Good afternoon everybody, ladies and gentlemen, thank you for coming along here for this symposium which is about adolescence and borderline personality disorders, the experience from a European multi-centric research network, the French, Swiss, Belgium contribution for the understanding and the managing of borderline and dependent features of personality. Thank you to the French Colony to be here and to support us. Let me introduce myself, my name is Maurice Corcos, I am the Chief of the Department of Psychiatry of Adolescents and Young Adults at Paris, Institut Mutualiste Montsouris, and the Chief of this network, I will be the Chairman of this symposium. During this symposium, my colleague will present several interventions focusing on the design, the data collection and main results of this research and also some features about therapeutic innovation and collaboration with family. All the communication comes from clinical searchers who share the common concern and philosophy of integrating differential psychopathological approach and therapeutic strategy in clinical practice. It means that research oriented but also sensitive to the vicissitude of clinical practice. Our practice places us at a cross-section between psychiatry and psychoanalysis and at the level of the patient between the intra-psychic reality and behavior and conduct. The first intervention will be the intervention of Dr. Alexandra Fams-Cotes, who works in the Department of Psychiatry in Saint-Anne Hospital, GHU Neuroscience in Paris. Alexandra? Thank you Maurice. Hello everybody, it's a great pleasure for me to be with you and I'm going to show you the study which is called ERNET BPD and with a focus with the MSI, Borderline Personality Disorder instrument. First my disclosure and acknowledgements. I have no conflict of interest about the data. So borderline personality disorder is the most frequent personality disorder in general population and in clinical setting. But borderline personality disorder in adolescence is a topic of debate with controversial results about its validity and stability over time. But the early detection of BPD at adolescence would allow for better patient care and reduce health costs. So ERNET BPD is the European research network on borderline personality disorder. Our goal is to explore the phenomenology of BPD in adolescence. We are 10 clinical and research teams, all specialized in BPD from three European French-speaking countries, France, Switzerland, and Belgium. So 10 teams from three countries. The main goal of ERNET BPD are to explore the diagnostic validity of BPD in adolescence, the factor structure, BPD criteria, a diagnosis instrument, SIDSP4, and a screening instrument, MSI BPD. Then we want to describe the specificity of BPD features in adolescence, axis 1 and axis 2 comorbidity, self-injurious behaviors and suicide attempts, the quality of depressive experience, attachment patterns, emotional regulations or dysregulation, cognitive functioning, school and university patterns, and mental health care service use. So the flowchart of the study. The first step of screening, 109 adolescent patients with a BPD according to the psychiatrist were screened. And then the study sample, 85 adolescent patients with a BPD according to the SIDSP4 instrument. Then we compared them to match controls, 84 adolescents from general population without BPD according to the SIDSP4 instrument. The assessments by psychiatrists, SIDSP4, we used the DIB, we used the KD-SADS for axis 1 diagnosis, and the general assessment of functioning. And we had a lot of self-assessment, general information, a screening instrument, temperament, impulsivity, self-injurious behaviors, suicidality, depressive patterns, alexithymia, attachment, family relationships, trauma history, and defense mechanism. The inclusion criteria were patients from one of the recruiting centers, girls or boys from 15 to 19 years old, hospitalized or outpatients, having a BPD, and speaking French fluently, and they had to sign a consent form with one of their parents if they were under 18. There were few exclusion criteria. The final study sample, 85 patients from five recruiting centers with a BPD according to the SIDSP4, the mean age was 16.3. They were mainly girls, they were mainly hospitalized, and they were mainly living with their parents. And the match controls were from the general population and without BPD. About the criteria, the most frequent BPD criteria were anger, impulsivity, affective instability, self-injurious behaviors, and suicide attempts, and the mean SIDSP4 borderline score was 70.6. About the SIDSP4 inter-rater reliability, the rating team was composed of five raters, psychiatrists or psychologists, with clinical experience of BPD patients. After two days of intensive training with me, I translated the SIDSP4 into French. And then we conducted an inter-rater reliability with 10 videotaped interviews, and the kappa coefficients were very good. For example, 0.77 for borderline personality disorder. About the factor analysis, after a pro-max oblique rotation, we found two main factors, and we published the data. The factor 1 was more internally oriented. It's an internal oriented dimension with several core BPD symptoms that could represent the most stable pattern. And an external oriented dimension, factor 2, that could more be influenced by age-related behaviors and symptoms. And affective instability is part of the two factors, and it should be a core feature of BPD. Axis 1 comorbidity, most of the patients