9.1. INTRODUCTION
This guideline uses the term ‘young people’ to refer to those aged under 18 years as people of this age prefer this descriptor to the term ‘adolescent’.
There are very few studies of the prevalence of borderline personality disorder in young people, but two suggest that the disorder affects between 0.9 to 3% of the community population of those aged under 18 years (Lewinsohn et al., 1997; Bernstein et al., 1993). Employing lower symptom thresholds results in an increase to between 10.8 to 14% (Bernstein et al., 1993; Chabrol et al., 2001). Chanen and colleagues (2004) cite data suggesting a prevalence rate of 11% in adolescent outpatients. A more recent study by the same group suggests a rate of 22% in outpatients (Chanen et al., 2008b). Grilo and colleagues (2001) report a prevalence rate of 49% in adolescent inpatients. Further studies are needed before firm conclusions can be drawn about prevalence.
Adolescence is a period of major developmental transitions – physically, psychologically and socially. During this period young people experience emotional distress, frequent interpersonal disruptions and challenges in establishing a sense of identity. Consequently, young people with borderline personality disorder may experience a minimisation or dismissal of their difficulties from staff, their families or from their wider social circle, who attribute their problems to the typical stresses and strains of the adolescent transition. This may preclude access to appropriate help for their difficulties. However, many clinicians are reluctant to diagnose borderline personality disorder in young people because of a number of factors: uncertainties about whether personality disorder can be diagnosed in this age group; the appropriateness of the diagnosis at a time of major developmental change characterised by some of the behaviours within the diagnosis; and possible negative consequences of the diagnostic label. Many clinicians also do not believe that making the diagnosis will add to their understanding of the young person, their difficulties or the treatment plan.
Given the concerns about diagnosing young people with borderline personality disorder, the current approach to diagnosis and conceptualisation of the problems presented by young people with borderline personality disorder is highly variable. Consequently, treatment strategies are also inconsistent. While assessing the behaviours that would form a diagnosis of borderline personality disorder, healthcare professionals often do not conceptualise the problems as borderline personality disorder or make a formal diagnosis. In some circumstances clinicians may use an axis I diagnosis rather than a diagnosis of borderline personality disorder because of concerns about the person living with the diagnosis (Chanen et al., 2007a). In addition, because young people with borderline personality disorder often have multiple comorbidities, clinicians tend to focus on the assessment and treatment of axis I disorders. Because of the complexity and comorbidity of the problems, some young people will receive a multitude of interventions with varying degrees of coordination. In these circumstances, the absence of coordination and a failure to involve other systems around the young person (for example, family and school) may limit the effectiveness of interventions. Other young people will receive less frequent interventions. In some cases, either the service or the individual practitioner experiences frequent demands and requests for help from the young person, their family or other services involved and the intensity of service required may exceed the capacity of either the individual practitioner or the service.
Deciding on the main goals of treatment often presents a challenge given the complexity of the difficulties and the limited nature of the evidence base for working with young people with borderline personality disorder. Frequently interventions focus exclusively and sometimes unhelpfully on the assessment and management of risk to the exclusion of treatment of the disorder or comorbid disorders. Current practice includes a range of different psychological and pharmacological treatments. Psychological treatments currently offered may include CBT, DBT, CAT, family therapy, psychodynamic psychotherapy, counselling, treatments derived from attachment theory and non-specific talking therapies. Pharmacological treatments currently prescribed may include SSRIs, mood stabilisers and low-dose neuroleptics, either with the intention of treating a comorbid condition (for example, an SSRI for depression) or of addressing specific symptoms (for example, a neuroleptic to reduce impulsivity). Some services will utilise the CPA for young people with borderline personality disorder, but others will not. Irrespective of the treatment offered, healthcare professionals may have difficulty remaining appropriately focused on the goals of treatment in the presence of multiple comorbidities and social or family problems. The emotional lability of the young person with borderline personality disorder, and the motivational fluctuations that often accompany it, can lead professionals unintentionally away from the pre-determined focus of the intervention.
There are potential risks associated with intervention. The most common risk, which can occur both in outpatient and inpatient treatment, is the reinforcement of problematic behaviours, leading to deterioration in functioning. Young people may then require more intensive treatment and, in a small proportion of people, this can lead to expensive out-of-area placements and/or placements with higher levels of security. Young people with borderline personality disorder and a history of childhood trauma may also deteriorate if trauma therapy that involves repeated and/or in-depth exposure to the trauma is embarked upon before their more impulsive behaviours are stabilised.
Young people with borderline personality disorder may also be known to social services either as a result of child protection concerns or because the young person is designated a ‘child in need’. Young people in these circumstances, as well as receiving routine services, may also live in foster placements, therapeutic foster placements or residential settings. They may also come to the attention of the Youth Justice Service or be in prison as a result of impulsive behaviours that are antisocial or criminal in nature. Some young people with borderline personality disorder may have a statement of special educational need and/or may find it difficult to access standard educational settings.
This chapter considers first the diagnosis of borderline personality disorder and its stability in young people. The assessment of young people with borderline personality disorder is then considered, including which assessment tools may assist clinicians in identifying borderline personality disorder in young people. As with adult patients, the assessment and management of suicide risk frequently forms a major focus of the work and this chapter reviews the evidence for suicide risk in young people with borderline personality disorder. Treatment options are then reviewed. The chapter concludes with a care pathway and associated recommendations.
9.2. DIAGNOSIS
DSM-IV allows for all personality disorders, with the exception of antisocial personality disorder, to be diagnosed in young people with certain caveats (APA, 1994). To diagnose a personality disorder in a young person the maladaptive personality traits must be assessed as pervasive and persistent and not limited to periods of an axis I disorder or to a specific developmental stage (APA, 1994). The criteria for diagnosing borderline personality disorder are the same in young people as for adults. As a degree of emotional lability, interpersonal instability and identity confusion are more typical in adolescence, however, assessing clinicians must establish that the severity and intensity of these behaviours exceed what is typical for young people before concluding that the criterion is present. Sub-cultural differences in the prevalence of the behaviours must also be considered. ICD-10 also allows for a diagnosis of emotionally unstable personality disorder, borderline type, to be made in young people using the same criteria as for adults (World Health Organization, 1992). However, it states that, in general for personality disorders, it is ‘unlikely that the diagnosis of personality disorder will be appropriate before the age of 16 or 17 years’. Defining the beginning and end of the adolescent stage of development varies across cultures. Using a chronological age to demarcate the stage can present difficulties as young people of the same chronological age may differ greatly in their levels of developmental maturity. For this same reason using a specific age as the lower limit to define when to consider the recommendations in this guideline is problematic. The GDG and the specialist advisors decided, therefore, that rather than using age as a criterion, the recommendations in this chapter would apply to young people post-puberty and that it would be highly unusual to consider the diagnosis in young people under the age of 13.
