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Cited by 147Personality Disorders and PsychopathologyClinical practice guidelines implementationPersonality Traits and Psychology

European guidelines for personality disorders: past, present and future

Open access
Simonsen, Sebastian, Bateman, Anthony, Bohus, Martin, Dalewijk, Henk Jan, Doering, Stephan, Kaera, Andres, Moran, Paul, Renneberg, Babette +4 more·2019·Borderline Personality Disorder and Emotion Dysregulation
DOI 10.1186/s40479-019-0106-3PMC PMC6530178
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Abstract

Personality disorders (PD) are common and burdensome mental disorders. The treatment of individuals with PD represents one of the more challenging areas in the field of mental health and health care providers need evidence-based recommendations to best support patients with PDs. Clinical guidelines serve this purpose and are formulated by expert consensus and/or systematic reviews of the current evidence. In this review, European guidelines for the treatment of PDs are summarized and evaluated. To date, eight countries in Europe have developed and published guidelines that differ in quality with regard to recency and completeness, transparency of methods, combination of expert knowledge with empirical data, and patient/service user involvement. Five of the guidelines are about Borderline personality disorder (BPD), one is about antisocial personality disorder and three concern PD in general. After evaluating the methodological quality of the nine European guidelines from eight countries, results in the domains of diagnosis, psychotherapy and pharmacological treatment of PD are discussed. Our comparison of guidelines reveals important contradictions between recommendations in relation to diagnosis, length and setting of treatment, as well as the use of pharmacological treatment. All the guidelines recommend psychotherapy as the treatment of first choice. Future guidelines should rigorously follow internationally accepted methodology and should more systematically include the views of patients and users.

AI snapshot

Written from the paper’s full text.

TL;DR

This review summarizes and evaluates European clinical guidelines for personality disorders, identifying nine guidelines from eight countries and comparing their recommendations on diagnosis, psychotherapy, and pharmacological treatment. It finds broad agreement that psychotherapy is first-choice treatment but important contradictions in diagnosis, treatment length/setting, and medication use, and calls for more rigorous, patient-inclusive future guidelines.

Key findings

  • Nine European guidelines from eight countries were identified: five on borderline personality disorder (BPD), one on antisocial personality disorder (ASPD), and three on personality disorders in general.
  • All guidelines recommend psychotherapy as the treatment of first choice; for BPD there is broad consensus that outpatient psychotherapy should be primary, but recommendations on length and setting conflict—e.g., Danish guidelines allow short-term (< 12 months) or long-term (≥ 12 months) psychotherapy, while British guidelines warn against brief interventions of less than 3 months, and Swiss recommendations describe outpatient psychotherapy 1–2 sessions per week over 1–3 years.
  • Pharmacological treatment is generally not recommended as the primary intervention for PD; it is mainly for comorbid disorders or brief crisis use, though Swiss, Finnish, and Dutch guidelines suggest medication may target specific BPD dimensions such as anger, impulsivity, or negative mood, while British guidelines say not to use drug treatment specifically for BPD or its individual symptoms and limit crisis sedative use to no longer than 1 week.
  • Diagnosis recommendations show some consensus on semi-structured interviews, but Swedish guidelines state such interviews alone are insufficient and recommend the LEAD principle, Danish guidelines do not recommend routine screening in primary care, Swiss guidelines recommend screening for specific symptoms and differential diagnoses, and only the Swiss guideline directly addresses severity.

Methods

  • Narrative review/overview of European PD guidelines known to the authors, organized by geographical region and evaluated with attention to AGREE domains, especially rigour of development and applicability.
  • Guidelines covered include Sweden (2017), Finland (2015), Denmark (2016), Germany (2009), the Netherlands (2008), the UK (2009 BPD and ASPD), Switzerland (2018), and Catalonia/Spain (2011); no Norwegian national clinical guidelines for PDs currently exist.
  • The authors compared recommendations across three main areas—diagnosis, psychological treatment, and pharmacological treatment—using tables and qualitative synthesis; they did not perform formal AGREE scoring.