had at least one axis 1 comorbidity. The more frequent comorbidities were major depressive episodes, then eating disorders, anorexia nervosa, and bulimia nervosa. And then substance abuse and substance dependence, and oppositional disorder with provocation. About the axis 2 comorbidity, other PDs are often comorbid with BPD in adults, but only few studies explore this comorbidity in borderline adolescents. We calculated prevalence rate and confidence intervals for the whole sample and by gender. And the most frequent comorbid personality disorders were obsessive-compulsive, avoidant, and antisocial. There is a trend for antisocial personality disorder in boys. About the MSI BPD, you have in the right side of the slide. It's a maculine screening instrument for borderline personality disorder. It was created by Mary Zanarini. It's derived from the DIPD4. It's self-administered. And it's 10 yes-no items. It takes less than five minutes to fill. It was translated in several languages. And the cutoff, the initial cutoff for Mary Zanarini was seven of 10 items. It was translated in French after the agreement of Mary Zanarini. So we took our 54 borderline controls and our sample of borderline patients. And they had the MSI BPD. The internal consistency was excellent. The conversion validity, too. And here, you have the raw curve. And five was the optimal cutoff point with a high sensitivity and a high specificity. So here are the main references of the MSI BPD, and in red, our French validation. So questions and answers about the maculine screening instrument for borderline personality disorder. What is the false answer? MSI BPD should be used only with adults. What do you think about? False, of course. It can be used with adolescents, too. It's a semi-structured interview. It's false, too. Because it's a self-assessment instrument. It can be used as a screening tool for BPD for clinical purposes or research studies. This is the right answer. It has good psychometric properties to be an efficient and a quick screening tool for BPD for clinical purposes or in research studies. And MSI BPD is available only in English version. Of course not, because it's now translated and validated in many, many languages, French, Chinese, Spanish, Portuguese, German, Dutch, Finnish, Persian, and even Urdu. So a very, very brief clinical presentation, because as a clinical worker, I'm working in the psychiatric emergencies. So Marie is a 19-year-old girl consulting for the third time this year to the Psychiatric Emergency Center of Paris. That's where I am working. She's consulting for self-injurious behaviors, and she's accompanied by her mother. She has already consulted five psychiatrists, never more than three consultations. She always refused to take antidepressant treatment. She said, I'm not depressed. We suspected the borderline personality disorder, and she filled the MSI BPD, non-yes answer of 10. We then quickly explained what borderline personality was. She was surprised. This is the first time I've been asked these questions. You understood perfectly how I felt. We referred her to a psychiatrist specialized in the management of borderline personality disorder. So the MSI BPD has made it possible to create a good quality therapeutic alliance with these young patients with borderline personality disorder, and to stop psychiatric nomadism and repeated visits to psychiatric emergencies. So here are the reference of our research network. Today, 23 international articles, and we wrote a book, too, but now it's only in French, perhaps one day in English, who knows. Thank you for your attention. Thank you, Alexandra. We have time for one or two questions. Is there any question in the audience? Maybe you can wait at the end of the symposium. Okay. Yes? Are you finding that outside of Paris, people are using the instrument, and they're diagnosing In France, we try to diffuse the MSI BPD, but it's not now in clinical practice. I think it's a pity, because it's very useful for the patients, but now very, very few psychiatrists use it, only psychiatrists who have research purpose, too, because they know it. But clinicians don't know this instrument. I see. Thank you. Okay. Marion. Second intervention. Marion Robin is a psychiatrist in the Department of Psychiatry of Adolescent and Young Adults in Paris. Thank you, Maurice. Hi. I'm happy to be there. Thank you for your presence. And I will tell you about... Now we will talk about specific pathways from adverse experience to BPD in adolescence with a criteria-based approach of trauma. Apart from the genetic, temperamental, and biological factors, it is now assumed that childhood adverse experiences are important risk factors for the development of BPD. But the way these adverse factors interact in BPD development remains partly unknown. The international literature has robustly described childhood traumatic events in adults with BPD. 71% of individuals report severe maltreatment in childhood. And similar results have been found in studies on children and adolescents. We know that adverse experiences are a common and dose-dependent risk factor in BPD in borderline features among children, adolescents, and adult BPD, and leading to a harsher and earlier disorder. Adults with BPD are 14 times more likely to develop maltreatment, mainly emotional abuse and neglect, than healthy controls, and three times more likely than other psychiatric groups. All types of abuse and neglect significantly and independently are associated with it, and they report childhood