Both the research literature and clinicians use a variety of terms to refer to young people who present with behaviours consistent with a diagnosis of borderline personality disorder. Often, when referring to young people a qualifying term is added to the borderline personality disorder diagnosis. The most commonly used qualifiers include ‘possible’, ‘putative’, ‘tentative’, ‘emerging’ and ‘emergent’. The guideline does not use any of these qualifying terms but rather refers to those aged under 18 years who meet criteria for the disorder as ‘young people with borderline personality disorder’. The view of the guideline group was that the use of qualifying terms most likely stems from concerns about whether or not it is possible to make the diagnosis in young people and/or concerns about the negative effects of labelling. Concerns about labelling are legitimate and apply equally regardless of age. To mitigate these concerns the GDG recommends that the diagnosis only be employed following a thorough assessment and that it should be used to inform an appropriate treatment plan and not as justification for refusing or limiting access to services.
9.3. STABILITY OF THE DIAGNOSIS OF BORDERLINE PERSONALITY DISORDER IN YOUNG PEOPLE
9.3.1. Introduction
One concern over the appropriateness of the diagnosis of borderline personality disorder in young people is its stability, particularly at a time of major developmental change during which some of the features that constitute the disorder are present, albeit at lower levels of intensity. The issue of stability of the diagnosis is important because it has an impact on the identification, diagnosis and treatment of borderline personality disorder in young people.
9.3.2. Reviewing the evidence base
The most appropriate research design to establish whether the borderline personality disorder diagnosis is stable in young people is the prospective cohort study. The evidence base reviewed, therefore, comprised all available prospective studies undertaken in young people in whom a diagnosis of borderline personality disorder had been made either at baseline or at follow-up. Review studies focusing on borderline personality disorder in young people were also sought to ascertain the state of the available literature and to check that the relevant references had been identified by the search strings used.
The summary study characteristics and descriptions of the studies are given in , but more information is available in Appendix 16. Reviewed studies are referred to by first author surname in capitals plus year of publication.
Summary study characteristics of included studies of the stability of borderline personality disorder in young people.
9.3.3. Evidence search and overview of studies found
The electronic databases searched are given in . Details of the search strings used are in Appendix 7.
Databases searched and inclusion/exclusion criteria for studies of stability of diagnosis of borderline personality disorder in young people.
Studies of young people diagnosed with borderline personality either at baseline or at follow-up were included. Forty-four prospective cohort papers were found from searches of electronic databases, of which 33 were excluded. The most common reasons for exclusion were that there were no useable data, no longitudinal data were reported or there were no data reported for borderline personality disorder specifically (further information about both included and excluded studies can be found in Appendix 16).
Eighteen of the 44 prospective studies found from the searches reported data from the Children in the Community Study (see for example Cohen et al., 2005). This study followed-up a randomly selected sample of 976 children recruited in 1975. Despite the fact that this is a prospective study with a large sample size, a considerable limitation of the dataset is that the study began before the diagnosis of borderline personality disorder in DSM-III. Therefore, the study authors retrospectively applied a diagnostic instrument to identify borderline personality disorder using an algorithm for scoring items from self-report questionnaires and structured interviews conducted by trained lay interviewers. This study has therefore been excluded from the analysis below.
In addition, a number of studies were found that reported data for cluster B personality disorders but did not report any data specifically for borderline personality disorder. These studies were also excluded from the analysis because it cannot be assumed that the stability of different cluster B personality disorders is similar. This is illustrated by Chanen and colleagues (2004) who report that the stability of different cluster B personality disorders ranges from 0% for histrionic and narcissistic to 100% for antisocial in a sample of young people over a 2-year period.
9.3.4. Prospective longitudinal short follow-up studies of borderline personality disorder
Study descriptions
This is a 2-year prospective study of 101 young people drawn from an adolescent outpatient service in Australia. Participants were assessed using the SCID-II at baseline and 97 were re-interviewed 2 years later by interviewers who were blind to the baseline assessment. At baseline, 11 participants met the criteria for borderline personality disorder. At the 2-year follow-up, six participants who had met the criteria at baseline no longer did, eight new cases of borderline personality disorder were diagnosed and four people who met the criteria at baseline retained the diagnosis 2 years later. The overall proportion of enduring cases of borderline personality disorder over 2 years was 40%.
This is a US-based study of 21 inpatients with borderline personality disorder. Participants were contacted 2 years following discharge. Symptoms were assessed using the Personality Disorder Examination at baseline and again at follow-up by raters who were blind to the baseline diagnosis. At the 2-year follow-up, seven participants retained the diagnosis of borderline personality disorder and 14 no longer met the criteria; the overall proportion of enduring cases in this sample was 33%.
The authors also examined the ability of baseline criteria for borderline personality disorder to predict the diagnosis of borderline personality disorder at the 2-year follow-up. For the subgroup of participants who were diagnosed with borderline personality disorder both at baseline and at follow-up, the most stable symptoms were emptiness or boredom (100% agreement between baseline and follow-up), inappropriate and intense anger (86% agreement), affective instability (71% agreement), identity disturbance (71% agreement) and suicidal behaviours (67% agreement). The least stable symptoms were impulsiveness (57% agreement) and unstable intense relationships (50% agreement).
This Dutch study followed-up 36 inpatients, 14 with borderline personality disorder and 22 without. The Diagnostic Interview for Borderline Patients was administered to all participants at baseline and at the 3-year follow-up by raters who were blind to baseline diagnosis. At the 3-year follow-up, two people who met the criteria for borderline personality disorder at baseline retained their diagnosis. Twelve people no longer met the criteria but it was reported that some borderline symptoms were still present. There were no new cases of borderline personality disorder in the sample. Overall the proportion of enduring cases was 21%. The authors report the most persistent symptoms were conflict about giving and receiving care, dependency and masochism, and ‘areas or periods of special achievement’.
Clinical summary
These prospective longitudinal studies of the stability of borderline personality disorder in young people over a period of 2 to 3 years suggest that the stability of this disorder is between 21 and 40%. However, it should be noted that all the studies have very small sample sizes, with only 46 people with borderline personality disorder at baseline across the three studies.
9.3.5. Quasi-prospective studies of developmental antecedents of borderline personality disorder
Study descriptions
This is a Norwegian quasi-prospective study investigating the developmental antecedents of borderline personality disorder in 25 participants with borderline personality disorder compared with 107 controls. Baseline diagnosis was determined on the basis of medical records and follow-up interview after 28 years. At follow-up, SCID-I and SIDP-IV were administered by raters who were blind to the baseline diagnosis. Twenty-five participants met the criteria for borderline personality disorder at some point in their life; of these 16 met at least five of the borderline personality disorder criteria at follow-up, while nine with a history of lifetime borderline personality disorder no longer met at least five of the criteria. Overall 64% of people with a history of borderline personality disorder met the diagnostic criteria at follow-up.
This US study followed up 19 children who had been diagnosed with borderline personality disorder in the preceding 10 to 20 years. These children had been identified with borderline personality disorder at baseline according to the criteria of Bemporad and colleagues (1982, 1987). At follow-up participants were assessed using the SCID and unstructured clinical interviews. Three of the 19 participants met the diagnostic criteria for borderline personality disorder at follow-up. A further 13 met the criteria for a personality disorder other than borderline. Overall the proportion of enduring cases was 16% in this sample.