Limitations

  • Stated: the authors acknowledge that using the AGREE system would have been a more systematic approach for guideline quality appraisal, but this was not considered feasible due to language barriers and the unfunded nature of the project; the AGREE manual recommends at least 2 and preferably 4 appraisers for reliable rating.
  • Stated: existing guidelines vary in quality, recency, completeness, transparency of methods, combination of expert knowledge with empirical data, and patient/service user involvement; many recommendations are based on clinical/expert consensus or very low levels of evidence, and implementation and severity are generally neglected.
  • Evident from the text: this is a narrative overview rather than a systematic review, with no formal quality scoring, and the guideline set is limited to those the authors were aware of, so language and awareness barriers may have excluded relevant European guidelines.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.1186/s40479-019-0106-3

Cites

26 of 26 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

0 of 31 cited sources checked · 0 supported · 0 flagged

  • Findingown data

    The Swedish guidelines do not include a method section outlining a systematic evaluation of the empirical support underlying different recommendations.

    “They do not include a method section outlining a systematic evaluation of the empirical support underlying different recommendations, but rather rely heavily on guidelines from other countries”
    Quote in the paperNot a substantial claim
  • Findingreasoning

    The main limitation of the Swedish guidelines concerns the rigour of development, specifically that the path from evidence to recommendation is not always transparent and reproducible.

    “From an evidence-based guidelines perspective, the main limitation concerns the rigour of development, more specifically that the path from evidence to recommendation is not always transparent and reproducible.”
    Quote in the paperNot a substantial claim
  • Findingcitation

    In Germany, treatment guidelines for personality disorders were first developed in 2009 by a committee of experts.

    “Treatment guidelines for PD were first developed in 2009 by a committee of experts as delegated by a variety of professional societies and associations [15].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [15] DGPPN - Deutsche Gesellschaft für Psychiatrie, P.u.N.H., Behandlungsleitlinie Persönlichkeitsstörungen. Reihe: S2 Praxisleitlinien in Psychiatrie und Psychotherapie, Band 1. 2009.

      Not checked in the free run.

  • Findingcitation

    A Standard of Care for patients with BPD was published in 2017.

    “This perspective has now been covered in a standardized procedure of care for patients with BPD published in 2017 [18].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [18] Instituut, T, Zorgstandaard persoonlijkheidsstoornissen: Kwaliteitsontwikkeling GGZ [Care standard personality disorders: Quality development mental health care]. 2017.

      Not checked in the free run.

  • Findingown data

    The first German guideline was at level S2.

    “The first guideline was at level S2.”
    Quote in the paperNot a substantial claim
  • Classified as probably not a substantial claim. 57
  • May combine two claims. 29
  • The quote only partly states this claim. 1

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingcitation

    The Finnish Current Care Guidelines for BPD were developed by the Finnish Medical Society Duodecim in cooperation with the Finnish Psychiatric Association in 2015.

    “The Finnish Current Care Guidelines for BPD were developed by the Finnish Medical Society Duodecim in cooperation with the Finnish Psychiatric Association in 2015 [12].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [12] Association, F.M.S.D.a.t.F.P., Epävakaa persoonallisuus. Käypä hoito -suositus. [Borderline Personality Disorder. Current Care Guidelines]. 2015.

      Not checked in the free run.

  • May combine two claims.

    Findingnone given

    Five of the guidelines are about Borderline personality disorder, one is about antisocial personality disorder, and three concern personality disorder in general.

    “Five of the guidelines are about Borderline personality disorder (BPD), one is about antisocial personality disorder and three concern PD in general.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingnone given

    In the Finnish guideline, systematic method and evidence reviews were applied, but the recommendations can only partly be traced back to the supporting evidence.

    “Systematic method and evidence reviews were applied in the development process, but the guideline recommendations can only partly be traced back to the supporting evidence.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingcitation

    In Denmark, the National Health Authority published guidelines for BPD in 2016.