sexual abuse in 40% to 71% of cases. Emotional abuse also is more than 40% of cases reported in BPD. Stressful life events also are reported, and they are more frequent in BPD than in other personality disorders or in major depressive disorders, leading to a decreased psychosocial functioning over time. Early separation or losses are frequent in this population, with high rates of chaotic family life, parental divorce, domestic violence, criminality, psychiatric family history, and substance misuse. Third, the dysfunctional parenting style were also identified as risk factors across studies. Parental hostility, maternal inconsistency, and over-involvement are specifically associated with an increased risk of BPD. So, these three types of adverse events, maltreatment, stressful life events, and dysfunctional parenting, bonding, might all contribute to the development of BPD and are often inter-correlated. However, their specificity remains unclear. For example, sexual abuse and BPD, or self-harm and dissociation, the publication about these adverse events doubt about the specificity of their links and correlation. For example, death-related life events are more specific to major depressive disorders than to BPD. So, it underlies the importance of studying pathways to BPD symptoms other than self-harm, which is the most studied one. The context includes also the fact that early interventions to prevent or treat BPD are now widely accepted, but there are only a few studies disentangling the effects of traumatic events and their specific pathways to the disorders, in particular in its early stages. So, in this study, we included the patient from the early BPD, adolescents from 13 to 19 years old, with 89 patients and 84 healthy controls in this part of the study. And the aim of this research is to investigate the combination of these three types of adversity, maltreatment, stressful life events, and parental dysfunction, as predictors of BPD in a criteria-based approach. For this, we chose exploratory models that allowed detection of the associated contribution of this adverse event to each BPD criterion. Our hypothesis was that combination of adverse events would be differently associated to the nine different BPD criteria. The methods included the use of the CTQ, the Childhood Trauma Questionnaire, for assessing maltreatment. This is a 28-item self-report instrument exploring history of abuse and neglect. For the stressful life events, we used a questionnaire about some factors, like being separated from a parent for at least a month between the age of one year old, or being separated from both parents for at least a year. Also, we explored a history of parental chronic disease, physical or psychological disease, or a history of parental suicide attempt. For the exploring parent-child bonding, we used the PBI, Parental Bonding Instrument, which is a self-administered questionnaire from the child's point of view. These items were used to generate care and control levels evaluated for each parent. A care level and a control level. Then, we used a multivariate regression model predicting each of the nine BPD criterion scores. Each one was ranging between 0 and 3, and one model predicting the SIDP total score, so the BPD total score explored with the structured interview, ranging from 0 to 27. This was an exploratory procedure. The results revealed that the highest score for BPD criteria were anger, affective instability, and impulsivity in the BPD group. Anger, affective instability, impulsivity, and self-harm were the most frequent BPD that were met in this population, whereas in a healthy control group, it was anger, affective instability, and relational instability. Here in table 2, we can see the frequency of all adverse events, which occurred much more frequently in BPD patients than in control groups, including early separation from parents with 32%, parental chronic disease, 29%, and parental suicide attempt, 24.6% of borderline patients in adolescence. So, BPD patients reported significantly more experience of maltreatment, all maltreatment, than healthy control, and they also reported a lower level of maternal care and more control than healthy controls. Here in the multivariate regression analysis, we can see that for each criterion of BPD, anger, affective instability, etc., with here the total score of the nine criteria, we can see that each criterion is predicted by at least one adverse event, and mostly by two, three, or more adverse events. The most often is one type of maltreatment, one type of stressful life event, and one type of parent-child dysfunction. For example, anger was predicted by emotional abuse and parental suicide attempt, plus a decrease in paternal level of care. Affective instability was most predicted by emotional neglect and a low level of paternal care. We can see that some adverse events were predicting of one or two criteria, as if there was a little bit specific of one criterion, and some of them were broadly correlated to BPD criteria, as emotional abuse, which is correlated to anger, to self-harm, to abandon, to emptiness, to self-image instability, and to the total score. Also, the low level of paternal care was correlated to anger, affective instability, impulsivity, self-harm, relational instability, and emptiness. We have observed in this study a cumulative traumatic experiences, which largely characterize borderline adolescence history. This cumulative adversity includes the three types of maltreatment, stressful life event, and