: Local data collection.
b) Proportion of people with antisocial personality disorder who chose the duration and intensity of group-based cognitive and behavioural therapy they received.
Numerator – the number in the denominator who chose the duration and intensity of the group-based cognitive and behavioural therapy they received.
Denominator – the number of people with antisocial personality disorder who received group-based cognitive and behavioural therapy.
Data source: Local data collection.
Outcome
Evidence from experience surveys and feedback that service users feel actively involved in shared decision-making.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals, and commissioners

Service providers (mental health trusts) offer people with antisocial personality disorder group-based cognitive and behavioural therapies that are defined by the service user in terms of duration and intensity.
Healthcare professionals offer people with antisocial personality disorder group-based cognitive and behavioural therapies that are defined by the service user in terms of duration and intensity.
Commissioners (clinical commissioning groups, NHS England local area teams) commission services that have sufficient resources to provide group-based cognitive and behavioural therapies for people with antisocial personality disorder that are defined by the service user in terms of duration and intensity. They also ensure that referral pathways are in place for people with antisocial personality disorder to be referred to these services.

What the quality statement means for service users and carers

People with antisocial personality disorder are offered group therapy that helps them manage their condition. They can choose the length of the sessions, treatment and frequency of the therapy they receive.

Source guidance

Equality and diversity considerations

Consideration should be given to the provision of services for adults within the prison population who present with symptoms of antisocial personality disorder.
Specialist mental health services should ensure that culturally appropriate psychological interventions are provided to people from diverse ethnic and cultural backgrounds and that interventions address cultural and ethnic differences in beliefs regarding biological, social and family influences on mental states and functioning.

Pharmacological interventions

This quality statement is taken from the personality disorders: borderline and antisocial quality standard. The quality standard defines clinical best practice in personality disorders: borderline and antisocial care and should be read in full.

Quality statement

People with borderline or antisocial personality disorders are prescribed antipsychotic or sedative medication only for short-term crisis management or treatment of comorbid conditions.

Rationale

No drugs have established efficacy in treating or managing borderline or antisocial personality disorder. However, antipsychotic and sedative medication can sometimes be helpful in short-term management of crisis (the duration of treatment should be no longer than 1 week) or treatment of comorbid conditions.

Quality measures

Structure
a) Evidence of local arrangements to ensure that people with borderline or antisocial personality disorder are prescribed antipsychotic or sedative medication only for short-term crisis management or treatment of comorbid conditions.
Data source: Local data collection.
b) Evidence of local arrangements to ensure that when people with borderline or antisocial personality disorder are prescribed antipsychotic or sedative medication, there is a record of the reason for prescribing the medication and the duration of the treatment.
Data source: Local data collection.
Process
a) Proportion of people with borderline or antisocial personality disorder prescribed antipsychotic or sedative medication in a crisis or to treat comorbid conditions.
Numerator – the number in the denominator who were prescribed the antipsychotic or sedative medication in a crisis or to treat comorbid conditions.
Denominator – the number of people with borderline or antisocial personality disorder prescribed antipsychotic or sedative medication.
Data source: Local data collection.
b) Proportion of people with borderline or antisocial personality disorder prescribed antipsychotic or sedative medication in a crisis and who had it prescribed for no longer than a week.
Numerator – the number in the denominator prescribed antipsychotic or sedative medication for no longer than a week.
Denominator – the number of people with borderline or antisocial personality disorder prescribed antipsychotic or sedative medication in a crisis.
Data source: Local data collection.
Outcome measure
Antipsychotic and sedative medication prescribing rates.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals, and commissioners

Service providers (GPs and mental health trusts) ensure that staff only prescribe antipsychotic or sedative medication for people with borderline or antisocial personality disorder for short-term crisis management or treatment of comorbid conditions.
Healthcare professionals only prescribe antipsychotic or sedative medication for people with borderline or antisocial personality disorder for short-term crisis management or treatment of comorbid conditions.
Commissioners (clinical commissioning groups, NHS England local area teams) commission services that only prescribe antipsychotic or sedative medication for people with borderline or antisocial personality disorder for short-term crisis management or treatment of comorbid conditions.

What the quality statement means for service users and carers

People with borderline or antisocial personality disorder are only prescribed antipsychotic or sedative medication for a short time if they have a crisis or if they have another condition that needs that medication.