    “In Denmark, the National Health Authority published guidelines for BPD in 2016 [14].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [14] Vind, AB, et al. National klinisk retningslinje for behandling af emotionel ustabil personlighedsstruktur, borderline type. 2015.

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingnone given

    In the German guideline, a systematic search for evidence was conducted and the body of evidence is well described.

    “A systematic search for evidence was conducted, and the body of evidence is well described.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingnone given

    Ten specific questions regarding screening in primary care, diagnosis, length of treatment, uni- or multimodality treatment, monitoring outcomes and pharmacological treatment formed the starting point for the Danish guideline.

    “Ten specific questions with regards to screening in primary care, diagnosis, length of treatment, uni- or multimodality treatment, monitoring outcomes and pharmacological treatment formed the starting point for the development of the guideline.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingreasoning

    In the Dutch guideline, the connection between evidence and strength of recommendations is not fully transparent and many recommendations were based on very low levels of evidence.

    “However, the connection between evidence and strength of recommendations is not fully transparent and many recommendations were based on very low levels of evidence.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    The Dutch guideline was developed by an expert workgroup and is based on scientific research critically and systematically appraised according to the level of evidence and completed with professional expertise.

    “The guideline was developed by an expert workgroup and is based on the results of scientific research critically and systematically appraised according to the level of evidence and completed with professional expertise.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    The Danish guideline used the GRADE system in developing recommendations.

    “The GRADE system was used in developing the recommendations.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingnone given

    Currently, there are no Norwegian national clinical guidelines for personality disorders.

    “Currently, there are no Norwegian national clinical guidelines for PDs.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based). May combine two claims.

    Findingnone given

    The first systematically developed European guidelines on the management of personality disorders were published in 2008 and 2009 and came from Finland, Germany, the Netherlands and the UK.

    “The first systematically developed European guidelines on the management of PDs were published in 2008 and 2009 and came from Finland, Germany, the Netherlands and the UK.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingnone given

    The Dutch guideline was developed to improve the treatment of individuals with personality disorders.

    “The guideline was developed to improve the treatment of individuals with PDs.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingcitation

    The earliest European guidelines identified derived from The Swedish Psychiatric Society, which developed Clinical guidelines for personality disorders in 2006, recently updated in 2017.

    “The earliest European guidelines that we were able to identify derived from The Swedish Psychiatric Society. The Society developed Clinical guidelines for personality disorders in 2006, which were recently updated (2017) [9].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [9] Ekselius L, et al. Personlighetssyndrom, kiniska riktlinjer för utredning och behandling. 2017: Gothia Förlag AB.

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingnone given

    The Danish guideline's working process, methods and analyses behind the recommendations are publicly available on the National Health Authority website.

    “The working process, methods and analyses behind the recommendations are publicly available on the National Health Authority website”
    Quote in the paperNot a substantial claim

  • May combine two claims. The quote only partly states this claim.

    Findingown data

    The nine European guidelines from eight countries differ in quality with regard to recency and completeness, transparency of methods, combination of expert knowledge with empirical data, and patient/service user involvement.

    “To date, eight countries in Europe have developed and published guidelines that differ in quality with regard to recency and completeness, transparency of methods, combination of expert knowledge with empirical data, and patient/service user involvement.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingnone given

    Currently, an S3 guideline on BPD is in progress in Germany.

    “Currently, an S3 guideline on BPD is in progress”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingnone given

    The major limitation of the Dutch guideline concerned implementation, especially in regard to systematically considering barriers and monitoring progress.

    “The major limitation of the guideline concerned implementation, especially in regard to systematically considering barriers and monitoring progress.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based). May combine two claims.

    Findingnone given

    The NICE guidelines cover many clinically important questions, but recommendations are often based on clinical/expert consensus rather than evidence.

    “The guidelines cover many clinically important questions, but recommendations are often based on clinical/expert consensus rather than evidence.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingnone given

    The Swedish guidelines suggest adopting the LEAD principle as the gold standard.