dysfunctional parenting, and the combination of these three types of adverse events maltreatment, stressful life event, and dysfunctional parenting. The combinations are different for each criterion, suggesting specific pathways in BPD. As I said, some seem to be specific, like sexual abuse, emotional neglect, physical abuse, physical neglect, which each appear to be associated to one or two models predicting a BPD criterion, respectively sexual abuse predicting self-harm, emotional neglect predicting self-harm and affective instability, physical abuse predicting impulsivity and relational instability, and physical neglect predicting dissociation. And some other adverse events had a broader role in BPD pathogenesis, for example, emotional abuse and paternal low care, which is in echo with what Zanarini developed with her concept of bi-parental failure in the childhood experiences of BPD patients. So our results are in line with previous study, in the sense that it confirmed that all types of abuse and neglect were found to be significantly associated, but not only, it reinforced the idea that emotional abuse is a core feature of BPD psychopathology, having demonstrated a strong and specific association with BPD diagnosis above other type of maltreatments in previous studies. In our study, the associated contribution of six factors to self-harm suggests that it may be the most multifactorial criterion of BPD. In line with previous observation of an additive effect of child sexual abuse and another maltreatment type, showing a stronger association with self-injury than child abuse alone. So our findings may reinforce the importance of considering emotional and relational difficulties of patients' parents when treating BPD patients, the importance to treat all the family and to support parents with their own history of adversity. The limits of our study were first the technique of an exploratory result, which is justified by the sample, the size of the sample and the absence of clinical control group, the small number of boy. Nevertheless, this is the exploration of the mechanism of trauma at an early stage of BPD development. And we think that the experience of adversity should be systematically explored when facing BPD symptoms, because BPD may be conceptualized as a trauma-related disorder. So we have to take into account environment of patient and to implicate parents in BPD therapy with systemic family therapy, family-focused therapy, close articulation between child psychiatric and protection services on one side and adult psychiatric services for parents on the other side. Preventive strategies should help primary caregivers providing continuity of care and security for children, given the parental dysfunctions and the proportion of early separation from caretakers in BPD. So we should help the involvement of caretakers in meeting the child's basic needs in terms of attachment security. Thank you for your attention. Thank you, Marion. So, maybe one question in the audience. Yes, thank you. Sorry? Do you mean all types of abuse? Emotional, physical, sexual abuse? If you add abuse and neglect, you have 67% of patients concerned. Yes, exactly. Yes, this is self-report in this study, but we work in the inpatient department where adolescents are hospitalized and we work a lot with families, so in other studies and in our clinical daily observation, we can see all aspects of the experience, of the situation, and with the parents' advice also, and with the whole environment which is taken into account. So it didn't surprise us. We can imagine that there is a large part of patients who do not reveal the abuse, of course. Thank you. Yes? more or less nine. Very often when a borderline person is asked to account an experience and the parents or other family members are asked to account and a bias to the negative, so it's very upsetting to see that, because in my experience, I don't see the level of abuse that you're describing. What we do see is enormous perceptual differences in how they infer. In fact, first of all, if we treat family, we can see that in brothers and sisters and all the family group, we can see how in a systemic rezoning and transgenerational rezoning, we can see easily how a child and his brother or sister won't have the same treatment. That's a part of the aspect. I also talked just at the beginning about the genetic and temperamental aspect of the research about borderline personality. Of course, this is an argument, an important argument. And most of the time, we can see, every time we can see the difficulty to perceive from the patient, their relationship with their parents. So as you say, and Jean will talk about it, their perception is affected by a difference between what is perceived and reality. And we work with family to understand, because we have to treat borderline adolescents. We have to get out of the rezoning about bad and good relationships. We don't, as Spinoza said, don't cry, don't laugh, just not crying, not laughing, just understanding. And this is it with borderline patients. We have just to understand how it happens. And the aim of this presentation is not to say they are bad parents, not at all, because they have also a trauma history. So we have to go to their history and treat the trauma where it is, without laughing or crying. It's a big history of adversity for everyone. I told you, 24% of suicide attempts in parents, this is not perception of just adolescents. So we have to treat the parent history to treat the children. That's very