Source guidance

Definitions of terms used in this quality statement

Short-term crisis management
Using sedative or antipsychotic medication for short-term crisis management means using it cautiously in a crisis as part of the overall treatment plan for people with borderline or antisocial personality disorder. The duration of treatment should be agreed with the person, but should be no longer than 1 week.
Crisis may be suicidal behaviour or intention, panic attacks or extreme anxiety, psychotic episodes, or behaviour that seems out of control, or irrational and likely to endanger the person or others.
[Mental health crisis care concordat, Department of Health (2014) and expert opinion]

Managing transitions

This quality statement is taken from the personality disorders: borderline and antisocial quality standard. The quality standard defines clinical best practice in personality disorders: borderline and antisocial care and should be read in full.

Quality statement

People with borderline or antisocial personality disorder agree a structured and phased plan with their care provider before their services change or are withdrawn.

Rationale

Once in treatment, people with borderline or antisocial personality disorder may build a strong attachment with practitioners and services that support them. Any change to the familiar arrangements is likely to cause anxiety and be associated with an increased risk of crisis. Self harming behaviour and suicide attempts often occur at the time of change. Discussing changes in advance and coming up with a structured and phased plan acceptable to the service user, gives them a greater sense of control and reduces associated anxiety. People with borderline or antisocial personality disorder also need to know that they can access services easily in time of crisis. Integrating services is important to establish clear pathways for transitions between services and agencies, and facilitating well organised services, care and support.

Quality measures

Structure
a) Evidence of local arrangements that people with borderline or antisocial personality disorder agree with their care provider a structured and phased plan before their services change or are withdrawn.
Data source: Local data collection.
b) Evidence of local arrangements to ensure that people with borderline or antisocial personality disorder can easily access services in time of crisis.
Data source: Local data collection.
Process
Proportion of changes to services or service withdrawals that have been planned and agreed beforehand by people with borderline or antisocial personality disorder and their care provider.
Numerator – number in the denominator planned and agreed beforehand by people with borderline or antisocial personality disorder and their care provider.
Denominator – changes to services or service withdrawals for people with borderline or antisocial personality disorder.
Data source: Local data collection.
Outcome
a) Service user experience of integrated care.
Data source: Health and Social Care Information Centre 2014 Adult Social Care Outcomes Framework
b) Frequency of crisis situations linked to transitions.
Data source: Local data collection.
c) Evidence from experience surveys and feedback that service users feel actively involved in shared decision making.
Data source: Local data collection.

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers (mental health trusts, primary care services, social services, care homes, probation and prison services) ensure that systems and processes are in place for people with borderline or antisocial personality disorder to agree with their care provider a structured and phased plan before their services change or are withdrawn. This should include plans for accessing services at times of crisis.
Health and social care practitioners ensure that they agree with people with borderline or antisocial personality disorder a structured and phased plan before their services change or are withdrawn. This should include plans for accessing services at times of crisis.
Commissioners (clinical commissioning groups, local authorities and NHS England local area teams) commission services that allow people with borderline or antisocial personality disorder to agree with their care provider a structured and phased plan before their services change or are withdrawn. This should include plans for accessing services at times of crisis.

What the quality statement means for service users and carers

People with borderline or antisocial personality disorder agree with the people providing their care a plan setting out how their services will change before any changes happen. The plan includes what will happen if services are stopped and how they can get help if they have a crisis.

Source guidance

Definitions of terms used in this quality statement

Changes to services
Changes to services include but are not limited to:
  • transition from 1 service to another
  • transfers from inpatient and detention settings to community settings
  • transition from child and adolescent mental health services to adult mental health services
  • discharges after crisis
  • withdrawal of treatment or services
  • ending of treatments or services
  • changes to therapeutic relationship.
Any changes need to be discussed, agreed and documented in a care plan written in collaboration with the service user to enable smooth transitions. The care plan should clearly identify the roles and responsibilities of all health and social care practitioners involved for each person with a personality disorder.

Equality and diversity considerations

Specialist mental health services should ensure that interpreters and advocates are present if any changes need to be discussed with a service user who may have difficulties in understanding the meaning and implications of these changes.

Education and employment goals

This quality statement is taken from the personality disorders: borderline and antisocial quality standard. The quality standard defines clinical best practice in personality disorders: borderline and antisocial care and should be read in full.

Quality statement

People with borderline or antisocial personality disorder have their long term goals for education and employment identified in their care plan.

Rationale

The symptoms of borderline and antisocial personality disorders can often be improved with a range of interventions yet people still find it difficult to live well in the community. Health and social care practitioners develop comprehensive multidisciplinary care plans in collaboration with service users, which identify short term aims such as social care and housing support. However, these care plans should also look at long term goals for education and employment.