    “Instead, they suggest adopting the LEAD principle (Longitudinal Expert All Data) as the gold standard.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingreasoning

    Screening tools are addressed in three guidelines.

    “Screening tools are addressed in three guidelines.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingreasoning

    The Danish guidelines do not recommend the use of screening in primary care due to the high rate of false positives and negatives.

    “while the Danish guidelines go even further in not recommending the use of screening in primary care due to the high rate of false positives and negatives.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingnone given

    The question of severity of the disorder is only directly addressed in the new Swiss guidelines, which state that it should be taken into consideration.

    “The question of severity of the disorder is only directly addressed in the new Swiss guidelines, which state that it should be taken into consideration.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    There is a considerable overlap between the different national guidelines, but also significant differences.

    “we found a considerable overlap between the different national guidelines, there were also significant differences”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingnone given

    The German guideline specifically states that DBT has better empirical evidence than other types of specialized psychotherapy for BPD.

    “the German guideline, which specifically state that DBT has better empirical evidence than other types of specialized psychotherapy for BPD”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingcitation

    The Spanish guideline was developed using the SIGN system.

    “Methodologically, the guideline was developed using the system SIGN (Scottish Intercollegiate Guidelines Network) [22].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [22] Network, S.I.G., R.T. Harbour, and L. Forsyth, SIGN 50: a guideline developer's handbook. 2008: Scottish Intercollegiate Guidelines Network.

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingnone given

    Danish guidelines include a practice-based recommendation of both short (<12 months) and long-term treatments.

    “the Danish guidelines include a practice-based recommendation of both short (< 12 months) and long-term treatments”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingcitation

    In 2009, NICE published Guidelines on BPD and Antisocial Personality disorder.

    “In 2009, the Guidelines on BPD [10] and Antisocial Personality disorder [19] were published.”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [10] Excellence, N.I.f.H.a.C., Borderline personality disorder: treatment and management (CG78). 2009.

      Not checked in the free run.

    • cites [19] Excellence, N.I.f.H.a.C., Antisocial personality disorder:prevention and management (Clinica guideline CG77). 2009.

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingcitation

    In Switzerland, the Swiss Association for Psychiatry and Psychotherapy set up a task force that published recommendations for BPD in 2018.

    “In Switzerland, the Swiss Association for Psychiatry and Psychotherapy set up a task force consisting of personality experts with the aim of coming up with practical and relevant clinical treatment recommendations for BPD rather than a new guideline. The task force published recommendations in 2018”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [21] Euler S, et al. Borderline-Störung: Behandlungsempfehlungen der SGPP. Psychiatr Psychother. 2018;169(5):135–43.

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingreasoning

    The Swiss recommendations were based on a consensus view giving weight to scientific evidence, good clinical practice and national applicability.

    “Recommendations were based on a consensus view giving weight to scientific evidence, good clinical practice and national applicability.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim. May combine two claims.

    Findingnone given

    There are both similarities and discrepancies across European guidelines.

    “It is clear that there are both similarities and discrepancies across guidelines.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingnone given

    The emergence of new evidence has been monitored since 2009, but none of the emergent evidence has been deemed sufficiently strong to warrant changing the NICE guideline recommendations.

    “The emergence of new evidence has been monitored since 2009, but none of the emergent evidence has been deemed sufficiently strong to warrant changing the guideline recommendations.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable), S4 (based).

    Findingnone given

    Existing guidelines still have many limitations that need to be effectively tackled in future iterations.

    “existing guidelines still have many limitations that need to be effectively tackled in future iterations”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingreasoning

    These specific recommendations are not consistent and are somewhat at odds with the more general recommendation of being cautious with the use of medications.

    “However, these specific recommendations are not consistent and are somewhat at odds with the more general recommendation of being cautious with the use of medications.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingnone given

    In the United Kingdom, NICE is an independent public body that provides national guidance and advice to improve health and social care.