important. But the score I evoked of 67% is all types of abuse and neglect. But the most, the highest score is for emotional neglect, which is the most difficult to describe in psychiatry. Emotional neglect is the impossibility for a parent to identify the child's affective need. And this is very frequent in these families. And we have to take into account this difficulty in parents. This doesn't make bad parents again, but their difficulty made them, made in part impossible to identify where the affective need is in their child. But with the support of therapy, of a psychiatrist's team, of psychological support, of protection services, they learn it with the years. And so the prognosis is good, almost when it's treated early. Okay. Thank you. Merci. Jean? Okay. Hello, everyone. Thank you for being here. I'm glad to present to you this paper, Paradoxes in Borderline Emotional Dysregulation in Adolescents, and How Influence of Parenting, Stressful Life, Events, and Attachments Interact. So paradoxical reactions, I'd like to introduce this presentation by quoting a patient of mine that was saying recently, it makes me angry that my parents want to help me. But at the same time, I feel like they don't pay attention to me. So how can we understand that? That's one of the paradoxes we'll try to answer with this presentation. So for the context, well, it's been said a bit before by Marion Robin, but we know that up to 50% of inpatients in adolescence are suffering from borderline disorder. We do know that they are at great risk of self-harm and suicide. And that's why, of course, it's a matter of interest for us. We do know that anger outbursts and emotional instability, which is switching from excitement to intense hopelessness, is common and predictive of the illness impact. It's also known that some minor stress can cause, can lead to disproportionate reactions like being contradicted, being forgotten, or if you show late to an appointment. And surprisingly, some major stress will lead to no reaction at all, like serious stress, like being assaulted, experiencing stress or danger. It draws our attention to the discrepancy between the magnitude of the life event and the psychological factors that will be giving meaning to it. So the paradox revealed in this peculiar fact is not really explained to date. And emotional dysregulation is more often described as emotional hyper-reactivity, that it could be also, of course, temperamental, than it is as a combination of hyper-reactivity and hypo-responsiveness. So of course, we know that difficult parent-child interaction, as well as other forms of adversity that Marion Robin quoted earlier in childhood, such as abuse, stressful life events, are known to be associated with borderline disorder. But the respective contribution of these factors and of the psychological ones, such as attachment insecurity or alexithymia, on affective symptoms is not yet clear. And that's kind of the goal of this paper. So we had two hypotheses, the first one being the attachment system is responsible for the emotional manifestations in borderline, such as borderline affective symptoms and emotional dysregulation, such as hopelessness, and independently of environment. And that's maybe what we just evoked seconds ago. And two, that borderline patients have developed a phenomenon of habituation to stress, disconnecting them from their emotions. And we think it is done through alexithymia. So the study, I won't explain it long because it's been explained before. So this is the ERNET network that has been presented. So we assessed the stressful life events through 20 questions about life traumatic experiences, like being separated from a parent for at least a month before the age of one, history of parental chronic disease, history of parental suicide attempt, death of the mother, death of the father, of a close relative, parental separation or divorce, and so on. We assessed the relationship with parents, current relationship, through the parental bonding instrument. Then we assessed the attachment through the relationship scale questionnaire, and the alexithymia through the Toronto alexithymia scale, the hopelessness, and the affective symptoms of borderline disorder through the diagnostic instrument for borderline revised. So with no further ado, I go to the results. This is the basic comparison between the borderline and the controls on parental bonding, stressful life event, attachment, affective symptoms, hopelessness, alexithymia. As expected, adversity events occurred more frequently in borderline patients compared to controls. Similarly, borderline patients had significantly higher scores of both attachment anxiety and attachment avoidance than matched controls. Hopelessness, borderline symptoms, and alexithymia were also more intense in borderline than controls. That could be expected. Then that's the correlation. So stressful life events have opposite correlation between, well, I'm just going to go to the main results from these numbers. So the main results were that dysfunctional parental interactions were linked to affective symptoms and hopelessness in ethic controls, but actually the dysfunctional parental interactions were not linked to them in borderline personality disorders. Also, we found that cumulative stressful life events were correlated with increase of affective symptoms in ethic control, which seems logical. But in the contrary, cumulative stressful life events were correlated with a reduction of affective symptoms and hopelessness