This quality standard covers treatment and management of borderline and antisocial personality disorders. For borderline personality disorder, this quality standard applies to adults aged 18 and over and young people post puberty. For antisocial personality disorder, this quality standard applies only to adults aged 18 and over. NICE's quality standard on antisocial behaviour and conduct disorders in children and young people covers antisocial behaviour and conduct disorder in children and young people under 18 years. For more information see the personality disorders topic overview.
NICE was asked by NHS England to develop a quality standard on 2 specific personality disorders, that is, borderline personality disorder and antisocial personality disorder. Borderline and antisocial personality disorders are 2 distinctive conditions that affect people differently and have different care pathways. The diagnosis affects how the condition is managed and the interventions and services that are appropriate. The 2 disorders have been grouped into 1 quality standard to reflect similarity in approaches, not to imply that the 2 conditions are the same.
Antisocial personality disorder can only be diagnosed in adults, whereas borderline personality disorder can also be diagnosed in young people post puberty. For borderline personality disorder, statements within this quality standard apply to young people post puberty as well as adults recognising that young people would be supported by age‑appropriate services (child and adolescent mental health services).
Borderline personality disorder is characterised by significant instability of interpersonal relationships, self‑image and mood, and impulsive behaviour. There is sometimes a pattern of rapid fluctuation from periods of confidence to despair, with fear of abandonment, rejection, and a strong tendency towards suicidal thinking and self‑harm. Borderline personality disorder is often comorbid with depression, anxiety, eating disorders, post‑traumatic stress disorder, alcohol and drug misuse, and bipolar disorder (the symptoms of which can often be confused with borderline personality disorder).
Borderline personality disorder is present in just under 1% of the population. It most commonly presents in early adulthood, with women presenting to services more often than men. It is not usually diagnosed formally before the age of 18 years, but features of the disorder can be identified earlier.
Most people with borderline personality disorder show symptoms in late adolescence or early adult life, although some may not come to the attention of mental health services until much later. With formal psychiatric assessment and appropriate treatment, symptoms improve sufficiently so that at least 50% of people no longer meet the criteria for borderline personality disorder 5–10 years after diagnosis.
NICE quality standards are a concise set of prioritised statements designed to drive measurable improvements in the 3 dimensions of quality – patient safety, patient experience and clinical effectiveness – for a particular area of health or care. They are derived from high‑quality guidance, such as that from NICE or other sources accredited by NICE. This quality standard, in conjunction with the guidance on which it is based, should contribute to the improvements outlined in the following 3 outcomes frameworks published by the Department of Health:
Ensuring that care is safe and that people have a positive experience of care is vital in a high‑quality service. It is important to consider these factors when planning and delivering services relevant to people with borderline or antisocial personality disorder.
NICE has developed guidance and associated quality standards on patient experience in adult NHS services and service user experience in adult mental health services (see the NICE Pathways on patient experience in adult NHS services and service user experience in adult mental health services), which should be considered alongside this quality standard. They specify that people receiving care should be treated with dignity, have opportunities to discuss their preferences, and are supported to understand their options and make fully informed decisions. They also cover the provision of information to patients and service users. Quality statements on these aspects of patient experience will not usually be included in topic‑specific quality standards. However, recommendations in the development sources for quality standards that impact on service user experience and are specific to the topic are considered during quality statement development.
The quality standard for borderline and antisocial personality disorders specifies that services should be commissioned from and coordinated across all relevant agencies encompassing the whole borderline or antisocial personality disorder care pathway. A person‑centred, integrated approach to providing services is fundamental to delivering high‑quality care to people with borderline or antisocial personality disorder in a range of settings.
The Health and Social Care Act 2012 sets out a clear expectation that the care system should consider NICE quality standards in planning and delivering services, as part of a general duty to secure continuous improvement in quality. Commissioners and providers of health and social care should refer to the library of NICE quality standards when designing high‑quality services. Other quality standards that should also be considered when choosing, commissioning or providing a high‑quality borderline or antisocial personality disorder service are listed in related NICE quality standards.
The quality standard should be read in the context of national and local guidelines on training and competencies. All health, public health and social care practitioners involved in assessing, caring for and treating people with borderline or antisocial personality disorder should have sufficient and appropriate training and competencies to deliver the actions and interventions described in the quality standard. Quality statements on staff training and competency are not usually included in quality standards. However, recommendations in the development sources on specific types of training for the topic that exceed standard professional training are considered during quality statement development.
Quality standards recognise the important role families and carers have in supporting people with borderline or antisocial personality disorder. If appropriate, health and social care practitioners should ensure that family members and carers are involved in making decisions about assessment, care planning and provision of treatment.