This Canadian study followed up 59 young people who had been treated in a child psychiatric day hospital 5 to 7 years earlier. The child version of the Retrospective Diagnostic Interview for Borderlines was used to review participants’ medical charts; on this basis 28 participants were diagnosed with borderline pathology of childhood while 31 participants who did not have a history of borderline pathology of childhood served as the comparison group. Borderline personality disorder was assessed at follow-up with the Diagnostic Interview for Borderlines. At follow-up, five participants met the criteria for a current diagnosis of borderline personality disorder and 23 participants who had a history of borderline pathology of childhood did not. Overall 18% of people who were diagnosed with borderline pathology of childhood met the diagnostic criteria for borderline personality disorder at follow up.
Clinical summary
These quasi-prospective studies of the antecedents of borderline personality disorder in children and young people suggest that the stability of the diagnosis over a longer period of time is less clear; the proportion of participants who retained the diagnosis for borderline personality disorder at follow-up varied from between 16 and 64%.
9.3.6. Children with disruptive and/or emotional disorders followed-up as young people
Study descriptions
This US study followed up 147 participants diagnosed as hyperactive in childhood and 73 matched community controls. Participants were originally assessed at age 4 to 12 years; this study followed them up an average of 14 years later. At follow-up, SCID-NP (non-patient edition), including SCID-II, was administered. Two out of 73 (3%) of participants in the control group, and 20 out of 147 (14%) of those in the hyperactive group, were diagnosed with borderline personality disorder. Borderline personality disorder was one of the most common diagnoses in the hyperactive group.
Data are also presented for comorbidities in the hyperactive group: having major depressive disorder, passive-aggressive personality disorder or histrionic personality disorder significantly increased the likelihood of having borderline personality disorder. Likewise, having borderline personality disorder was a significant risk for major depressive disorder, passive-aggressive personality disorder, histrionic personality disorder and antisocial personality disorder. In addition, severity of conduct disorder at adolescent follow-up significantly predicted risk for borderline personality disorder.
This Norwegian quasi-prospective study assessed personality disorders in adulthood in a group of participants who were admitted to an adolescent unit 28 years earlier with emotional and/or disruptive behaviour disorders. One hundred and thirty participants were re-diagnosed based on hospital records and were interviewed with the SIDP-IV at 28 years, follow-up by a rater who was blind to the baseline diagnosis. Young people with disruptive behaviour disorders were significantly more likely to have borderline personality disorder in adulthood than those with emotional disorders: at follow-up, two out of 45 (4%) participants with emotional disorder in adolescence, and 22 out of 85 (26%) participants with disruptive disorder in adolescence, were diagnosed with borderline personality disorder.
This Swedish study followed-up 56 children at age 16 years who had deficits in attention, motor control and perception at age 7 years and compared them with 45 control children. The Personality Disorder Examination was administered at follow-up. Psychiatric disorders and personality disorders were more common in participants who had deficits in attention, motor control and perception as children compared with the controls. Three out of 13 (23%) participants who had severe deficits in attention, motor control and perception as children, and 5 out of 26 (19%) participants who had mild deficits in attention, motor control and perception as children, were diagnosed with borderline personality disorder at follow-up. Two out of 11 (18%) participants who had motor control/perception dysfunction only and three out of six (50%) who had attention deficits only as children had borderline personality disorder at follow-up compared with four out of 45 (9%) participants in the control group.
This Swedish study assessed personality disorders in a group of 158 former psychiatric inpatients. Childhood and adolescent axis I disorders were obtained from medical records and coded into DSM-IV diagnoses. Participants were followed up an average of 16 years later and personality disorders in adulthood were assessed using the DSM-IV and ICD-10 Personality Questionnaire (DIP-Q). At follow-up, 50 of the 158 (32%) participants were diagnosed with borderline personality disorder. The authors report that childhood and adolescent depression and substance-related disorders were significant risk factors for borderline personality disorder in adulthood.
This Australian study followed up 145 young adults who had been diagnosed with a variety of emotional and disruptive disorders during adolescence, an average of 14 years earlier. The Personality Disorder Examination was administered at follow-up and a total of 11 of the 145 (8%) participants were diagnosed with borderline personality disorder in adulthood. Of these, nine out of 80 (11%) participants who had a disruptive disorder in adolescence were diagnosed with borderline personality disorder at follow-up; three had an adolescent diagnosis of attention deficit hyperactivity disorder (ADHD), one had oppositional disorder, two had conduct disorder and three had conduct disorder and ADHD. Two out of 65 (3%) participants who had an emotional disorder in adolescence were diagnosed with borderline personality disorder at follow-up; both had an adolescent diagnosis of dysthymic disorder.
Clinical summary
These studies of children with disruptive and/or emotional disorders followed up in adolescence or adulthood report a higher incidence of borderline personality disorder at follow-up for participants who were diagnosed with a disruptive disorder in childhood (between 11 and 26%).
9.3.7. Overall clinical summary for stability of the diagnosis of borderline personality disorder in young people
summarises the stability statistics for each of the studies described above. Limited evidence makes it difficult to draw any firm conclusions regarding the stability of the diagnosis of borderline personality disorder in young people. There is some evidence that the diagnosis is stable in between 21 and 40% of young people over a 2- to 3-year period; the picture becomes less clear, however, over longer follow-up periods, partly due to the fact that the diagnosis of borderline personality disorder was only introduced in 1980 with DSM-III. A follow-up time of 2 to 3 years is insufficient to establish stability or instability.
Summary stability data for borderline personality disorder in young people.
This limited evidence on the stability of the borderline personality disorder diagnosis in young people has led some commentators to argue for its instability(Becker et al., 2002) and others to argue that the diagnosis is stable over time (Bradley et al., 2005a). It may be that there are different sub-groups of young people who receive a diagnosis of borderline personality disorder, some of whom will recover more rapidly and others who will experience more enduring difficulties. Some young people with the diagnosis may experience a reduction in symptoms as they develop and mature or in response to positive changes in their family or social environment. Further research into the developmental course of young people with the diagnosis, or symptoms and behaviours suggestive of the disorder, is warranted. One recent study conducted in the US with adults reported that the prognosis of the disorder was more positive than was previously believed (Zanarini et al., 2003) and it may be that even those young people with a stable diagnosis over 2 years (Garnet et al., 1994) may go on to recover over a longer time period. Given the limitations of the evidence base and the size of the stability estimates in the studies that are available, healthcare professionals should exercise caution in making the diagnosis of borderline personality disorder in young people especially given the stigma associated with the diagnosis. Assessment issues are discussed further in section 9.5.