variables in borderline. So that's what you can see here. In red, you have the borderline population. So we can see that they have more hopelessness, of course, and more affective symptoms. But when there are more stressful life events, their hopelessness and affective symptoms tend to reduce, while in the control group, in blue, they have, of course, less. But when they get more stressful life events, when they have more stressful life events, hopelessness and affective symptoms will increase. So we also find that the cumulative stressful life events had no correlation at all with alaketamia in LC controls, however, they were correlated with alaketamia in borderline personality disorder. So to circle back to our first question, we found that two types of adversity had different effects from one another in terms of emotional regulation and affective symptoms. We also found that these effects differed from borderline and controls. But for us, it remains to be seen how attachments interact with these variables. In order to do that, we compared the effect of a model of parenting called affectionless controlling parenting, which is considered the most pathogenic, and of stressful life events on affective symptoms and on attachments in borderline personality disorder and on the control group. So what did we find? We found that, first, we found that, again, borderline and controls had different pathways from adversities to emotional manifestations in borderline, as it is shown here. The dysfunctional parent-child interaction had no direct effect on hopelessness or affective symptoms, but it had an effect on the insecure attachment that in turn had an effect on hopelessness and affective symptoms. Concerning stressful life events, what we found is that it had no effect on the insecure attachment but it had a direct effect on hopelessness and affective symptoms by lowering this manifestation. And stressful life events had an indirect effect by increasing Alexithymia which in turn reduced hopelessness and affective symptoms. This is different than what we found in the control group because in the control group the dysfunctional parent-child interaction had a direct effect on hopelessness and affective symptoms not mediated by insecure attachment. So controls and BPD have distinct emotional regulation pathways. Emotional dysregulation in borderline is one of survival. It seems to be an automatic response relying on an anachronic attachment frame that is made in early life. We think that stressful life events can be a coping mechanism but coming maybe from a direct deactivation of emotion maybe through the stress axis and the increasing of Alexithymia. This coping mechanism comes with a cost because this is the cost of repetition. Because if stressful life events are less traumatic in a pure emotional way and because they tend to be coherent with the attachment frame where the self is represented as not worthy of good, the risk is that this stressful life event will repeat in the borderline lives. So our three main points. Adversity factors are related to borderline emotional dysregulation. Some through attachment, this is about parental bonding, and others independently of it. This is the stressful life events. In highly insecure conditions, cumulative adversity produces paradoxical effects. That is a lowering of affective symptoms and hopelessness. Events are perceived through the prism of attachment which regulates emotions and the prism of attachment is not directly linked to the reality of the parental relationship, the current parent-child relationship. So why is it important to notice that and how do we deal with it? What is therapeutic once you've said it? And what is the place for the family? That's why I will try to maybe illustrate by coming back to the patient who told me, it makes me angry that my parents want to help me. So we're talking about Anna, she's a girl, a 15-year-old girl. She's an inpatient. She's been hospitalized for suicidal, strong suicidal ideation. She dropped out of school for three months. She lost 18 pounds a year ago from restriction, voluntary restriction. When it is now stabilized, she has some bulimic days, but not that much. But she is self-harming herself, by that I mean scratching to blood, when she's feeling bad, angry. She's the elderly of two. She has a 12-year-old sister. No particular medical history. She's an excellent pupil. She's in Henri IV High School. She's described by her parents as an easy child. So when I meet her, she says, I don't understand why my parents want to help me. There's no reason to worry. She's hospitalized for suicidal ideas. And then she says, it actually makes me angry. So she explains to me that she was harassed in elementary school about her weight, and she never talked about it to her parents. I ask her why. She says, I don't really know why. The mother that I meet, on another note, explains that growing up, Anna was jealous of her younger sister. And the mother tells me, although I did everything right, it is unfair. Since she dropped out, the father quit working to take care of her. He's feeling a major guilt. Anna feels herself very guilty and angry against herself. So as I was working with her, I was wondering and asking her why she couldn't request her parents' support as a child. And she talked about the fear to disappoint. At that point, I understood that maybe the anger today of her parents being available can come from a mismatch between past and met support needs in her childhood and their current engagement. For