Introduction

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 quality standard 59 covers antisocial behaviour and conduct disorder in children and young people under 18 years. For more information see the personality disorders topic overview.

Why this quality standard is needed

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

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.

Antisocial personality disorder

Traits of antisocial personality disorder include impulsivity, high negative emotionality, low conscientiousness and associated behaviours, including irresponsible and exploitative behaviour, recklessness and deceitfulness. As a result of antisocial personality disorder, people may experience unstable interpersonal relationships and may disregard the consequences of their behaviour and the feelings of others. The disorder may also result in a failure to learn from experience and in egocentricity. Antisocial personality disorder is often comorbid with depression, anxiety, and alcohol and drug misuse.

The prevalence of antisocial personality disorder in the general population is 3% in men and 1% in women. The prevalence among people in prison is around 47%, with serious crimes being less common than a history of aggression, unemployment, and unstable and short‑term relationships.

The course of antisocial personality disorder is variable and although recovery is achievable over time, some people continue to experience social and interpersonal difficulties.

Most people with antisocial personality disorder receive the majority of their care outside the health service. They may be supported by education, social care and housing services and, as result of offending, by the criminal justice system.

Care for people with borderline and antisocial personality disorder

Although borderline and antisocial personality disorders are both associated with significant morbidity and increased mortality, the care people receive is often fragmented. Borderline and antisocial personality disorders are frequently misdiagnosed because of comorbid conditions, and people are often prescribed medication or therapies that are unsuitable for them. Sometimes they are excluded from health or social care services because of their diagnosis or their behaviour. This may be because staff lack the confidence and skills to deal with these conditions or have negative attitudes towards people with borderline or antisocial personality disorder. Some topic experts and people with personality disorder feel that the stigma attached to borderline and antisocial personality disorders still prevails even within mental health services.

In 2011, the government published its mental health strategy, No health without mental health, which set out long‑term ambitions for transforming mental healthcare and the way people with mental health problems are supported in society as a whole. The strategy was built around 6 objectives:

  • more people will have good mental health

  • more people with mental health problems will recover

  • more people with mental health problems will have good physical health

  • more people will have a positive experience of care and support

  • fewer people will suffer avoidable harm

  • fewer people will experience stigma and discrimination.

The quality standard is expected to contribute to improvements in the following outcomes:

  • quality of life for people with serious mental illness

  • service user experience of health/care services

  • excess under 75 mortality rate in adults with serious mental illness

  • employment of people with mental illness

  • experience of integrated care.

How this quality standard supports delivery of outcome frameworks

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:

Tables 1–3 show the outcomes, overarching indicators and improvement areas from the frameworks that the quality standard could contribute to achieving.

Table 1 Adult Social Care Outcomes Framework 2015–16

Domain

Overarching and outcome measures

1 Enhancing quality of life for people with care and support needs

Overarching measure

1A Social care‑related quality of life*

Outcome measures

People manage their own support as much as they wish, so that they are in control of what, how and when support is delivered to match their needs

1B Proportion of people who use services who have control over their daily lives

Carers can balance their caring roles and maintain their desired quality of life

1D Carer‑reported quality of life

People are able to find employment when they want, maintain a family and social life and contribute to community life, and avoid loneliness or isolation

1F Proportion of adults in contact with secondary mental health services in paid employment**

1H Proportion of adults in contact with secondary mental health services living independently, with or without support*

1I Proportion of people who use services and their carers, who reported that they had as much social contact as they would like*

2 Delaying and reducing the need for care and support

Overarching measure

2A Permanent admissions to residential and nursing care homes, per 100,000 population

3 Ensuring that people have a positive experience of care and support

Overarching measure

People who use social care and their carers are satisfied with their experience of care and support services

3A Overall satisfaction of people who use services with their care and support

3B Overall satisfaction with social services of carers

3E Effectiveness of integrated care

Outcome measures

Carers feel that they are respected as equal partners throughout the care process

3C The proportion of carers who report that they have been included or consulted in discussion about the person they care for

People know what choices are available to them locally, what they are entitled to, and who to contact when they need help

3D The proportion of people who use services and carers who find it easy to find information about support

People, including those involved in making decisions on social care, respect the dignity of the individual and ensure support is sensitive to the circumstances of each individual

4 Safeguarding adults whose circumstances make them vulnerable and protecting them from avoidable harm

Overarching measure

4A The proportion of people who use services who feel safe**

Outcome measures

Everyone enjoys physical safety and feels secure

People are free from physical and emotional abuse, harassment, neglect and self‑harm

People are protected as far as possible from avoidable harm, disease and injuries

People are supported to plan ahead and have the freedom to manage risks the way they wish

4B The proportion of people who use services who say that those services have made them feel safe and secure

Aligning across the health and care system

* Indicator complementary

** Indicator shared

Table 2 NHS Outcomes Framework 2015–16

Domain

Overarching indicators and improvement areas

1 Preventing people from dying prematurely

Overarching indicator

1a Potential Years of Life Lost (PYLL) from causes considered amenable to healthcare

Reducing premature death in people with mental illness

1.5 Excess under 75 mortality rate in adults with serious mental illness*

2 Enhancing quality of life for people with long‑term conditions

Overarching indicator

2 Health‑related quality of life for people with long‑term conditions**

Improvement areas

Ensuring people feel supported to manage their condition

2.1 Proportion of people feeling supported to manage their condition**

Enhancing quality of life for people with mental illness

2.5 Employment of people with mental illness****

4 Ensuring that people have a positive experience of care

Overarching indicators

4a Patient experience of primary care

4b Patient experience of hospital care

Improvement areas

Improving people's experience of outpatient care

4.1 Patient experience of outpatient services

Improving hospitals' responsiveness to personal needs

4.2 Responsiveness to inpatients' personal needs

Improving people's experience of accident and emergency services

4.3 Patient experience of A&E services

Improving the experience of healthcare for people with mental illness

4.7 Patient experience of community mental health services

Improving people's experience of integrated care

4.9 People's experience of integrated care**

Alignment across the health and social care system

* Indicator shared with Public Health Outcomes Framework (PHOF)

** Indicator complementary with Adult Social Care Outcomes Framework (ASCOF)

**** Indicator complementary with Adult Social Care Outcomes Framework and Public Health Outcomes Framework

Table 3 Public health outcomes framework for England, 2013–16

Domain

Objectives and indicators

1 Wider determinants of health

Objective

Improvements against wider factors that affect health and wellbeing and health inequalities

Indicators

1.06ii – % of adults in contact with secondary mental health services who live in stable and appropriate accommodation

1.07 – People in prison who have a mental illness or a significant mental illness

1.08iii – Gap in the employment rate for those in contact with secondary mental health services and the overall employment rate

1.13i – % of offenders who re‑offend from a rolling 12‑month cohort

1.13ii – Average number of re‑offences committed per offender from a rolling 12‑month cohort

2 Health improvement

Objective

People are helped to live healthy lifestyles, make healthy choices and reduce health inequalities

2.15i Successful completion of drug treatment – opiate users

2.15ii Successful completion of drug treatment – non‑opiate users

2.18 Alcohol‑related admissions to hospital

4 Healthcare public health and preventing premature mortality

Objective

Reduced numbers of people living with preventable ill health and people dying prematurely, while reducing the gap between communities

Indicators

4.09 Excess under 75 mortality in adults with serious mental illness

4.10 Suicide rate

Service user experience and safety issues

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.

Coordinated services

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 quality standards.

Training and competencies

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.

Role of families and carers

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.