9.4. SUICIDE RISK IN YOUNG PEOPLE WITH BORDERLINE PERSONALITY DISORDER
9.4.1. Risk factors for suicide in young people with borderline personality disorder or symptoms of borderline personality disorder
A separate review of factors associated with suicide in young people with symptoms of borderline personality disorder or borderline personality disorder was undertaken. Personality disorder in this age group may not be stable, therefore different factors are likely to be important compared with risk factors in adults.
Nine studies of suicide in young people with borderline personality disorder were found. Two of these were excluded (see below). See for a summary of the characteristics of the included studies.
Summary study characteristics of studies of risk factors for suicide in young people with borderline personality disorder.
Studies that did not look at specific risk factors were excluded (CRUMLEY1981; FRIEDMAN1989).
9.4.2. Studies of general psychiatric populations
Study descriptions
This US study compared 37 psychiatric inpatients aged between 13 and 19 years who had made a suicide attempt in the year prior to admission with 29 inpatients who had never made a suicide attempt. The sample was not consecutive but was frequency matched (the term is not explained by the authors) with a previously gathered sample of young people who had completed suicide on age, gender and primary psychiatric diagnosis. Despite this, the never-attempted group contained more boys than the group of young people who had attempted suicide (90% and 38% respectively), which also comprised more young people with affective illness. The study compared the two groups on various factors. As well as finding that those who had attempted suicide were more likely to be girls and to have an affective illness (notably major depressive disorder, bipolar disorder mixed state and bipolar spectrum disorder), the study found that this group was less likely to have diagnoses of conduct disorder or ADHD. They were more likely to have a personality disorder (81.1% versus 58.6%), particularly cluster C disorders (70.3% versus 48.3%). There were more patients with borderline personality disorder or borderline traits (32.4%, 10.3%), and this group were more likely to have made a previous attempt.
This study reports on 58 consecutive suicides among young people and young adults (aged 15 to 29 years) completed between 1984 and 1987 in Sweden. Data were collected in semi-structured interviews with relatives. In some cases relevant healthcare professionals were also interviewed. In 69% of cases psychiatric records were consulted. Diagnoses were made by consensus based on DSM-III-R criteria. Of the total 58 cases, 21 were given a diagnosis of borderline personality disorder. There was a relatively high rate of depressive disorders (42% in the borderline personality disorder group, 56% in the non-borderline personality disorder group).
Those given a borderline personality disorder diagnosis were more likely to have had absent or divorced parents, and to have been exposed to alcohol and drug misuse by their first-degree relatives. They were also more likely to have had more than two jobs, to have had financial problems, to have been homeless and to have received a court sentence. Unfortunately, these data are not broken down by age, so may be dominated by those over 18 years.
This is a report of a study following a cohort of patients admitted to the New York State Psychiatric Institute between 1963 and 1976. The authors reported on the nine patients who completed suicide as young people (aged 20 years or younger). Five of these had a diagnosis of borderline personality disorder (DSM-III criteria) and four presented with a psychosis.
The study found that those who had completed suicide were more likely to experience traumatic life events than others, particularly those with borderline personality disorder. This group were also more likely to have experienced parental brutality than those with psychosis.
This US study looked at the families of 55 young people aged 14 to 18 years who had been admitted to an adolescent and family treatment unit. Patients were admitted following self-harm, dangerous drug use, suicidal behaviour, treatment-resistant eating disorders, depression and OCD. Based on DSM-III-R diagnoses, 21 were diagnosed with borderline personality disorder. Of these, 29% had a comorbid eating disorder, 33% major affective disorder, 19% PTSD and none had OCD. There were 16 girls and 5 boys. Fifty-seven per cent had an intact family, 24% were adopted, 19% had parents who were divorced or separated and 24% had parents who had remarried. Of those with borderline personality disorder, 66% were suicidal, all had shown self-destructive behaviour and 67% were aggressive. Data were collected in a 2-hour standardised family assessment between 2 and 5 weeks after admission.
The study compared the young people’s views with those of their parents, making comparisons between those with borderline personality disorder and those without. It reported that young people with borderline personality disorder who were more suicidal tended to see themselves as more alienated from their parents, more socially isolated and with poorer overall functioning than others. Their parents, however, did not see their children in the same way, which the study authors believe illustrates the young people’s alienation. Within the group of those with borderline personality disorder, those who were more self-destructive (such as self-harming or running away) tended to see themselves as more socially isolated than other young people.
Clinical summary
It is not surprising that many of the studies reviewed found that young people with borderline personality disorder or traits of borderline personality disorder are more likely to attempt suicide than others since suicidal behaviour is a diagnostic criterion of the disorder. However, the studies help to emphasise the fact that young people with borderline personality disorder are at risk. In addition, those who are suicidal are more likely to feel alienated from their families and more socially isolated than others. Those completing suicide are also more likely to have experienced traumatic events and parental brutality, absence or divorce.
9.4.3. Studies comparing people with depression with those with borderline personality disorder
Study descriptions
This study looked at suicidality in 40 young people referred to an outpatient clinic following a suicide attempt. It was undertaken in Israel and compared those with major depressive disorder (n = 20) with those with borderline personality disorder (n = 20). These groups were further compared with a control group (n = 20) who had no psychiatric diagnosis or suicide attempts and who were matched on age and sex. Those with comorbid borderline personality disorder and major depressive disorder were excluded. Participants were interviewed within a month of the index admission.
The study found that young people with depression had statistically significantly higher BDI depression scores than those with borderline personality disorder, who in turn had statistically significantly higher scores than those in the control group. On a suicide risk scale, both the major depression and borderline personality disorder groups had significantly higher scores than the control group. This pattern was the same for the number of serious life events. Those with borderline personality disorder had experienced significantly more sexual abuse events than either of the other groups: 30% compared with 5% of those with major depressive disorder and 5% of the control group.
This study, also conducted in Israel, looked at 65 young people with either major depressive disorder (n = 32) or borderline personality disorder (n = 33). Some of the young people in each group had made a recent (that is, within 30 days of assessment) suicide attempt (n = 17), and some had never attempted suicide (n = 16). Comorbid disorders among those with borderline personality disorder included major depressive disorder (n = 10), dysthymia (n = 11) and conduct disorder (n = 3).
The study found that among those with a diagnosis of borderline personality disorder, those with a recent suicide attempt were more impulsive, while those with major depressive disorder with a recent suicide attempt had higher intent scores than those with a recent suicide attempt and borderline personality disorder.
Clinical summary
These studies confirm that those with borderline personality disorder who make a suicide attempt are likely to have increased depressive symptoms compared with those with no psychiatric diagnosis. However, these symptoms are unlikely to meet diagnosis for major depressive disorder. Young people who made a suicide attempt were also more likely to have suffered sexual abuse. However, a diagnosis of borderline personality disorder does not necessarily imply someone will make a suicide attempt, but it appears that those who do are likely to be more impulsive than those who do not.
9.4.4. Overall clinical summary suicide risk studies
There are relatively few studies of risk factors for suicide in young people with borderline personality disorder or traits. Young people with borderline personality disorder who attempt suicide are likely to have some depression symptoms and to be more impulsive. Young people with borderline personality disorder completing suicide are more likely to have experienced traumatic events and parental brutality, absence or divorce. These findings indicate that, as with adults, assessment and management of suicide risk is likely to form part of the treatment plan.