me, to take care of her in this therapeutic, it was important to identify that her emotional dysregulation that was causing self-harm couldn't be treated if the attachment representations of self and others were not disentangled. So we can understand her anger as coming from the feeling that some part of herself, her vulnerability, may not be acceptable for her parents, and the anger is reversed toward herself as not being good enough, fearing to lose the relationship with them otherwise. It's important to work on this representation, to work with the family as they tell us their story. It helped us to put meaning on it, and it helped Anna to put meaning on it. So the mother told us, my parents worked a lot, there wasn't much proximity, and I was very much alone. So when I felt bad, all I did was take a step back, that we could understand as actually repressing and having no one to help her when feeling bad. The mother added, I promised myself I wouldn't have an only child, and she said, I saw all my friends having brothers and sisters, and to me it appeared like they were happy, which it is implied I was not. The father says, I have been harassed and never spoke about it because my father wasn't at home during the week, and my mom needed everything to go well, otherwise she would get very anxious. And they say, at some point, we always say to our daughter that she could talk about how she feels, and they meant it, but it was not easy for them to perceive what their daughter was going through. So the mother explained later, I felt disappointed that Anna would feel jealous of her sister, although I did all I could to avoid that. Anna answered that I feel like it's hard to just listen for my parents. They have to act. Unveiling parents' history allows Anna to understand the reaction of disappointment and guilt she felt in her parents. They had the idea that maybe as doing differently from what they lived as kids themselves, it would be good enough for their daughter, and it was too hard to maybe admit or to perceive that she could go bad anyways, and in terms to be available. Hearing the story of her parents, she can update her representation of herself as worthy of care, even with negative emotions, as it's no longer about her failing them. As well, the image of her parents go from ideal and demanding to a more complex image of parents with flaws, more differentiated from her. Once the representation of her and her parents is modified, she's able to elicit help and address her anger in a less paradoxical way. So I don't know if I'm supposed to ask the question now. To sum up the presentation, you are supposed to know what's the answer to this question. Emotional symptoms of borderline patients are linked to adversity and attachment. What proposition is correct? Attachment is independent of parent-child dysfunctional interaction in borderline patients. No, that's not true. Stressful life events, punctual traumatic events, are more significant than parent-child dysfunctional interactions regarding attachment in borderline patients. That's not true as well. Stressful life events, punctual traumatic events, and parent-child dysfunctional interactions impact borderline affective symptoms through different pathways involving, respectively, alixithymia and attachment in borderline patients. Yes, that's what we learned. Adversity factors do not differentiate from one another regarding their impact on borderline affective symptoms. Of course, this is false. Thank you for listening to me. Thank you. So maybe one question before the end. Is there any question in the audience? Yes, thank you. Maybe a microphone is useful. Thank you. In working with borderlines, I found that they have enormous reactions to shame. I didn't understand where it came from, so I started to look in the literature. There's a man, his name is Donald Nathanson, and he wrote about shame. He says there is a compass of shame that when a person feels shame, they will either be, they will avoid, or they will withdraw, or they will attack themselves, or they will attack others. Once I started to look at that, I found that very prevalent in people with BPD, and a lot of the anger comes from shame. I wondered if you ever considered that, because they ruminate into shame right away. The other question I ask is about alexithymia. I'm very happy to see you mention it, because we see it as very, very important in borderline, because they can't name what they feel. So when you ask them what are they experiencing, they will give you, it's wrong, they don't know what they're experiencing. It creates a lot of confusion, and misinformation, and misunderstanding with the families. I just wondered if you had thoughts on that. Maybe just thinking about it, when you're asking about the shame, I think the patients, and even this patient, would feel pretty much ashamed of not being good enough regarding what the expectations she guessed, she imagined, she reckoned, of her parents, and that would make her feel powerless. And this feeling of powerlessness would make her very angry in turn. So I think it's, yeah, shame and anger are very connected, of course. Yeah, if you look up Nathanson, you'll find it's very helpful. Okay. So, thank you, see you maybe in Paris, if you want, or next year in New York, of course. Thank you very much for your attention.

adolescents

borderline personality disorder

ERNET BPD study

emotional dysregulation

childhood trauma

alexithymia

attachment insecurity

family therapy

psychopathological methods