    “In the United Kingdom, National Institute of Health Care and Excellence (NICE) is an independent public body that provides national guidance and advice to improve health and social care in the United Kingdom”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim. May combine two claims.

    Findingreasoning

    Recommendations on pharmacological treatment are in overall agreement that medication should not be considered the primary intervention for PD, but should be used mainly for treating comorbid disorders and in some cases briefly during times of crisis.

    “recommendations on pharmacological treatment are in overall agreement that, based on sparse trial evidence, medication should not be considered the primary intervention for PD, but should be used mainly for treating comorbid disorders and in some cases used briefly during times of crisis”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingnone given

    The Swiss recommendations are currently available in French and German.

    “The recommendations are currently available in French and German.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingnone given

    The Swiss, Finnish and Dutch guidelines suggest that medication may be used to reduce specific dimensions of BPD such as anger, impulsivity or negative mood.

    “The Swiss, Finnish and Dutch guidelines suggest that medication may be used to reduce specific dimensions of BPD such as anger, impulsivity or negative mood.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingnone given

    The Standard of Care was developed and formulated from the patient's perspective and the main goal of care was psychosocial recovery.

    “This Standard of Care was developed and formulated from the patient’s perspective and the main goal of care was psychosocial recovery.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingcitation

    Both the British and German guidelines date back to 2009, with new relevant evidence having emerged since then.

    “However, both guidelines date back to 2009, with new relevant evidence having emerged since then [23, 24].”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [23] Bamelis LL, et al. Results of a multicenter randomized controlled trial of the clinical effectiveness of schema therapy for personality disorders. Am J Psychiatr. 2014;171(3):305–22. source

      Not checked in the free run.

    • cites [24] Weinbrecht A, et al. Avoidant personality disorder: a current review. Curr Psychiatry Rep. 2016;18(3):29. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingreasoning

    On a general level, the consensus regarding the diagnosis of personality disorder is focused on which instruments to use and with what purpose and caveats.

    “On a general level, the consensus regarding the diagnosis of PD is focused on which instruments to use and with what purpose and caveats.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingcitation

    The Spanish guideline was developed by a team including a methodology consultant, psychiatrists, psychologists, a nurse and social workers, and was based on a systematic search and rating (AGREE and OSTEBA) of evidence.

    “The guideline was developed by a team including a methodology consultant, psychiatrists, psychologists, a nurse and social workers, and was based on a systematic search and rating (AGREE and OSTEBA) of evidence.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingcitation

    There are similarities in the broader field of recommended PD treatment, but also important differences, for example with respect to treatment of suicidal and self-harming behaviours.

    “there are similarities in the broader field of recommended PD treatment, but also important differences, for example with respect to treatment of suicidal and self-harming behaviours”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    The Spanish guideline is oriented towards specialists in mental health responsible for the treatment and care of individuals with BPD.

    “The guideline is oriented towards specialists in mental health who are responsible for the treatment and care of individuals with BPD”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingnone given

    In Spain, a clinical practice guideline for BPD was developed in 2011 by the Catalan Agency for Health Information, Assessment and Quality.

    “In Spain, a clinical practice guideline for BPD was developed in 2011 by the Catalan Agency for Health Information, Assessment and Quality.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingreasoning

    Recommendations on length of treatment and use of multiple modalities are not clear and are sometimes contradictory within and between guidelines.

    “The recommendations in terms of both length of treatment and use of multiple modalities are not clear and are sometimes contradictory even within a guideline as well as between guidelines.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingnone given

    The Swedish guidelines specifically state that semi-structured interviews alone are not sufficient for diagnosis.

    “although the Swedish guidelines specifically state that such interviews alone are not sufficient.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingnone given

    The German guidelines state that CBT has the strongest empirical support in the treatment of Avoidant PD.

    “In addition, the German guidelines state that CBT has the strongest empirical support in the treatment of Avoidant PD (AvPD).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingnone given

    This focus on BPD has not always been made explicit by the authors.