9.5. ASSESSMENT
9.5.1. Reviewing the evidence base
In order to make recommendations about identification of borderline personality disorder in young people, the GDG asked the following clinical questions:
What can help clinicians identify features of borderline personality disorder in young peoples?
Are there tools/assessments which clinicians can use to assist in the identification/assessment process?
Are there tools/assessments which can be used in tier 1?
The questions regarding assessment were addressed by a group of special advisors (see Appendix 3).
9.5.2. Identifying the young person with borderline personality disorder
There are a number of clinical features that may indicate to the clinician the need to assess for borderline personality disorder as part of a comprehensive clinical assessment. These are:
frequent suicidal/self-harming behaviours
marked emotional instability
increasing intensity of symptoms
multiple comorbidities
non-response to established treatments for current symptoms
Questionnaire measures may also provide a useful screen to indicate that a comprehensive assessment is required. Chanen and colleagues (2008b) evaluated four screening measures for borderline personality disorder in an outpatient sample of young people: the McLean Screening Instrument for borderline personality disorder (MSI-borderline personality disorder); the Borderline Personality Questionnaire (BPQ); items from the IPDE; and the borderline personality disorder items from the SCID-II. All four measures performed well. The BPQ had the highest diagnostic accuracy and highest test – re-test reliability; it is also the longest of the four measures although administering and scoring can be completed within 15 minutes.
The criteria for diagnosing borderline personality disorder are the same in young people as for adults (with the caveats as indicated above in section 9.2). Diagnosing borderline personality disorder in young people can be assisted by a structured clinical interview and should be conducted as part of a comprehensive clinical assessment leading to a clear formulation of the young person’s difficulties. The diagnosis of borderline personality disorder in a young person should only be made after a comprehensive and rigorous assessment has been completed by a practitioner knowledgeable about the adolescent period and skilled in the assessment of mental health problems in this age group. Such an assessment should also include a developmental family history with the young person’s family or carers. Detailed and comprehensive assessments are important in all areas of mental health but are especially so when the diagnosis carries a significant likelihood of stigmatisation. To assist with the assessment, clinicians may use the questions from the SCID-II or the Shedler & Westen Assessment Procedure - Adolescents, which is a Q-sort technique based on a structured diagnostic interview that was specifically developed for the assessment of personality disorder in young people (Westen & Shedler, 2007). This latter assessment may be suitable in some specialist services but is likely to be too time consuming for most settings. None of these measures is suitable for use by tier 1 staff because such measures need to be part of a comprehensive diagnostic and clinical assessment.
Both the diagnostic criteria and retrospective studies indicate that borderline personality disorder develops in late adolescence/young adulthood, yet the diagnosis is made rarely at first presentation. Non-diagnosis early in the course of the disorder may relate to valid concerns about the appropriateness of diagnosing it during this developmental stage, concerns about misdiagnosis, the iatrogenic effects of diagnosis and/or to a failure to conceptualise the problems as belonging to a personality disorder. Given that a diagnosis of borderline personality disorder in adolescence predicts both axis I and axis II problems in adulthood (Cohen et al., 2007; Daley et al., 1999; Johnson et al., 1999b), failure to consider it early may mean that appropriate early interventions to ameliorate the difficulties for this group of young people are not offered. This may become increasingly important as more efficacious treatments for borderline personality disorder are developed.
9.6. TREATMENT
9.6.1. Review of the evidence base
In relation to treatment for young people, the GDG asked the following clinical question:
In order to address this question, the reviews of the literature of adults with borderline personality disorder were scanned to ascertain whether any studies had been conducted in young people. This yielded one study of CAT (CHANEN2008), but there was no effect for CAT compared with manualised ‘good practice’ other than for reducing self-harm and general functioning (see Chapter 5 for the data for this study). No study of a pharmacological intervention was found in young people aged under 18 years. This is not surprising because not only does no drug have marketing authorisation for the treatment of people with borderline personality disorder, but also few psychotropic drugs have marketing authorisation for young people aged under 18 for any indication.
In the absence of high-quality evidence, the GDG and its special advisors (see Appendix 3) agreed that both the general principles and the recommendations for treatment for adults described elsewhere in this guideline could be applied to young people.
9.6.2. Issues of consent to treatment for young people
It is desirable to gain informed consent from both the young person and their parents before treatment starts, not least because the success of any treatment approach significantly depends upon the development of a positive therapeutic alliance between the young person, the family and the professionals. In most outpatient settings consent is usually straightforward as the young person will generally have a choice to accept or decline treatment. Nonetheless, information about the potential risks and benefits of the intervention being offered should be given.
There may be times when professionals consider inpatient admission to be necessary, but either the young person or the family do not consent. In the Mental Health Act 2007 (HMSO, 2007), there have been some changes to the law regarding young people aged under 18 years. If a young person aged 16 or 17 years has capacity to give or refuse treatment, it is no longer possible for the person with parental authority to overrule the young person’s wishes. However, for those aged under 16 years, a ‘Gillick-competent’ young person can still be admitted against his or her wishes with the consent of someone with parental authority. While the use of parental consent is legal, it is generally good practice to consider the use of other appropriate legislation, usually the Mental Health Act, for prolonged periods of admission as it includes safeguards such as the involvement of other professionals, a time limit and a straightforward procedure for appeals and regular reviews.
On the other hand, a young person aged under 16 years has the right to consent to treatment if deemed ‘Gillick competent’. If the person with parental authority objects, these objections must be considered but will not necessarily prevail.
Alternative legislation includes using a care order (Section 31) under the Children Act 1989 (HMSO, 1989) or a specific issue order (Section 8). Both of these options normally involve social services and can be time consuming. Another more rapid alternative to the Children Act is to apply for a Wardship Order, which in an emergency can be organised by telephone.
9.6.3. Involvement of family and carers
The role of the family in the treatment of young people with borderline personality disorder is critical to consider. Issues within the family, both past and present, are likely to be highly relevant to the development or maintenance (or both) of the young person’s problems. Where modification of problematic family interactions is possible, it is likely to have a significant positive effect on outcome. It may also be the first opportunity some parents have had to consider and address some of their own particular problems. Severity of parental mental health problems also can impact adversely on treatment outcome. Where there are extreme family problems, however, working collaboratively with the family of the young person may prove impossible. Likewise, it may be difficult to form a meaningful therapeutic alliance with parents whose parenting style provokes child protection concerns.
9.7. SERVICE CONFIGURATION
9.7.1. Configuration of CAMHS
Interventions for young people with borderline personality disorder will usually be provided by specialist CAMHS, but some young people are helped significantly by non-specialist healthcare, social or educational services. In order to recognise the different levels of interventions for many mental health problems in children and young people, CAMHS has been organised into four main levels, or tiers, of delivery (NHS Health Advisory Service, 1995; Department of Health, 2004) (see ).