Quality measures

Structure
Evidence of local arrangements to ensure that people with borderline or antisocial personality disorder have their long term goals for education and employment identified in their care plan.
Data source: Local data collection.
Process
Proportion of people with borderline or antisocial personality disorder who have their long term goals for education and employment identified in their care plan.
Numerator – number in the denominator who have their long term goals for education and employment identified in their care plan.
Denominator – number of people with borderline or antisocial personality disorder.
Data source: Local data collection.
Outcome
Proportion of people in contact with secondary mental health services who are able and fit to work and are in paid employment.
Data source: Health and Social Care Information Centre 2014 Adult Social Care Outcomes Framework

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers (mental health trusts, primary care services, social services, care homes, probation and prison services) ensure that systems are in place for people with borderline or antisocial personality disorder to have their long term goals for education and employment identified in their care plan.
Health and social care practitioners ensure that people with borderline or antisocial personality disorder have their long term goals for education and employment identified in their care plan.
Commissioners (clinical commissioning groups, local authorities and NHS England local area teams) commission services that ensure that people with borderline or antisocial personality disorder have their long term goals for education and employment identified in their care plan.

What the quality statement means for service users and carers

People with borderline or antisocial personality disorder have a care plan that sets out their goals for education and employment.

Source guidance

Equality and diversity considerations

Services should work in partnership with local stakeholders, including those representing minority ethnic groups, to enable people with borderline or antisocial personality disorder to stay in work or education or access new employment, volunteering and educational opportunities.
Some people may be unable to work or may be unsuccessful in finding employment. In these cases, other occupational or education activities should be considered, including pre vocational training.

Staff supervision

This quality statement is taken from the personality disorders: borderline and antisocial quality standard. The quality standard defines clinical best practice in personality disorders: borderline and antisocial care and should be read in full.

Quality statement

Mental health professionals supporting people with borderline or antisocial personality disorder have an agreed level and frequency of supervision.

Rationale

Some mental health professionals may find working with people with borderline or antisocial personality disorder challenging. People with personality disorder can experience difficulties in communication, building trusting relationships and respecting boundaries. This can be stressful for staff and may sometimes result in negative attitudes. Mental health professionals have a varied remit when supporting people with borderline or antisocial personality disorder. This means that the level and frequency of support and supervision that mental health professionals receive from their managers needs to be tailored to their role and individual needs.

Quality measures

Structure
a) Evidence of local arrangements to ensure that mental health professionals supporting people with borderline or antisocial personality disorder have an agreed level and frequency of supervision.
Data source: Local data collection.
b) Evidence of local arrangements to ensure that the level and frequency of supervision of mental health professionals supporting people with borderline or antisocial personality disorder is monitored.
Data source: Local data collection.
Process
Proportion of mental health professionals supporting people with borderline or antisocial personality disorder who have an agreed level and frequency of supervision.
Nominator – number in the denominator who have an agreed level and frequency of supervision.
Denominator – number of mental health professionals supporting people with borderline or antisocial personality disorder.
Data source: Local data collection.
Outcome
a) Staff retention among mental health professionals.
b) Job satisfaction among mental health professionals.
Data source: Health and Social Care Information Centre (2014) NHS Outcomes framework and NHS Staff Survey.

What the quality statement means for service providers, mental health professionals, and commissioners

Service providers (mental health trusts) ensure that mental health professionals supporting people with borderline or antisocial personality disorder have an agreed level and frequency of supervision with their managers. This is recorded and reflects the individual professional’s needs.
Mental health professionals supporting people with borderline or antisocial personality disorder have an agreed level and frequency of supervision with their managers. This is recorded and reflects the individual professional’s needs.
Commissioners (clinical commissioning groups and NHS England local area teams) commission services that ensure that mental health professionals supporting people with borderline or antisocial personality disorder have an agreed level and frequency of supervision with their managers. This is recorded and reflects the individual professional’s needs.

What the quality statement means for service users and carers

People with borderline or antisocial personality disorder are supported by mental health professionals who are supervised by their managers to make sure they provide a good level of care.

Source guidance

Definitions of terms used in this quality statement

Staff supervision
Staff supervision can be focused on monitoring performance, supporting the individual professional or a mix of both these objectives. Staff supervision should:
  • make use of direct observation (for example, recordings of sessions) and routine outcome measures
  • support adherence to the specific intervention
  • promote general therapeutic consistency and reliability
  • counter negative attitudes among staff.
[Adapted from Antisocial personality disorder (2009) NICE guideline CG77]

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

Information for the public

NICE has written information for the public on each of the following topics.

Pathway information

Person-centred care

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 prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

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 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.

Supporting information

Glossary

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
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
child and adolescent mental health service
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
Care Programme Approach
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
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
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
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
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
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

Paths in this pathway

Pathway created: October 2013 Last updated: March 2017

© NICE 2017

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