    “although this has not always been made explicit by the authors”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingnone given

    According to Google Scholar, the two NICE guidelines have been cited more than 250 times in the scientific literature.

    “and according to Google Scholar, the two guidelines have thus far been cited more than 250 times in the scientific literature.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    The only recommendations found for Antisocial Personality Disorder were cognitive-behavioural therapy (CBT), recommended by both the British and the German guidelines.

    “The only recommendations we found for Antisocial Personality Disorder were cognitive-behavioural therapy (CBT), which was recommended by both the British and the German guidelines.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Findingnone given

    For BPD, there is broad consensus that outpatient psychotherapy should be the primary treatment.

    “For BPD, there is broad consensus that outpatient psychotherapy should be the primary treatment.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingnone given

    The Swiss guidelines recommend the use of screening instruments to ascertain specific symptoms and differential diagnoses.

    “Finally, the Swiss guidelines recommend the use of screening instruments to ascertain specific symptoms and differential diagnoses.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingnone given

    The Swiss guideline has strengths in addressing important clinical questions and considering national particularities but may be criticised for lack of transparency in using multiple levels of evidence without defining how this is reflected in the strength of recommendations.

    “The guideline has several strengths in addressing important clinical questions and in considering national particularities but may be criticised in terms of a lack of transparency in using multiple levels of evidence without defining how this is reflected in the strength of recommendations.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingnone given

    British guidelines specifically warn against psychotherapy treatments lasting less than 3 months.

    “the British guidelines specifically warn against the use of psychotherapy treatments lasting less than 3 months”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S4 (based).

    Findingnone given

    Over the past decade, throughout Europe, a range of clinical guidelines for the management of PDs have emerged.

    “Over the past decade, throughout Europe, a range of clinical guidelines for the management of PDs have emerged.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingnone given

    Inpatient treatment specifically adapted to BPD and day hospital treatment are also recommended.

    “However, inpatient treatment specifically adapted to BPD and day hospital treatment are also recommended.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingnone given

    The Swedish guidelines warn against using screening for diagnostic purposes.

    “The Swedish guidelines warn against using screening for diagnostic purposes”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingnone given

    Some guidelines recommend the prescription of antipsychotic or antidepressant medication to target specific symptoms, while other guidelines insist on a general caution when it comes to psychopharmacological treatment.

    “some guidelines recommend the prescription of antipsychotic or antidepressant medication to target specific symptoms, other guidelines insist on a general caution when it comes to psychopharmacological treatment”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S4 (based). May combine two claims.

    Findingnone given

    Guidelines for other PDs are either outdated or missing completely.

    “guidelines for other PDs are either outdated or missing completely”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S4 (based).

    Findingnone given

    The issue of severity is generally neglected in existing guidelines.

    “the issue of severity is generally neglected in existing guidelines”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Guideline quality can be assessed and quantified using the AGREE system across six domains.

    “Guideline quality can be assessed and quantified using the AGREE system (Appraisal of Guidelines, Research and Evaluation), where a guideline is assessed across six domains [6].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [6] Brouwers MC, et al. AGREE II: advancing guideline development, reporting and evaluation in health care. Can Med Assoc J. 2010;182(18):E839–42. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Compared to people without a personality disorder, individuals with personality disorder lead shorter lives and have significantly reduced quality of life.

    “Compared to those without a PD, they lead shorter lives, and their quality of life is often significantly reduced [1, 2].”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [1] Fok ML-Y, et al. Life expectancy at birth and all-cause mortality among people with personality disorder. J Psychosom Res. 2012;73(2):104–7. source

      Not checked in the free run.

    • cites [2] Cramer V, Torgersen S, Kringlen E. Personality disorders and quality of life. A population study. Compr Psychiatry. 2006;47(3):178–84. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    GRADE provides guidance on how to link the body of evidence with the degree of strength of the recommendation.

    “The Grade working group (www.gradeworkinggroup.org) provides guidance on how to link the body of evidence with the degree of strength of the recommendation (strong vs. weak/conditional).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    GRADE emphasizes the importance of phrasing recommendations using active language and avoiding ambiguous or unclear wording.