Structure of CAMHS’ tiers.
9.8. SUGGESTED CARE PATHWAY FOR YOUNG PEOPLE WITH BORDERLINE PERSONALITY DISORDER
Available evidence for a care pathway for young people with borderline personality disorder was minimal. The care pathway in this guideline was drawn up in consultation with experts and from extrapolation from the adult care pathway.
9.8.1. General principles to be considered when working with young people with borderline personality disorder
As with adults, both the type of interventions offered to the young person with borderline personality disorder and the manner of delivery are equally important. The general principles outlined for adults that aim to promote a constructive therapeutic relationship are also applicable, with some caveats, to young people. There are some additional principles for working with young people with borderline personality disorder that are also important and are outlined below.
Active participation
Young people with borderline personality disorder find coping with the developmental challenges of adolescence difficult and consequently struggle to function effectively at home, at school and with their peer group. Frequently, their experiences in childhood, as well as causing distress and difficulty, have also failed to prepare them for adolescence. Given these difficulties and the age of the young person, service providers frequently attempt to take responsibility for the young person or strongly encourage parents or carers to do so. This presents particular challenges as the developmental task for young people is to separate and individuate from parents/carers and to develop a degree of autonomy. Young people with borderline personality disorder often attempt to become autonomous in the absence of key capacities to exercise autonomy safely, which increases anxiety in families/carers and professionals alike. Encouraging active participation in this context presents challenges but is highly important. Promoting active engagement in decision making (for example, outlining treatment options, highlighting the consequences of certain behaviours or choices and evaluating the benefits and disadvantages of behaviour change) may assist in developing and maintaining the therapeutic alliance.
An assumption of capacity
In working with adults, assuming that the person has capacity is important. With young people a key goal of treatment may be developing capacity. In working with young people with borderline personality disorder professionals must balance the developing autonomy and capacity of the young person with the responsibility of parents and carers. Professionals need to be familiar with the various legal frameworks surrounding consent in young people to manage this balance effectively.
Experienced and well-trained professionals
Young people with borderline personality disorder often form intense relationships with adults endeavouring to help them. In this context, professionals require the ability to balance validation and nurturing with limit setting around both the frequency and type of contact with the young person. Frequently the intensity and extremity of emotional and behavioural disturbance in these young people, combined with the contextual variability in their functioning, results in different staff members or groups of staff having widely differing views of the nature of the young person’s problems. This can lead to major conflict between staff, which is often referred to as ‘splitting’. Staff must have the capacity to reflect on this process rather than act upon emotions generated by it and maintain collaborative working relationships both with the young person, their family or support system and other professionals engaged with the young person. Staff must avoid lone working, especially in the absence of supervision. Professionals should be alert to circumstances where young people who are hard to engage form intense relationships with tier 1 staff where such staff are inadequately trained to manage the difficulties arising in the helping relationship. Such circumstances warrant consultation from more specialist services (tiers 2 and 3).
Teamwork and communication
Young people frequently see other people and circumstances in extreme terms. This tendency is exacerbated for young people with borderline personality disorder. Regular communication among professionals helps to ensure a consistent treatment approach. Clear leadership with an established and open decision-making hierarchy can ensure that disagreements in teams about treatment planning and delivery are handled sensitively and effectively.
Monitoring the type and intensity of treatment
Often young people with borderline personality disorder receive either uni-modal interventions or multiple uncoordinated interventions. Frequently each additional crisis leads to the addition of new interventions or the involvement of new staff or services. Too little but also too much treatment may be unhelpful. Careful monitoring of the impact of interventions is, therefore, warranted. Young people with borderline personality disorder who also meet criteria for a diagnosis of PTSD present a particular clinical dilemma, especially if the young person is highly unstable (for example, where there is frequent, severe suicidal/self-harming behaviour, severe substance misuse or other severe psychopathology). In such circumstances trauma processing work or exploratory approaches may be contra-indicated until a reduction in risk or increase in emotional stability has been achieved. With other young people interventions to address the trauma may facilitate a reduction in risk and an increase in stability. Consequently, professionals should consider carefully whether to offer trauma-focused work and how best to do so safely where the young person presents with high levels of risk. As with all interventions, effectiveness must be reviewed regularly.
Realistic expectations
Improvements in the symptoms and functioning of young people with borderline personality disorder, as with adults, tend to be gradual rather than sudden. Therefore, setting realistic goals for progress in both the short and long term can assist young people in remaining motivated. Professionals must also guard against becoming demoralised about slow rates of change.
Being consistent and reliable
As with adults, young people with borderline personality disorder may find engaging with others difficult because of previous or indeed current experiences of abuse and neglect. Providing a consistent approach to the service user provides a sound basis for developing other therapeutic interventions. Consistency can be promoted by providing regular appointment times, being clear about how to access the service in times of crisis, having a clear theoretical model/approach and explaining reasons for certain professional responses.
Multi-agency response
Many young people with borderline personality disorder have needs that span health, social care and education. Coordinating a multi-agency response for these young people is often exceptionally difficult. Often, the presence of one agency in the care of the young person reduces the likelihood of involvement, or in some cases precipitates the withdrawal, of another agency. Withdrawal by one agency when the young person has identified needs that are their responsibility is unhelpful. Those involved with the young person will need to decide which agency is taking responsibility and ensure mechanisms are in place for clear multi-agency communication that do not compromise a young person’s rights to a confidential service, and minimise confusion, particularly for young people who often have disturbed interpersonal communications.
There are some groups of young people with borderline personality disorder who find it especially difficult to access services, for example, those who are homeless and/or substance dependent. Professionals may need to be creative and flexible in attempting to engage these young people.
Management of acute and chronic risks
As with adults, young people with borderline personality disorder may experience high levels of suicidal ideation and repeated self-harm. Therefore working with young people with borderline personality disorder necessarily requires active engagement in the management of both chronic and acute exacerbations of risk. Acute and chronic risks may require different approaches. For example, a service may provide time-limited increased support during a period of heightened acute risk. Yet in response to a less severe increase in risk, the same service may promote more active engagement of the young person in problem solving rather than providing more service input. Professionals must carefully consider strategies to manage acute and chronic risks and develop these in the care plan as appropriate.
Staff and services need to be able to not under- or overreact to crises. Staff must remain alert to the potential dangers of reinforcing behavioural escalations with increased input and involvement and to the risk of withdrawing prematurely during periods of apparent stability and calm. Staff must also take care not to ignore or minimise risks. Failure to respond appropriately to high-risk behaviours may also result in behavioural escalations that cannot be ignored. In general terms, a comprehensive treatment plan to address the needs of the young person facilitates taking a considered approach to risk management. Because striking the right balance in managing risk is difficult, all changes in service input must be carefully considered both with the young person and their family/support system and with other professionals (for example, the treating team or clinical supervisor).
Focusing interventions solely on risk may lead to inappropriate early withdrawal when risk decreases but also may mean that significant interpersonal issues remain unaddressed, possibly leading to later deterioration. Services must structure interventions to provide ongoing intervention and treatment beyond crisis periods.
