Official symptoms: •unstable self image or sense of self •frantic efforts to avoid real or imagined abandonment •a pattern of unstable and intense interpersonal relationships •impulsivity in areas that are potentially self-damaging •affective instability due to a marked reactivity of mood •chronic feelings of emptiness •inappropriate, intense anger or difficulty controlling anger •transient, stress-related paranoid ideation or severe dissociative symptoms •self-harm and suicidal ideation •
Government (NICE)* Guidelines (2009 & 2013)
BPD 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 BPD are particularly at risk of suicide.
The extent of the emotional and behavioural problems experienced by people with BPD varies considerably. Some people with BPD are able to sustain some relationships and occupational activities. People with more severe forms experience very high levels of emotional distress. They have repeated crises, which can involve self-harm and impulsive aggression. They also have high levels of comorbidity, including other personality disorders, and are frequent users of psychiatric and acute hospital emergency services. While the general principles of management referred to in this guideline are intended for all people with BPD, the treatment recommendations are directed primarily at those with more severe forms of the disorder.
BPD is present in just under 1% of the population, and is most common in early adulthood. Women present to services more often than men. BPD is often not formally diagnosed before the age of 18, but the features of the disorder can be identified earlier. Its course is variable and although many people recover over time, some people may continue to experience social and interpersonal difficulties.
BPD is often comorbid with depression, anxiety, eating disorders, post-traumatic stress disorder, alcohol and drug misuse, and bipolar disorder (the symptoms of which are often confused with BPD).
People with BPD should not be excluded from any health or social care service because of their diagnosis or because they have self-harmed.
When working with people with borderline personality disorder:
· explore treatment options in an atmosphere of hope and optimism, explaining that recovery is possible and attainable
· build a trusting relationship, work in an open, engaging and non-judgemental manner, and be consistent and reliable
· bear in mind when providing services that many people will have experienced rejection, abuse and trauma, and encountered stigma often associated with self-harm and BPD.
When assessing a person with BPD:
· explain clearly the process of assessment
· use non-technical language whenever possible
· explain the diagnosis and the use and meaning of the term borderline personality disorder
· offer post-assessment support, particularly if sensitive issues, such as childhood trauma, have been discussed.
People with BPD have sometimes been excluded from any health or social care services because of their diagnosis. This may be because staff lack the confidence and skills to work with this group of people.
When treated consistently with primarily psychological approaches the outcome is good and relapse unlikely, so these longer-term treatments are much more cost-effective.
For people with BPD, overcoming the difficulties associated with this diagnosis can be a huge struggle. However, this struggle is made much more difficult by the frequent lack of understanding and the stigma people with this disorder receive from both inside and outside mental health services; they can be denied services, told they are untreatable, or seen as being blamed for their difficulties. It is frequently overlooked that people with this diagnosis often have had difficult early experiences and difficult lives. This guideline is an important step forward in addressing these issues. If people with this diagnosis are able to have better access to treatment that addresses their needs and are in an environment that encourages understanding, optimism and hope, then more people will be able to move on from this disorder to live fulfilling lives. Recovery is possible.
The implementation of these guidelines will ensure that individuals who are often extremely vulnerable and have complex health and social care needs are no longer excluded from mental health services but are able to access responsive, equitable, quality care.
*NICE—National Institute of Clinical Excellence (sets guidelines for the NHS to follow)
Sue: despite these guidelines, which I believe show an excellent insight into BPD, some counties are still without dedicated services. My home county of Derbyshire, is one of them.