    “GRADE emphasizes the importance of phrasing recommendations using active language and of avoiding ambiguous or unclear wording, such as ‘if clinically appropriate’ or ‘if necessary’ [7].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [7] McDonald CJ, Overhage JM. Guidelines you can follow and can trust: an ideal and an example. Jama. 1994;271(11):872–3. source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    A recent meta-analysis concluded that both DBT and psychodynamic approaches are effective for BPD symptoms.

    “in a recent meta-analysis it was concluded that both DBT and psychodynamic approaches (the last category defined very broadly and including both MBT and brief therapy based on psychoanalytic principles) are effective for BPD symptoms [25].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [25] Cristea IA, et al. Efficacy of psychotherapies for borderline personality disorder: a systematic review and meta-analysis. JAMA Psychiatry. 2017;74(4):319–28. source

      Not checked in the free run.

  • May combine two claims.

    Interpretationreasoning

    Because of proficiency in English by most academics across Europe, the NICE guidelines have been used and referenced in all later European guidelines.

    “Because of the proficiency in English by most academics across Europe, these guidelines have been used and referenced in all later European guidelines”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Interpretationreasoning

    A lack of diverse representation in the Swiss guideline development group may have limited the utility of these recommendations.

    “However, a lack of diverse representation in the guideline development group may have limited the utility of these recommendations.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationreasoning

    The differences identified between national guidelines are probably due, to a large extent, to the lack of methodological rigour with which guidelines have been developed along with the paucity of evidence for many of the clinical questions addressed by the guidelines.

    “the differences we have identified are probably due to, to a large extent, the lack of methodological rigour with which guidelines have been developed along with the paucity of evidence for many of the clinical questions addressed by the guidelines”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationreasoning

    The differences between national guidelines may in part reflect the different ages of the guidelines.

    “These may in part reflect the different ages of the guidelines.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing).

    Interpretationreasoning

    Guidelines based on consensus are likely to have limited impact.

    “This is a major limitation as guidelines based on consensus are likely to have limited impact.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing).

    Interpretationreasoning

    For PDs in general, a five years criterion for guideline expiry might be too strict due to the slower accumulation of evidence.

    “For PDs in general a five years criterion might be too strict due to the slower accumulation of evidence.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Premisecitation

    The AGREE manual recommends at least 2 appraisers and preferably 4 in order to achieve a reliable rating.

    “the AGREE manual [6] recommends at least 2 appraisers and preferably 4 in order to achieve a reliable rating”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [6] Brouwers MC, et al. AGREE II: advancing guideline development, reporting and evaluation in health care. Can Med Assoc J. 2010;182(18):E839–42. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductreasoning

    Due to language barriers and the unfunded nature of the project, use of the AGREE system was not considered feasible.

    “due to language barriers and the unfunded nature of the project this was not considered feasible”
    Quote in the paperNot a substantial claim
73 of 73

  • The paper relies on this without support.

    Recommendations in diagnosis and general treatment are independent of national health systems and thus generalizable to the whole of Europe.

    “These areas were chosen because recommendations in diagnosis and general treatment should be independent of national health systems and thus be generalizable to the whole of Europe.”

  • The paper relies on this without support.

    Widespread comorbidity is often seen in people with PDs, including several comorbid PDs and comorbidity with other clinical syndromes such as anxiety, depression, PTSD and substance use disorders.

    “the widespread comorbidity often seen in people with PDs, not only in terms of several comorbid PDs, but also in terms of comorbidity with other clinical syndromes, such as anxiety, depression, post-traumatic stress disorder and substance use disorders”

  • The paper relies on this without support.

    People with multiple disorders often receive too many or conflicting therapies.

    “People with multiple disorders often receive too many or conflicting therapies”

  • The paper relies on this without support.

    Guidelines should base their recommendations on an evidence-based paradigm.

    “guidelines should base their recommendations on an evidence-based paradigm”

  • The paper relies on this without support.

    Patients' needs and values are important sources of knowledge for clinical guidelines.

    “Patients’ needs, and values are important sources of such knowledge”

  • The paper relies on this without support.

    The strongest recommendations of guidelines stem from randomized controlled trials.

    “their strongest recommendations stem from randomized controlled trials”

  • The paper relies on this without support.

    DSM-5 and ICD-11 focus a great deal on severity in the diagnosis of PDs.

    “The recently published DSM-5, with its Alternative Model for PDs as well as the upcoming ICD-11, focuses a great deal on severity in the diagnosis of PDs.”
7 of 7

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • Danish guideline has conflicting publication years

    Minor

    The text dates the Danish guideline to 2016, while the cited reference [14] dates it to 2015.

  • British guideline also addresses severity

    Minor

    The paper says only the Swiss guideline addresses severity, but its table says the British guideline recommends routinely assessing the severity of antisocial personality disorder in forensic services.

2 of 2

Cites

Flagged first, then by citations

Research works printed but not linked: 3

  1. Vind, AB, et al. National klinisk retningslinje for behandling af emotionel ustabil personlighedsstruktur, borderline type. 2015.
  2. Committee DPMG. Dutch multidisciplinary guideline for personality disorders. Utrecht: Trimbos-institute; 2008.
  3. Instituut, T, Zorgstandaard persoonlijkheidsstoornissen: Kwaliteitsontwikkeling GGZ [Care standard personality disorders: Quality development mental health care]. 2017.

Cited by

Sorted by citations

Related

Authors
Simonsen, S., Bateman, A., Bohus, M., Dalewijk, H. J., Doering, S., Kaera, A., Moran, P., Renneberg, B., Ribaudi, J. S., Taubner, S., Wilberg, T., & Mehlum, L.
Affiliations
  • University of Copenhagen (DK)
  • Heidelberg University (DE)
  • Medical University of Vienna (AT)
  • Kanta-Hämeen Keskussairaala (FI)
  • University of Bristol (GB)
  • Freie Universität Berlin (DE)
  • Oslo University Hospital (NO)
  • University of Oslo (NO)
Corresponding author
Simonsen, Sebastian
ORCID
Venue
Borderline Personality Disorder and Emotion Dysregulation
Publisher
Springer Science and Business Media LLC
Published
2019-05-21
Volume
6
Issue
1
Pages
9-9
ISSN
2051-6673 (ISSN-L)
DOI
10.1186/s40479-019-0106-3
PMC
PMC6530178
OpenAlex
W2947641077
Semantic Scholar
22c2b16c9d4a9752b9fd180695dba6300ad0d886
Cited by
147
References
26
Citations by year
2026: 11 · 2025: 31 · 2024: 27 · 2023: 22 · 2022: 27 · 2021: 18 · 2020: 10 · 2019: 1
FWCI
2.22
Type
journal article
Language
en
Open access
Licence
Locations
  • Borderline Personality Disorder and Emotion Dysregulation (publishedVersion, cc-by)
  • PubMed Central (publishedVersion, cc-by)
  • PubMed (publishedVersion)
  • heiDOK (Heidelberg University) (acceptedVersion, other-oa)
  • Dipòsit Digital de Documents de la UAB (Universitat Autònoma de Barcelona) (submittedVersion, cc-by)
  • DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion)
  • Explore Bristol Research (submittedVersion, cc-by)
  • Bristol Research (University of Bristol) (submittedVersion, cc-by)
  • NORA - Norwegian Open Research Archives (submittedVersion, cc-by)
Topics
  • Social Sciences › Psychology › Clinical Psychology › Personality Disorders and Psychopathology
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Clinical practice guidelines implementation
  • Social Sciences › Psychology › Clinical Psychology › Personality Traits and Psychology
Keywords
personality disorders, borderline personality disorder, antisocial personality disorder, psychotherapy, pharmacotherapy, diagnosis, guideline methodological quality, European guidelines

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-10-08.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-08.

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