Involvement of family/carers
Many young people with borderline personality disorder continue to live with their parents. Even for young people no longer with parents, they live in circumstances where significant others may be legally responsible for them. Family or carer involvement in treatment is an essential component of working with young people with borderline personality disorder. The nature and type of family involvement, however, needs careful consideration. Rarely are family relationships unproblematic and in many cases may contribute significantly to the difficulties of the young person. Equally the levels of difficulty for the young person frequently have an adverse impact on the family’s capacity to function effectively. When young people with borderline personality disorder are engaging in risky behaviours, professionals need to consider carefully the balance of maintaining confidentiality regarding the young person with ensuring families and carers have enough relevant information to make informed decisions about safety and the amount of autonomy to give the young person. Involvement of the young person in this decision making process is helpful as is an attitude of honesty about the reasons for certain responses by professionals.
9.8.2. Child and adolescent mental health services
Tier 1
Professionals in tier 1 are most likely to encounter young people with borderline personality disorder as a consequence of interpersonal difficulties (for example, bullying at school), as a result of self-harm, or in association with family difficulties. Tier 1 professionals are unlikely to be involved in diagnosing borderline personality disorder, rather they are involved in providing for the service user’s physical health-care, social and educational needs. An awareness of borderline personality disorder and the principles underpinning its management may contextualise the difficulties of the young person with borderline personality disorder and help tier 1 professionals continue to provide routine services to this vulnerable group of young people. Awareness of borderline personality disorder may prevent inappropriate dismissal of the difficulties presented by the young person and encourage more flexible approaches to meeting the young person’s needs. For tier 1 professionals to be able to fulfil these roles they will need appropriate training. Training programmes for tier 1 staff may require modification to cover borderline personality disorder or behaviours suggestive of the diagnosis. In order for professionals to contextualise appropriately the difficulties of these young people an understanding of personality and personality development will also be beneficial. This training may be most effectively targeted at services that have young people with higher rates of mental health concerns (for example, key stage 4 pupil referral units). Following appropriate training, tier 1 professionals may be involved in the sensitive detection of borderline type difficulties. Such identified concerns should lead to referral to or consultation with tier 2 professionals.
Tier 2
Tier 2 professionals provide consultation and training to tier 1 professionals in regard to all mental health problems. Tier 2 professionals therefore require an awareness of the problems of young people with borderline personality disorder and the general principles of intervention in order to intervene effectively in collaboration with tier 1 professionals. Tier 2 professionals may also be involved in early identification of borderline personality disorder in young people and determining whether more specialist assessment and intervention from tier 3 is warranted. Young people presenting with serious suicidal behaviour and repeated self-harm combined with deterioration in functioning either at home or at school should be referred to tier 3 for assessment. Significant family difficulties alongside behavioural concerns also require more specialist assessment. Referral to social services either under Section 47 (Child Protection) or Section 17 (Child in Need) of the Children Act 2004 (HMSO, 2004) may also be required alongside referral to tier 3.
Tier 2 professionals may consider low-intensity coping or skills interventions focusing on emotional regulation and alternatives to self-harm for young people with sub-threshold symptoms of borderline personality disorder where risk is low and functioning is maintained. In the absence of a robust evidence base caution should be exercised in using such interventions and professionals should remain alert for signs of deterioration.
Tier 2 professionals, alongside colleagues in tier 1, often have significant involvement with young people with borderline personality disorder who either refuse referral to tier 3 in the first instance or who do not engage with tier 3 services. While tier 3 services may need to expand the range and type of interventions to engage more effectively this hard-to-reach group of young people, services may also need to develop capacity to provide more extensive consultation and supervision to tier 2 staff supporting these young people.
Tier 3
Tier 3 services can provide a comprehensive assessment of the young person with borderline personality disorder. Tier 3 services must ensure that they consider borderline personality disorder along with other diagnostic possibilities in formulating the young person’s difficulties and be aware that young people assessed and treated at Tier 3 frequently have multiple comorbidities. The management of comorbidities in young people is no different from that for adults (see Chapter 8).
Given that most young people with borderline personality disorder live with their families, with foster parents, or in social services’ residential placements, involving carers in treatment may be helpful, although no studies evaluating such treatment appear to have been undertaken. Some treatment programmes (for example, DBT-A, an adapted form of DBT for young people) have specific treatment modalities involving the family. Other programmes (for example, some home-based treatment models) work entirely with the family. In some treatment models intervention may focus primarily on developing the capacity of families or carers to support the young person with borderline personality disorder therapeutically. Such interventions may be especially important when the young person does not consent to or is unmotivated to have treatment, although evaluation studies do not appear to have been undertaken.
As many young people with borderline personality disorder require a multi-agency response, clarity about the responsibilities of each agency facilitates the delivery of care. Agencies must strive to collaborate to provide coordinated care. Different thresholds for entry into services can compromise this objective, for example, tier 3 professionals may have concerns about a young person’s social care that may not meet social service thresholds for intervention. This can reduce the effectiveness of therapeutic interventions as tier 3 staff become involved in trying to coordinate or meet social care needs. Likewise social services may find accessing specialist therapy services for some of the young people they care for difficult because tier 3 staff consider that the young person’s social care needs are not met sufficiently to enable therapeutic work to begin. Failure to engage at all with the young person in these circumstances may prevent the success of social service interventions to improve the young person’s social care. Professionals need to work flexibly and creatively around these tensions over service thresholds. Respecting the validity of the principles leading to the development of thresholds while trying to meet the needs of the young person is required in these circumstances.
Tier 3 teams must develop sub-teams of professionals with expertise in the management of young people with borderline personality disorder. Such professionals must also have the capacity to provide consultation and training to tier 2 staff. In some areas the specialist borderline personality disorder provision may be nested within tier 3, in others it may be stand alone. There is no evidence to support one model over the other. Where the breadth of services offered for young people with borderline personality disorder is wide and the level of intensity and expertise in the service is high, these services may be more appropriately considered tier 4 services.
Healthcare professionals in tier 3 should also follow the recommendations for adults in Chapters 5, 6 and 7.
Tier 4
For young people with borderline personality disorder tier 4 services comprise inpatient services, specialist outpatient services and home-based treatment teams. There is an extremely limited evidence base for the effectiveness of treatment in these settings.
Inpatient services. There are several circumstances in which healthcare professionals consider admission of people with borderline personality disorder to inpatient services: to manage an acute crisis, to treat chronic risk, to treat the borderline personality disorder itself or to treat a comorbid condition. Admissions for the management of acute risk should be clearly linked to an acute exacerbation of risk, be time-limited and have clear goals. Admission may also be required when risk is high and the motivation of the client to collaborate in treatment is very low or non-existent. The aim of such admissions is to ensure that the client is ‘just community ready’. Transfer back to the community is clearly facilitated in circumstances where the young person is effectively engaged in a structured outpatient programme.
Factors warranting consideration for admission by a tier 4 team for treatment of borderline personality disorder, other axis I difficulties or chronic risk include repeated self-harm combined with a significant deterioration in functioning and a reduced capacity of either the family or community team to manage the young person. Caution should be exercised in these circumstances, however, because admission to a general purpose adolescent unit with a mixed client group can lead to an escalation of risk and deterioration in symptoms and functioning. The consistent application of the general principles of treatment delivery with this client group, and the application of a structured model of intervention during admission, may mitigate the potential damaging effects of admission.
Adolescent units offering treatment for chronic risk, borderline personality disorder or other diagnoses must have the following characteristics:
A clearly defined treatment programme.
A sub-team of professionals with training and expertise in the management of borderline personality disorder.
Clear leadership and decision making structures in both the main team and the sub-team.
A clear theoretical model/therapeutic approach to the treatment of borderline personality disorder that all staff in the sub-team know thoroughly and staff in the main team are aware of and support.
An ability to tolerate and take therapeutic risks, in particular the capacity to discharge young people who remain at high risk of suicide.
A system of monitoring of outcomes to ensure that deterioration is noted early and strategies implemented to resolve the problem.
Attention to the mix of clients on the unit. There may be specific contraindications for mixing young people with acute psychosis and those with borderline personality disorder in a single treatment programme. Both groups of young people may be adversely affected by the problems of the other, and the requirements of treatment programmes for these two groups differ so widely that staff may experience extreme difficulty in applying flexibly the different approaches needed. Admission of young people for the management of acute risk alongside those in treatment for a broader range of difficulties may also present challenges; separating young people admitted for a crisis from those in a more comprehensive treatment programmes may prove more effective.
Specialist outpatient services and home-based treatment teams Home-based treatment teams for young people are in the early stages of development in the UK and consequently their place in the treatment of borderline personality disorder has yet to be established. Like inpatient services, existing teams frequently manage acute risk and attempt to address chronic risk and/or low functioning patients.
Services are likely to take different forms depending on whether their focus is on acute or chronic problems. When focused on acute risk, services usually combine characteristics of assertive outreach and crisis intervention with intensive case management. These services have proved effective both when tier 3 treatment has been disrupted and as a mechanism for organising an effective outpatient intervention plan. Typically services have a capacity for rapid and intensive engagement lasting no more than a few weeks, followed by client/family-centred intensive case management.
Services focused on chronic risk and/or low functioning are characterised by a stronger psychotherapy focus, a longer duration of treatment and an active engagement phase pre-treatment. These services have also been used as step-down from inpatient care or when inpatient stays have become ineffective. This type of intervention might be considered when parenting has become distorted by the client’s presentation and family relationships are undermining individually-focused treatment plans.
In most cases, psychoeducational work with parents is required before implementing more intensive interventions that may often be experienced as intrusive. These forms of home-based treatment are best avoided where there are longstanding concerns about parental capacity.
Home-based treatment services, regardless of whether they focus on the treatment of acute or chronic issues, share a number of characteristics: they require experienced staff with expertise in borderline personality disorder and a team structure that allows a high level of supervision and the effective management of risk in the community; each is likely to offer time-limited treatment but of different durations; and each is likely to balance limit setting with developing autonomy. Services need to differentiate clearly between interventions for the young person, and those involving parents, family, and the wider system, and to focus primarily on the management of risk and the promotion of functioning rather than longer-term behavioural change.
In the case of services focused on chronic presentation, staff will require broad-based and sophisticated psychotherapy skills and teams will need to operate according to a clear theoretical model.
9.8.3. Transition to adult services
The transition to adult services for young people is often marked by a series of discontinuities in terms of personnel, frequency of treatment (often less intense in adult services) and treatment approach, and often a failure to recognise and adapt treatment to developmental stage. This can be particularly difficult for the young person with borderline personality disorder, who is likely to find endings and beginnings especially challenging. In such circumstances the CPA and joint working between adult mental health services and CAMHS may facilitate the transition. Flexible working around age-limit cut-offs is also likely to be helpful in promoting smooth transitions.
Many young people who have been treated by CAMHS will not meet the referral criteria for adult mental health services, either because the services do not accept people with a personality disorder or because the service does not consider their difficulties to be severe enough to warrant intervention. This latter scenario can be particularly frustrating for young people and CAMHS staff alike, who may have worked together successfully to reduce the intensity and severity of problematic behaviours and are now seeking treatment for the young person for current comorbidities or to consolidate treatment gains. In some circumstances this can be a major disincentive for young people in transition to adult services to work on their difficulties constructively.
Protocols with adult mental health services need to be in place to ensure the smooth transition of young people to adult services when they turn 18 years old. Such protocols need to ensure that access criteria to adult services are consistent with young people who have been previously treated by CAMHS. Commissioners of CAMHS and adult mental health should collaborate to identify service gaps and explore service models, for example, jointly commissioned services across the age range, to address the needs of young people in transition from CAMHS to adult mental health services. In exceptional circumstances where no age appropriate services are available for young people, adult services need protocols in place for young people admitted to adult wards. These protocols should include liaison with and involvement of CAMHS.
9.9. OVERALL CLINICAL SUMMARY
Young people present to services with patterns of behaviour and functioning consistent with a diagnosis of borderline personality disorder. Both DSM-IV and ICD-10 allow clinicians to diagnose borderline personality disorder in young people with certain caveats. There is very little evidence of the effectiveness of treatments for young people with borderline personality disorder (with the exception of the study by CHANEN2008), which is not surprising given the relatively small evidence base in adults.
Given the limited evidence base, however, there is no reason why the recommendations developed for adults should not be adopted for the treatment and management of young people with borderline personality disorder, with additional recommendations relating to issues specific to young people, such as the structure of services and the presence of parents or other carers. Clearly further research into the treatment of borderline personality disorder in young people is required.
9.10. CLINICAL PRACTICE RECOMMENDATIONS
Clinical practice recommendations for young people also appear elsewhere in the guideline where they apply to other evidence review chapters.
- 9.10.1.1.
Young people with a diagnosis of borderline personality disorder, or symptoms and behaviour that suggest it, should have access to the full range of treatments and services recommended in this guideline, but within CAMHS.
- 9.10.1.2.
CAMHS professionals working with young people with borderline personality disorder should:
balance the developing autonomy and capacity of the young person with the responsibilities of parents or carers
be familiar with the legal framework that applies to young people, including the Mental Capacity Act, the Children Acts and the Mental Health Act.
- 9.10.1.3.
CAMHS and adult healthcare professionals should work collaboratively to minimise any potential negative effect of transferring young people from CAMHS to adult services. They should:
time the transfer to suit the young person, even if it takes place after they have reached the age of 18 years
continue treatment in CAMHS beyond 18 years if there is a realistic possibility that this may avoid the need for referral to adult mental health services.
- 9.10.1.4.
NHS trusts providing CAMHS should ensure that young people with severe borderline personality disorder have access to tier 4 specialist services if required, which may include:
