I have the great honor to introduce our speakers this morning for our clinical updates on personality disorders, diagnosis, and treatment. But before I introduce them, I would also like to mention that if you're looking for the slides, you don't have to take pictures, and you can just focus on the slides and on the lecture today, because you actually have access to the slides through the clinical updates toolkit webpage on the APA. It's on the APA website. So you will have that for most of, actually, the clinical updates series. So you can relax and just listen. So I would like to introduce our speakers this morning. We have two very distinguished speakers. Dr. Carla Sharpe, she's the John and Rebecca Moores Professor at the University of Houston and Associate Dean for Faculty and Research. And that's all that's in there. And I asked Carla, I said, wait, because I also know that she is considered in those in the world who are experts in the world of personality disorders, had also indicated to me that you are also very much the rising star. And Kaz Nelson is an ABPN certified, board certified psychiatrist, a distinguished fellow of the APA. She is the Chief Psychiatrist at the VA Nebraska-Western Iowa Healthcare System, Omaha. Both of them, Dr. Sharpe and Nelson, were expert members of the writing group for the APA Practice Guidelines for Borderline Personality Disorders, which was recently released. Dr. Nelson is certified in ABPN. As I mentioned, she's a distinguished fellow and where she practices. Her clinical interests lie in the area of best practices in the diagnosis and management of severe personality disorders, suicide, and psychotherapeutic communication with patients in acute settings. And she also serves as the Associate Designated Institutional Officer with leadership responsibilities across residency and fellowship programs. And I'd like to introduce first, Dr. Sharpe. Good morning, everybody. Thank you for coming out 8 a.m. in the morning to talk about this topic. It's not a topic often discussed in mental health. Personality disorder is sort of the stepchild of psychiatry. So really pleased that the organizers chose this topic and I want to thank you for letting Kaz and I talk about this. I'm going to talk for about 30, 35 minutes and I'm going to cover diagnosis and assessment and then Kaz will take over and she will talk about psychopharmacology. I'll do a very brief coverage of psychotherapy as well. No disclosures. So I am hoping that at the end of the 35 minutes I have with you, you will come away being able to differentiate new approaches to the assessment and diagnosis of personality disorder. I hope you will come away being able to conduct state-of-the-art assessment of personality disorder and also differentiate available evidence supporting treatment options for personality disorder. The work that I'm going to present is also covered in several articles. This is one in New England Journal of Medicine, The Lancet. We did a seminar with a German group on borderline personality disorder, but it covers the new approaches that I'm going to present today. In annual review of clinical psychology, there's a specific coverage of the level of personality functioning, which I'll talk about a lot today. And then I want to draw your attention also to a 2022 10-year retrospective that was done in personality disorders, theory, research, and treatment that covers all of the validity data on the alternative model. Finally, ICHOM, the International Consortium for Health Outcomes Research, got a whole international consortium of folks together to determine what is the best outcome measures for personality disorder. So I'll also talk about that. All of these papers are uploaded in your folder for clinical updates, so you are able to get that. I'm going to give you a very distilled version of all of this material. So I'm going to start with this Lancet seminar that we did, and I'm going to give you three cases. And I want you to think about whether these individuals have personality disorder. If so, why? If not, why not? If they do have personality disorder, which personality disorder do you think they have? All right, I hope you can read it. I'll read it as well. A 17-year-old female patient was admitted to the emergency room after attempting suicide by overdose. Although her act had been impulsive, prompted by a breakup with her boyfriend, she'd been hoarding medication beforehand in case she could no longer stand it. Her home life was difficult, filled with violence, but she did not want to talk about that experience during admission. She reported having struggled with suicidal thoughts, self-harm, and significant bouts of loneliness since age 12. Her self-harm acts had started as superficial razor blades, cuts to her forearms, but recently had progressed to inflicting deeper cuts in her genital area. And when this was ineffective in relieving her intimated, unbearable feelings of distress, she would resort to alcohol. She expressed little concern for her physical well-being, hatred of her body and person, and recurrent episodes of unreality and out-of-body experiences. She rejected counseling because she felt that she did not deserve to be well. A few days after admission, her boyfriend indicated that he wanted to reconcile, after which she reported that everything was fine again and requested discharge. A 52-year-old female high school teacher presented at a psychiatric outpatient clinic. Although she was coping adequately at the professional level, she had been experiencing extreme strain, mostly due to the retirement of her current therapist. Over many years of therapy, some aspects in her life had improved. She was not self-harming anymore and was managing to live on her own, but she felt infinitely lonely and empty. She was unable to cultivate social relationships and needed all her energy for her job. Life felt like a quiet sea of desperation. Somatic problems such as joint pain, headaches and migraines had increased, which she believed was due to the large number of medications she was taking. And here's the third case. A 36-year-old male patient came looking for therapeutic support after his wife told him that she wanted to separate and take their daughter with her because she was fed up with his escapades. He reported feeling intense rage and hatred towards her and worried that he might seriously harm her. Due to instances of domestic violence, social services had already become involved and he feared that he might not see his daughter again. When asked, he revealed that the marriage had always been filled with screaming arguments. Most physical violence had been directed at objects, but there had been two incidents where he had assaulted his wife when he threatened to leave her. After these outbursts, he felt deeply ashamed and miserable. His last employment was with a security company, which he terminated after believing that his colleagues were out to get him. He acknowledged that this had been a typical pattern for him in his work life. So hands up if you think these three people, I'll do number one, do they have personality disorder? Number two? Number three? All right. So all three of these case examples were diagnosed with borderline personality disorder. And here are the nine criteria, you did very well by the way, thank you. You are all very familiar with those nine criteria, abandonment, unstable relationships, identity disturbance, impulsivity, self-harm and suicidal behaviors, affective instability, selflessness, anger, and transient stress-related paranoid ideation. So we're all familiar with these nine criteria for BPD. And we all know that in section two of the DSM-5, BPD is one of the 10 categorically defined disorders. There you see all of them, paranoid, schizoid, schizotypal, antisocial, borderline, histrionic, narcissistic, avoidant, dependent, obsessive, compulsive. Now when we look at the three cases that we discussed, we had different age ranges, 17, 54, and 36. We had gender differences. We had significant severity. Many of you didn't think that the second person met criteria, probably because it was a mild case of BPD. She was probably a little bit sub-threshold. Service use varies, inpatient, ER, psychiatric outpatient, general practitioner, private practice. The cause varies. It could be stable, it could be erratic. The manifestation we saw varied quite considerably. We had a mixed presentation in the first case, a more internalizing presentation in the second case, and a more externalizing presentation in the third case. And we see this high level of comorbidity so that people who meet criteria for personality disorder often meet criteria for substance use, anxiety, trauma, violence, aggression, and somatic complaints. They also meet criteria for more than one personality disorder. Were there any of you that thought about another personality disorder like paranoid personality disorder, avoidant personality disorder? There are some of you that thought, ooh, is that borderline or is that avoidant or paranoid? So those thoughts come up when you hear cases like that. Of course, we know that there are 256 ways of meeting criteria for BPD. And this is because of this heterogeneity within this disorder. The fact that the disorder can manifest itself in so many different ways. And of course, when all of this happens, we call into question the validity of the disorder. If we are not sure when we hear it, whether the person has avoidant or paranoid or BPD, that calls into question the categorical boundaries of a disorder like BPD. Moreover, when we do factor analysis, this is a paper that we published in 2015, when we do factor analysis, we want to see the criteria of each of the disorder load onto its respective factor. And what you can see there, I don't have a pointer, but you can see the borderline criteria in the first column there, abandonment, interpersonal instability. Those criteria should be loading onto a borderline factor. But what happens when we factor analyze criteria for personality disorder? It all cross loads onto each other. In other words, the factors underlying this set of criteria across all of the personality disorders don't crystallize into each own respective factor. So a better way of thinking about personality disorder is then thinking about a general factor of personality disorder. Now when you listen to all three of those cases, there was something that all three of those cases had in common. I'm not going to ask you what that was. It was maladaptive self and interpersonal functioning. All three of those cases had that problem as a shared common feature. And so a better way of understanding personality disorder and where we are at the moment is that there's a general factor that explains all of the covariance among the personality disorder criteria, a general factor. And then we have flavors that can manifest. So we can have, if you want to think about it like a borderline flavor or we can have, we can use maladaptive traits to describe that flavor. We can say that person has more of a detached flavor or a dependent flavor or a compulsive flavor. So we now think of personality disorder more like we think about IQ, the general G. All of us lie on a one dimension, a unidimensional continuum of intelligence with some people in the middle and some people at the extreme. And then we have these flavors of IQ that can manifest. Some people can be better at verbal comprehension but worse at perceptual organization. So this is then the new better conceptualization of personality disorder, which was published in 2013 in Section 3 of the DSM, the Alternative Model for Personality Disorder, the AMPD. What does the AMPD look like? The clinician has the first job of determining level of personality functioning. And level of personality functioning runs from a zero to a four. So if you have a healthy, typical personality functioning, then you are a zero. And what the clinician evaluates is maladaptive self and interpersonal functioning. For self-function, identity and self-direction is evaluated. Does this person have an experience as a unique person with clear boundaries between self and other? Is this person able to accomplish goals? In the interpersonal realm, we evaluate empathy and intimacy. Can a person take the perspective of other people and do they have productive relationships? Once the clinician has determined at which level the patient falls, zero, one, two, three or four, so five levels, a level two research has shown is clinical threshold. Once the clinician has determined that, they can give the flavor, the manifestation of that. And instead of using the 10 categories, say this is a borderline flavor, we use maladaptive traits. So negative affectivity, detachment, antagonism, disinhibition and psychoticism. Now these five maladaptive trait domains are the opposite of the big five that you may be familiar with from your, if some of you took psychology way back when. Now there's a third step in the AMPD and I'm almost reluctant to talk about it because it turns out that clinicians don't really use this. But this gives you an option to describe the flavor in terms of the old categories like a borderline pattern. But you can see that it's redundant, the borderline pattern, because as I will show you, the maladaptive traits fully cover the old category. So they're not necessary anymore. Now ICD-11 went a step further than the DSM-5 by accepting this dimensional model of personality disorder into its main section. So all of the 10 categories have disappeared in the ICD-11, which is now the main diagnostic system in the rest of the world, except for BPD, which was kept, as you can see, with a borderline pattern as a sort of placeholder to give services time to transition to the new dimensional system. Like the AMPD, self and interpersonal functioning is assessed. And then the ICD make the maladaptive trait domains, the flavor, optional. So the clinician doesn't even have to put that in the chart when they diagnose personality disorder. All that is needed is to say, where does a person lie in their maladaptive self and interpersonal functioning? I wanted to give you a flavor of a healthy personality. Identity, ongoing awareness of unique self and boundaries, consistent self-regulated positive self-esteem, experience, tolerates, regulates a range of emotions. Self-direction, reasonable goals, appropriate standards of behavior can reflect on and construct meaning of internal experience. Empathy can understand others' experience and motivation, comprehends and appreciates others' perspective, aware of effect of own actions on others. Intimacy maintains multiple satisfying, endearing relationships, desires and engages in a number of caring, close relationships, and strives for cooperation and mutual benefit. So this makes personality disorder diagnosis really unique, because we can actually, we have a benchmark for what a healthy personality looks like. Now if I ask all of you whether you function like this every day, I don't think you will say that you function like. We do not have perfect personality functioning every day. Most of us in this room will vary between a zero and a one on any good day, and sometimes we'll even have a day where we are on a two. But if we consistently function at level two, then we are someone that probably have personality disorder. The benefit of this dimensional system is that it opens up our ability to talk to people about personality functioning in this intra-individual way. With young people, I'll talk this afternoon about working with young people, with young people it also gives us the opportunity to say, your personality is a fluid thing. It's a malleable treatment target, something that moves up and down the severity spectrum, and we can intervene at any point. It's not a fixed trait. This I think is the advancement of the AMPD and the ICD-11 system. We are moving away from traits in order to talk about functioning as a malleable treatment target. Of course, when we get to level four, it looks very different. Experience of a unique self is virtually absent. There's a weak, distorted self image easily threatened. Emotions are not congruent with context, hatred and aggression dominate, may be disavowed, attributed to others. Severe differentiation of thoughts from actions, comprising goal setting with unrealistic incoherent goals, internal standards, problematic, profoundly unreflective, real problems in perspective taking and empathy, hypervigilance, focus on a need for fulfillment and harm avoidance. If they can mind read, that's really in service of manipulating, I don't want to use that word, chaos, sorry. It's really in service of having an influence on another person's behavior. Social interaction can be confusing and disorienting. Intimacy, the desire for affiliation is limited because of profound disinterest or expectation of harm. Engagement with others is detached, disorganized or consistently negative. And then of course, relationships don't work out. So what is the evidence in support of the AMPD? So this is a graph. We don't have to go into the detail of it, but I summarized all of the research now on the AMPD that have accumulated in the last 10 years. And you can see there's a lot of studies and this is according to the old, you know, Robinson Guzzi validity indicators. So a lot of studies have been done on antecedent validators, concurrent validators, predictor validators, reliability and clinical utility. And on all of the studies, the AMPD has a full system, but the LPF in particular does very well in terms of validity, reliability and clinical utility. There has been recently, I'm not going to go into the detail of these studies, but please do write to me if you want them. There's recently been studies that have done head to head comparisons of AMPD with a category, usually BPD. And the reason researchers have done this is because the APA for the AMPD to move into Section 2 will require evidence of superiority of the AMPD over the categories. And these studies have by and large shown either equal utility or superiority above the category in predicting certain outcomes. So where does this leave us with assessment? So I'm going to focus on this ICHOM paper, the Standard Set of Patient-Reported Outcomes for Personality Disorders. So an international group under the leadership of Mike Crawford came together. Lived experience was taken into account. So there was about three people with lived experience on the panel. And it went through a real rigorous one-year process of getting feedback from the public, getting feedback from professionals, until this comprehensive set of measures were identified. And this is the set of measures that are recommended. This is the set of measures that are recommended. And I'm going to upload the LPFS brief form onto the website for you so that you can look at that. I'm going to show you the items shortly as well. So identity disturbance and impulsivity and severity of PD is covered by the LPFS, takes five minutes, 12 items. For functioning, the WHO-DAS, that you are all familiar with, five minutes. Then suicidal ideation and behavior should be assessed. The Columbia was recommended. And then lived experience indicators where sense of belonging is really important. So the PROMIS short form for social isolation was added. Then a series of self-care, emotional distress, and quality of life, so quality of life constructs. And then optional outcomes, an emotion dysregulation measure, the DIRS, as well as aggression and self-harm. So this was the set of measures, and you can see the categories are not there. Because if you think about it, if you've got 10 minutes to assess outcome baseline, and we know that evidence-based assessment improves the quality of your care, if you do, you cannot ask 10 categories questions, that'll take too long. So this is the sort of parsimonious way of assessing for personality disorder associated now with the AMPD. Here's the LPFS. I often do not know who I really am. I often think very negatively about myself. My emotions change without me having a grip on them. I have no sense of where I want to go in my life. I often do not understand my own thoughts and feelings. I often make unrealistic demands of myself. I often have difficulty understanding the thoughts and feelings of others. I often find it hard to stand it when others have a different opinion. I often do not fully understand why my behavior has a certain effect on others. My relationships and friendships never last long. I often feel very vulnerable when relations become more personal. And I often do not succeed in cooperating with others in a mutually satisfactory way. So that's the LPF. I want to do this case with you now, and I'm going to ask you to decide the level of LPF, personality impairment. Miss B is a 32-year-old single Caucasian woman who was referred by a friend psychiatrist for mental health treatment for the first time after a four-month period of depression. She reported persistent feelings of emptiness and worthlessness, increased sleeping with difficulty getting out of bed, impaired concentration, decreased energy nearly every day, slight weight gain, and ruminations about her childhood and family life. The depression started after she was told at her firm that she was not going to be considered for partnership. Her initial reaction was one of anger, bitter disappointment, and shame. But this gave way to feelings of depression and worry about her future. She admitted to thoughts of death and dying, but denied having any suicidal ideation. Miss B does not drink alcohol and use any other substances, and she denies ever felt manic. Her physical health is good. She reported that she did not consider her life in general to be satisfactory or fulfilling. Although she'd been highly successful in school, earning excellent grades at first-rate college and law school, she has had difficulty making friends and now sees the few friends who she believes like her only occasionally for attention and support. She has only dated one man briefly in college, but she felt inhibited in the relationship, afraid and ashamed to let the man know that she cared about him. Even though they drifted apart after only a few months, she often thinks of him and wonders whether her life would be better if they had gotten together. She is pessimistic about her prospects for another relationship in the future because she believes that it would be very hard for her to find someone who would live up to her expectations. Miss B has few interests outside of her work. With respect to music, art, or sport, she says that whatever she tried, she was not very good at it, quickly lost interest and gave up. She reports having felt socially inept and made it personally unappealing since her pre-teen years and has steered clear of most social opportunities for fear that she would not be liked. She has always felt different and isolated from others. She said that she does not understand how to relate to others and how others manage to make friends easily and to maintain long-lasting relationships. On a recent visit with close married friends from college, she went out of her way to help them by offering free legal work, doing chores, running errands, and babysitting. When she did not receive sufficient praise, thanks, and appreciation, she felt disapproved of and hurt. She feels most comfortable at work, where she believes she excels because she's very smart, perfectionistic, and willing to work long hours. She's quite confident in her work abilities and sees herself as significantly better educated and more competent than most of her peers. She sets very high legal and moral standards for her work and she's often pointed out violation, regulations, or corner cutting to both fellow associates and to more senior attorneys with whom she worked. She feels that her abilities are underestimated by the senior partners at the firm and that she should have been considered for partnership despite her social awkwardness. She has considerable difficulty understanding the point of view of her bosses, who apparently tell her that she works too slowly, loses sight of the forest for the trees, and does not recognize her own contributions to her career setback. All right, does anybody think she's severely impaired? Four. What about a three? Two. We've got most saying two. One, sub-threshold, zero. Not healthy personality functioning. So this is the case that John Oldham, Andy Skodal presented in 2015. It is a two. So she meets clinical threshold. So you are a group of psychiatrists. You've not been trained in the LPF and you were mostly correct in diagnosing the LPF right now. Now if we were trying to use the categories, there was definitely an avoidant flavor. There was a bit of a borderline flavor. There was a bit of a OCPD flavor. There was a bit of a narcissistic flavor. We don't need all of those flavors, right? We can just say, where does this person lie on a unidimensional severity criterion of maladaptive self and interpersonal functioning? That's all we need for treatment. So this is a more parsimonious way of diagnosing personality disorder and that is why we want to move there because we hope that this will lead to better integration of personality disorder assessment and treatment in general care. All right, suicide risk and assessment. I was asked to talk about specifically. I'm not going to go into too much detail because I wanna show you a little bit of the treatment. But this is the APA guidelines for suicide assessment. This does not change when we use a dimensional model. You're still gonna ask about suicidal ideas, plans, intent. You're gonna ask about the course of action if the current symptoms worsen. You're gonna ask about prior suicide attempts. You're gonna ask about interrupted suicide attempts, intentional self-injury, a history of psychiatric hospitalization, of suicidal behaviors in biological relatives, anxiety symptoms, hopelessness, impulsivity, methods, current and recent dependence, so abuse will increase risk, presence of possible motivations for suicide at present, present of absence of psychosocial stresses, presence or absence of reasons for living, and then the quality and strength of the therapeutic alliance. All right, very briefly on treatment. Several meta-analyses have been carried out. This one was a few years ago now. This one is 2022 in British Journal of Psychiatry. And then finally, there's been a recent meta-analysis for young people. Kaz and I were on the American Association's Practice Guideline Group, and the draft of these guidelines are also available for you to go and look at. The take-home message of treatment is that there are five evidence-based treatments. You are all familiar with these. Dialectical behavior therapy, mentalization-based therapies, schema-focused therapy, transference-focused therapy, and STEPS. STEPS is a group-focused DBT light. And by and large, the effect sizes of these treatments are good, but there are also a lot of room for improvement. But one of the key take-home messages from the treatment literature is that these specialized treatments don't work for everybody, and they are not necessary for everybody. So the first big move in the field is to move in the same way that we're thinking about common factors in diagnosis, we are thinking about common factors in treatment. One of the common factors that are being suggested is mentalizing. This is a book I did with Dick and Bevington that makes the argument that regardless of your treatment modality, if you are in a mentalizing stance with a patient, you are going to be a better therapist. It is consistent with things that Kaz will also be talking about in the approach that works best to take with people with personality disorder. The therapeutic mechanism is really slowing down in talking to a person with personality disorder. This is the sort of loop that we talk about. You ask about the narrative of the event, the experience at the time, reflection on the event, the current feeling about the event, experience talking about it in therapy right now, and that leads to alternative perspective. I'm gonna show you about two minutes of Trudy Rousseau doing this. She's a child psychiatrist. We won't watch the whole video. Oh, I need to get it to. Everything feels like it's all happening at once, and there's nothing I can do about it, but I don't know how to deal with it either. Okay, okay. Can I pause you for a second, Cheryl? When you say everything's happening at once, can you tell me about all the things that are happening at the moment? Well, I have to go visit my dad, and that's just because my mom doesn't want to deal with me anymore, and so I have to deal with just problems from both sides of that, and it just, there's just too much happening all the time, and there's, I don't even know how to explain it. You're doing very well. You're helping me a lot, and I'm very proud of how you're managing. Let's just slow it down. You said something that I just want to understand a little bit better. Your mom doesn't have to, what did you say? Your mom doesn't want to be put up with you or deal with you, something like that? What did you say? Well, she doesn't want to deal with me anymore because she has to deal with my brother now, and so I'm too much for her. Well, I need to understand that a bit more. I don't follow. I mean, what does she need to, when you say she doesn't want to deal with you, is it like she doesn't want to help you when you are upset, or she doesn't want to have you around at all? What do you mean? She doesn't want to have to help me when I'm upset, and when I'm tired like this, and I feel like I'm always tired, so I'm always a problem. All right, so I hope you can see how slowed down this is and that she keeps coming back to the same question. She doesn't move on so quickly, and this is what we, when I work with PhD clinical psychology students, this is the hardest thing for them to learn is to stay right there and get a good understanding before you move on. We are so pressured for time, and if we come out of a CBT framework, we have sort of goals in our mind that we're working towards, DBT2, that we forget to just get a good understanding what happens when there's a good understanding, the client feels understood, and it is in feeling understood that the change happens in the psychotherapy. So that's the first message I want to give you for psychotherapy is that we're moving towards common factors, something like mentalizing, there are others. The second one is that specialized treatment is not necessary for all clients, and so this is good psychiatric management for borderline personality disorder, an adolescent version has been developed. John Gunderson developed it originally, and I do encourage you to engage with this because this gives basic principles for treatment of personality disorder that any clinician can do, regardless of whether you have specialized training. What are the basic principles? Diagnostic disclosure, work within the realm of self and interpersonal functioning, case management, focus on the life outside of the therapy room, psychoeducation, progress, constantly monitor progress, and if it's not working, have a discussion about this, move away from this idea of endless therapy. You can work psychodynamically or behaviorally, and family involvement if kids are involved. And that is it from me. I will hand over to Kaz. Thank you. There are lots of chairs up front. Anyone wants to take a moment to come up and find a chair, please do. Good morning. It warms my heart to see you all here. It tells me that you care. You care about people with BPD, otherwise you wouldn't be here at 8 a.m. on a Saturday. All of you here are interested in understanding the current situation and how to move the dial forward. Maybe you know somebody with BPD in your family or in your community. It's a very common disorder. Certainly in our clinical practice it happens every day. What are we teaching the next generation about personality disorders and BPD? I hope to cover some of that ground today because this is the opportunity for us to really make a difference. We have this legacy of troubling context for personality disorders in psychiatry and today it starts with us to do a little bit better on behalf of the many people in our communities that are impacted by this disorder. You see, I did focus here on BPD. It is the most common personality disorder. It is the most studied. There is the most evidence base for this. As I talk about therapy and other kinds of approaches, it's through this BPD lens, but as Carla was discussing, as we get more towards common factors and common understanding, we see BPD almost as representative in many ways for some of the other personality disorders. So I'm focusing where there is the impact and the evidence base for the purposes of our time together today. By way of disclosures, my full-time salary is from the Veterans Affairs Healthcare System in Nebraska-Western Iowa. I'm not representing the VA or the government in this talk today. I hold academic appointments at the University of Minnesota and the University of Nebraska Department of Psychiatry. I receive education research grant support from the American Board of Psychiatry and Neurology and I do receive honorary and consultation fees from UpToDate for authoring the chapter on treatment, pharmacological treatment of personality disorders and review of other personality disorder chapters. I have not received any financial remuneration or have any relationship with the pharmaceutical industry. I think that is very important to disclose, particularly for this talk, because there is no FDA-approved medication for any personality disorder. Everything I discuss will be completely off-label and we are in this uncharted territory in terms of FDA approvals. Does anyone know a person with a personality disorder who is on a medication? So I'm kind of bravely trying to enter this non-FDA-approved space with this acknowledgement. This is real. This is every day. This is in our clinics. Can we talk about it? I'm going to try. No, it's going to be controversial. You might hate what I have to say or love what I have to say, but let's dialogue here about this and not pretend we're not using medicines in this population because we are. So by the end of our time, I hope you are really feeling empowered to describe clinical strategies for adjunctive, off-label, and most importantly, rational pharmacological treatment of BPD and to design comprehensive and patient-centered management plans to meet the recovery needs of people living with BPD. I'll just invite you first to reflect on something I alluded to, but what was it that you were taught about personality disorders or borderline personality disorder? Many of you had wonderful mentors. You maybe had role models that had a compassionate stance towards people with BPD. You maybe had some role models who had more of a judgmental or kind of a detective stance. We have to find the people with BPD so that we don't try treatments that maybe aren't going to work. I'm just trying to phrase it nicely. What were you taught? I can disclose what I was taught. I was taught to run from patients with borderline personality disorder. That's a quote. I was taught don't focus on this disorder as an academic focus because people will think negative things about you. They'll be kind of a reflected bias if you go into this work. Also, you'll have kind of a miserable career because people with BPD will then seek you out and then that will be a difficult practice. Luckily, I also had mentors who supervised me in the delivery of dialectical behavior therapy and empowered me to be effective and skillful and compassionate and lean in to the care and treatment of BPD and see the successes in a way that empowered me through some of those other kinds of concurrent discouraging messages I was experiencing at the time. This was 20 years ago, but for those of you that are a little bit earlier in the training pathway, I'm wondering if some of this messaging still exists in our clinical training environment and if this is something that you're hearing. If so, I'm hoping that together, based on what I share, we can decide to discard some of those paradigms that are judgmental and non-patient-centered. This is a potentially fatal disorder. This is one of our more fatal disorders in psychiatry and there really is not room for pejorative connotations, eye-rolling, dehumanizing kind of behaviors in my mind, but there's been a bit of a permission structure for those kinds of behaviors historically in our field. Really based on the idea that this is untreatable, right? This is an access to disorder. It's unchanging. So that's the paradigm we were taught. It's on our boards. It's on our USMLE exams. Is our personality disorders treatable? Do they change over time? No. They're fixed, right? We all got that question right on those exams because we studied it so hard. Now we're learning it's not fixed. These are developmental disorders. You've seen it with your own eyes. People learn. People grow. Sometimes they don't survive it, horrifyingly. If they do survive it, they can get through to the other side where there's a life worth living. Now are they still impacted by social and occupational dysfunction from years of living with symptoms? Yes. It's not the rosiest of stories, but as John Gunderson points out in this seminal overview of the story really of borderline personality disorder, what we used to think was a untreatable fixed situation, over time and with study and research, it is now considered a good prognosis brain disease, actually better prognosis than some of our chronic psychiatric illnesses like severe schizophrenia or serious bipolar disorder. It's actually better to have a diagnosis of BPD prognostically than one of these other disorders. And so let's change our minds about the fact that this is an untreatable disorder. Years of study has not supported that. And this overview goes into detail. I think this is the most important article in psychiatry. I'm biased, but if you read this article and really understand our updated perspective on BPD, you will be so much kinder and more compassionate and more prepared to care for this population that tends to bring a level of difficulty or challenge to the day in our clinical contexts. Those challenges amazingly, you'll see them open up as more mitigatable, more manageable, better outcomes, really just with a change in your lens that you bring into the room, with the permission to care, the permission to try to help, and the knowledge that this will get better for this person if we get it right. It's incredibly empowering. So I had the privilege of hearing John Gunderson, the author of this, speak at APA in 2010 when I was a chief resident, and he said, please study this, please specialize in this, please care for people with this disorder, and I said, okay, I will, and now here I am today. So this is a really wonderful kind of full-circle moment for me. All right, so just summarizing sort of where we've been, a very slow translation of scientific progress to the clinical setting. You know, I think the DSM has something to do with it because the criteria just has been cut and pasted year after year, and it still says that these are generally stable and unchanging, right? And so until that official document evolves, we're still going to be teaching these exams where we say it's unchangeable. So that's a problem, and it's led to a slow translation to clinical setting. A relative lack of investment in investigation. So now where are the studies on BPD? People are dying, communities are impacted. Why is this not a priority for the NIMH and other, you know, grant and research funding agencies? It's very mysterious. I think it has to do with bias and stigma, but you tell me if you have ideas about that. You know, again, we're talking about the uncomfortable things. A really serious hesitancy to directly discuss the diagnosis with the patient. Have you ever met patients where you know they have BPD, and on their chart it says MDD, GAD, PTSD, eating disorder, substance abuse disorder, and OCD, you know, you name it, and you think, oh my goodness, this is BPD manifesting in all these different ways, but now they're on six different treatment plans for their six different diagnoses. Six different therapists. Six different, you know, anon. Why is it so hard? Well, because we're kind people, and it's a funny name, and if you look it up, it has a poor fixed unchanging prognosis. I think many of us have hope for our patients. We've seen progress, and so we think let's not label something so pejorative and with a poor outcome. But ultimately, if we don't directly diagnose and treat the disorder, we lead to treatment failures and other disorders. And what does that do to a person when they are a failed depression patient, when they really haven't just had their BPD treated? It's a really substantial identity shift to now be a treatment failure, essentially. Precision, precision in diagnosis is so key. We have no evidence supporting polypharmacy, but again, 12, 15, 19 medications in some cases, managing this melange of symptoms. No long-term psycho, no long-term pharmacotherapy studies, yet we have people on medications for their BPD 20 years, 30 years. We've seen cases like this. And then really robust discrimination, leading to health outcome disparities, discrimination against people with BPD, and then you get into intersectional factors, are these LGBTQ communities, communities of color. These marginalized identities are intersecting and then magnifying of health disparities. So it's incredibly important that we discuss this, especially with the rates of suicide and death and morbidity and mortality. The stakes are quite high and marginalized communities come out worse in this. And then I just want to introduce this term, asterisk disorder, that I coined because, you know, I'm kind of like that vignette that was talking about, you know, hey, this isn't quite consistent, you know, I have a little of that. And I learned medical ethics, where you disclose the diagnosis and you provide psychoeducation and you provide treatment, everything on Dr. Sharpe's list, but for some reason there's an asterisk with BPD, where those rules don't apply. We don't do those usual things for BPD. And if we could just remove the asterisk and treat people with BPD like we do any other psychiatric diagnosis by saying the diagnosis, by caring about it, by walking shoulder and shoulder with them through the diagnosis, that would, that would solve a lot. Dr. Sharpe already shared these treatment guidelines. They're so new, they're still in draft form. It's being copy-edited and any day now the final version will be published. But we're very proud of this in terms of an overview of the literature and really applying scientific rigor to the different standards for treatment guidelines. Now, when you look at this, you might, you know, if you had a patient with BPD and you read the treatment guidelines, you still might leave with some question marks, not quite knowing what to do, because the shortage of literature, the shortage of research, really, we couldn't really say definitively do this, this, and this. But we have, you'll have a nice sense of the literature and really some, some general suggestions that could be helpful. When it comes to psychopharmacology though, we do have efforts to collect the existing data and give us some clues. Nothing definitive, nothing at the point where we could have FDA approval, but as long as we are prescribing to this population, let's use the clues that exist. And so there's a Cochran Review, Pharmacology Interventions for Borderline Personality Disorder, and also this wonderful article by Ingenhoven that conducted a meta-analysis of randomized controlled trials, looking at class of medication, pooling the data in a manner that it wasn't just a certain medication for a certain symptom, but in order to get a little bit more power to the meta-analysis, he looked at classes of pharmacotherapy. This is the closest I've seen to being actual guidance that I feel comfortable using as, as the clues I look at. It's a step above sort of anecdotal experience, I guess. And so when I teach residents and medical students, this is what I show them. This is a summary of that meta-analysis. Again, low, this is not, this is not a high-power definitive meta-analysis, but general directions and clues. He found that mood stabilizers using similar dosing to that in bipolar disorder had very large effect size on impulsive behavioral discontrol, very large effect size on anger, large effect size on anxiety, and a moderate effect size on depressed mood. Antipsychotics using low doses had a moderate effect on cognitive perceptual symptoms, a moderate to large effect on anger. And then antidepressants using dosing similar to that used in major depression, small effect size on anxiety and anger. What I like about this is this actually does reflect some of the anecdotal experience I've seen. Of course people with BPD are put on antidepressants, SSRIs, SNRIs, because of the anxiety and the sadness that's present. They come back and they say, that didn't work. Okay, well let's increase the dose, let's add another one, let's augment with this. Pretty soon they're on, you know, they've tried six or seven medications, they're treatment resistant, now we need to, now we need to, you know, go further on the major depression algorithm. I think we just need to be so careful about that, because it turns out that antidepressants really aren't going to have a large effect size in this population. So again, precision on the diagnosis and then what's going to work. Now it should be, we're stated, stating that you don't have to use a medication in BPD. It's a wonderful privilege if they come in and they say, you know what, I'd really rather do other things than medication. You say, great, we don't have to do a medication. If they're extremely motivated to be on a medication or they're already on 10 and you're trying to pick one, this could provide guidance in that sense. So what do we mean by rational treatment? Comorbid diagnosis or diagnoses may dictate the medication regimen. If they already have actual bipolar disorder, that pharmacotherapy regimen is probably going to supersede the BPD targets. So essentially you can use a bipolar treatment at that point and similar for other conditions like schizophrenia. If BPD is the primary driver of their psychiatric symptoms, consider prescribing no medication. If there are severe or highly disruptive symptoms present, pick one medication through shared decision-making with, you know, you have to make the diagnosis. They have to hear the term BPD. Pick a medication to target the symptom domain posing the greatest impairment and then weigh existing evidence and risks and benefits. Never minimize the risks of BPD or of pharmacotherapy. If you're exploring using lamotrigine, for example, they need to hear about Stevens-Johnson syndrome, potentially life-threatening, okay. And if they say, well, you know, that risk isn't worth it to me, again, you say, okay, all right, little benefit, potentially severe life-threatening risks. If that math doesn't square for you, then we can honor that. Scheduled medications appear to be a better strategy compared to PRN usage. We see this feel-a-feeling, take-a-pill effect in BPD and it can set people off on sort of a roller coaster and a lack of agency, feeling like they can only modulate through in-the-moment medication. So I recommend scheduling if you're going to use them. And then always disclose off-label usage. Again, autonomy and empowering your patient with information is critical. And not changing medications in response to crisis. Again, we're really trying to move forward and sometimes it's two steps forward, one step back, but we can contribute to some of the chaos by constantly changing medications in response to crises. I avoid prescribing highly toxic medications like tricyclic antidepressants. You know, if there's any overdosing behavior whatsoever, these should not be in the medicine cabinet. Or if they have a family member with overdosing behavior, these should not be in the medication cabinet. If you have barriers to adherence, lamotrigine is not a good choice, too risky. No evidence supporting antihistamines. I'm sorry, I know, I know, I know we just love hydroxyzine. And yes, hydroxyzine is more benign than other things, of course, but there's no evidence. And then again, if it's feel-a-feeling and take a hydroxyzine, it kind of leads to that, you know, kind of dysfunctional relationship with medications. Benzodiazepines. Benzodiazepine-like medications are Z-drugs or polypharmacy. No evidence supporting this and potentially the liabilities of this approach could outweigh the benefits. As people are growing in this developmental disorder, we do not want to do anything that impairs the learning process or the cognitive process, because learning is going to be what gets them through this. So for that reason, I avoid benzodiazepines. And medications with sedating properties may be risk for impulsive overdose. Things like quetiapine. I had a lot of quetiapine overdoses in the, you know, 2015s, and so I stopped prescribing quetiapine and then the quetiapine overdoses went down. Sorry. Okay, so another clinical vignette. And as I read this vignette, I want you to think about, is this a common or did I pick a very rare or uncommon bizarre patient presentation? A 35-year-old presents for voluntary care in the psychiatric inpatient unit with suicidal ideation implants. They report previous diagnoses of depression and anxiety. They've had multiple previous trials of SSRIs and SNRIs. They are currently prescribed escitalopram and hydroxazine as needed by their primary care provider. Neither medication is helpful. They've engaged in multiple brief trials of individual and group supportive psychotherapy without benefit. They're desperate for a medication to help them feel better. This is their third psychiatric hospitalization for suicidal ideation. They've previously attempted suicide twice by overdosing on a friend's lorazepam. Upon interview, they report lifelong symptoms of rapid and intense mood changes, feelings of emptiness, disrupted relationships, impulsivity, self-injury in the form of skin cutting, passive and active suicidal ideation, and disrupted sleep. These symptoms have significantly interfered with social and occupational functioning. They are urgently seeking help, noting that no prior psychiatric treatment has ever been helpful. They feel they are a failed depression patient and are hopeless. They're wondering about new technologies to treat depression. They've never heard the term borderline personality disorder. Is this realistic? Or we say not this day and age. Nobody would present that way. It's very common, okay. Should, I know I know we do a full full diagnosis and that's just a vignette, but should BPD be considered? Even in the acute setting, you're meeting this person the first time, you'd consider a diagnosis of BPD? Yes! Let's talk about it. Let's pull up the criteria. Let's discuss it. Why does it have to be a secret from the patient? Why does it have to be a mystery? You go through the criteria and they say no, not really. Okay, but can we explore it even when you're meeting them the first time? Yes, it's a myth that you cannot diagnose BPD. Now you don't use it as a weapon. You don't look across the hallway on the nursing station and say that patient's yelling at the nurse so I think they have BPD, you know. That's what we're trying to avoid is these knee-jerk, judgmental diagnoses. Oh, you met them the first time on a bad day and you diagnosed BPD. That's not what I'm talking about. I'm talking about meaningful clinical dialogue, clinical evaluation, shared, you know, education with the patient and they're essentially making the diagnosis themselves based on the richness of your discussion and education about the symptoms. If we do make the diagnosis, should it be discussed with the patient and documented? That's a whole other issue, documenting BPD. I say if I don't discuss it with the patient, I don't document it. If I do discuss it with the patient, I'll document it. So much stigma with that chart that follows them around. If we document it without discussing it with them, again, it's a weaponization of a stigmatized label. Should psychoeducation be provided? Yes. Would you ever diagnose type 2 diabetes and not provide education on the blood sugar and the relationship to carbohydrates and, you know, things you can do to manage your blood sugar and check it? You wouldn't dream of that. That would be cruel and unusual to diagnose diabetes type 2 without educating on the role of management. So we provide that education and empower the patient and oftentimes in a self-directed manner, when they're empowered with the diagnosis, they can often implement a lot of self-management strategies that are empowering to them and not reliant on a hydroxyzine prescription. They can understand, oh, I'm having a BPD flare-up. I need to manage this skillfully. And what prognosis should be communicated? Sorry, this is a lifelong thing. If you make it to age 75, you're going to be just as miserable. No, we don't need to say that. We say there's a life worth living after this. We're going to get through it. Things are going to improve. Let's work together on this. Now, I have limits and boundaries, you know. Here's what is acceptable. Here's what's not going to work. Here's what is going to work. Of course, you can have limits and boundaries, but we're going to be compassionate, okay? All right, treatment plan for this individual. Careful assessment of suicide risk and drivers of suicide. Remember, there's been two previous suicide attempts, and this is potentially fatal. Just because we are holding a positive prognosis for them does not mean that somebody cannot die in the meantime, so we have to take this very seriously. It's not attention-seeking behavior. It's high-risk, potentially. Outpatient psychiatric care with a BPD-informed clinician. If somebody has read John Gunderson's article and understands that this is a good prognosis brain disease, and is not going to secretly have a hateful counter-transference towards the patient, they're probably going to do a pretty good job with that individual. Psychoeducation using updated sources of information, and then as we discuss medication, maybe SSRI is not for them. We could maybe taper that. I'm not going to prescribe PRN medications. I'm going to teach them distress tolerance skills to use for emotion spikes. I'm going to, with them, identify which symptom domain is causing the greatest disruption, and then use shared decision-making using informed consent to pick something, or consider no medication if the risks and benefits are not appealing to the individual. All right, and we have time for questions and answers. Thank you. Thank you, Dr. Nelson. Thank you, Dr. Sharpe. My name is Ron Wenchel. I will be moderating the Q&A together with Dr. Krohn. We have a remote audience, so we will be alternating questions here in the room with questions that are coming in from our remote audience. So, please, if your question is going to start with, I have a patient, don't. Please re-conceptualize it as a general question, and please try to keep questions to 30 seconds if you can. Thank you. It's not, yes, but I'm not sure everyone can. Do we have a tech person here? Is there a switch on there? No? Okay. I will step out to find a tech person to help us, and why don't you begin your question, Kathy, would you? versus like, is there any value to differentiating that, or do you just see it like, oh, hyper-morbidity, if I see the symptoms, I treat with a non-stimulant way. So that's one question, and then the other question is a little bit more controversial, like, you know, you don't want to over-pathologize gender identity confusion, because that's hard to have in a society that's not accepting, and yet, when you look at, like, unstable self-states, how do you, how do you tease that apart, and how do you deal with that? Very, let's see. Very, um, is that, is this working? No. Here, come on up. You managed to pick two of the hottest topics in, uh, in a very short period of time, and that is the intersectionality of essentially neurodivergence, and, um, uh, sort of, uh, gender identity diversity as intersecting with a developmental disorder, like BPD. Yeah, that's me, I'm repeating the question, uh, in a, in a, um. We're asking you to repeat the question. Uh, okay, so there were two questions. One was about, um, identity, gender identity development in the context of BPD, and how to conceptualize gender identity development in an unstable self, um, state. And the other question was about ADHD diagnosis in terms of comorbidity, uh, with this, also a developmental disorder, and some of the diagnostic and treatment challenges posed by those two conditions. So, um, those are two of the hottest topics that we can think of, and probably deserve their own, um, sessions alone, but, uh, the key ingredient in these is non-judgmentalism and precision and taking time to make a diagnosis. I think we've probably under-recognized neurodiversity and gender diversity as distinct entities to honor in the context of adolescents or adults with BPD because our BPD alarm bells go off and then we sort of undertreat or under-honor these other aspects. Now of course, though, in a neurodevelopmental picture, these things are changing and evolving. And so non-judgmentalism, honoring diversity, really not punishing an individual for the BPD by not exploring other diagnostic or identity-based entities, and then even disclosing some of the tensions around that and bringing the patient in themselves, they're bright. And they're living in their own experience and they can often help you understand what's working or what fits and what doesn't fit about the conceptualization. Doing a trial of a stimulant in somebody with BPD, I used to think, oh my goodness, we wouldn't do that. But if we do a brief trial and they do a lot better, why would we then withhold that? You know? So I think I just want to give you a little bit of a permission to go there, you know, and explore it thoughtfully and non-judgmentally, and there's probably little harm to that. »» So one of the remote questions is, where can I find the LPFS 2.0? »» So please do go back to the clinical update folder and I will upload that today. »» For those of you who did not hear at the beginning of the presentation, we now have a page on the APA website called the Clinical Update Toolkit, which will have both the slides from both of these presentations as well as we will be linking to some of the questionnaires. They're not there, but it will be before the end of the week. We have a call in to a specialist in the treatment of microphone disorder. Of course, there are no FDA approved medications, so we're hopeful. Meanwhile, I will repeat the questions from the audience. »» So I'm a community psychiatrist. I do research community treatment and first episode psychosis, and in both places I treat a lot of patients with personality disorders. I also have a side gig in clinical informatics. And so I love the new personality disorder diagnosis framework, but I'm trying to imagine how to put it in ethic, and it's making my head hurt. And I like the idea, you know, like I diagnose people that look different with schizophrenia all the time. Like that's not a problem. I can just diagnose people with personality disorder. But then I'm hearing the coders in my head being like, but you need to be more specific or else we're going to not code you at an appropriate level. So I guess is there talk within the community about how to consolidate this in a way that it's easy to communicate in these places that require discrete information? »» In case anyone did not hear the question, I will quickly capitalize it. For individuals who are working with database systems such as Epic that require answering lots of very specific questions, is there an approach being developed for simplifying how you would input this data to describe both the nature of the symptoms and the severity of the disorder? »» So thank you for that question. So first of all, I invite you to go to the ICD-11 information and see how they code it. Because I think that will be the model that will be used if AMPD gets into Section 2. The other thing I would say is there is a work group currently who's been working for about six to eight months. I'm on it. Simplifying the AMPD even further for consideration for Section 2. Because it was too complex. It was too complex to really, you know, very succinctly code it and put it into a chart. So, you know, watch this space, I think. But in the meantime, go look at the ICD-11 because I think it's coded. Each severity level has a code. The personality disorder itself has a code. If Roger Milder is still here, he could probably expand on how it works in the ICD with codes. But yeah, simplified version is the idea. And severity levels are coded. »» Thank you. »» So the question is, is there a clinical application or clinical usefulness to the BSL-23 or Borderline Symptom List 23 as an alternative to LPF questions? And someone's comment was, the BSL-23 is available in the BHL Touch application used at the VA hospitals that you can send out as self-assessment to patients. »» Well, you know, Kaz mentioned it very briefly that BPD. So I think if you want to, BPD has always been a good proxy for level of personality functioning. And the reason is, if you look at the nine borderline criteria, several of them do relate to intra and interpersonal functioning, self and interpersonal functioning. If you go to some of the other personality disorders, antisocial and narcissistic, the criteria is very behavioral and they don't actually get at self-functioning and interpersonal functioning to the extent that BPD does. So I do think any measure of borderline will get you there. Do you have anything else to say from the VA perspective? »» Yes. »» Hello. I'm Dr. Sandeep Vada from New Delhi, India. It's an excellent presentation by Catherine. And I was so happy to know somebody who actually has the same experience which I have. And I personally feel there is a subset of borderline personality disorders who are totally treatable. I'd like to share a recent example. One year back I got a severe personality disorder, borderline personality disorder with 30 years of experience. I thought I will not be able to help her 100%. And if I tell you I have the full treatment sheet with me in my phone, I was able to help her 100% over a period of six months. And she's on five medicines. So what my conclusion is, that one, benzodiazepines always cause inhibition in such cases. And when you think of treatability of borderline personality disorder, if you think and treat like them as bipolar mood disorder, atypical, then it's possible. »» Thank you. Rather than a question, I'll take that as an endorsement of what we're hearing from our speakers. So I won't review it. I'm going to take a moment to ask my own question. Early in my career, which goes back to the early 80s, the word borderline was essentially the longest four-letter adjective in psychiatry. Several years later, a patient came into my office waving a copy of Otto Kernberg's Treatment of Pathologic Narcissism in Borderline States, saying that this is me. First time I'd seen that. And after listening to his story, my response was, no shit, Sherlock. This is certainly you. And now we have the TikTokization of self-identification diagnosis. My question is this. What do we see as the impact of the patient being informed of or maybe self-identifying as somebody with mixed personality traits, particularly if they're considering themselves borderline? »» Thank you so much for the question. Because a really motivating experience for me is working with somebody later in life who never heard the term BPD. They come across it. And then they say, that is me. And then they have the opportunity for insight and recovery later in their life. Now, they have a lot of regret, though, about all the different treatments, the different medications, the different hospitalizations, the different therapists, and they are haunted by the question, did all those people know I had BPD and just not tell me? And so patients as consumers, access to information, I think overall is a good thing. And for us to be threatened by them coming in and say, well, I heard somebody with BPD and that's me, I think rather than saying, well, you can't just go off of that, I think rather, you know, oh, tell me. Tell me what you noticed. Tell me what you think. I'd love to learn more about your experience of learning about someone else's experience and how that resonated for you, what matched and what didn't match. And let's look at the criteria. If this is not a bad thing, we shouldn't cringe to diagnose it. We shouldn't say, well, you don't meet full criteria, but I hear you that you have these symptoms, and let's focus on that. None of that is a threat to us. It's not a threat to our field. Really, these healthcare outcomes are a co-production, and any of you who have had your own experience of receiving healthcare know that you being empowered and educated in the process improved your care. It's not a threat to the field for us to have access to the same high-quality information. Now, more of a problem is people's access to information that's negative and pejorative and kind of crummy about BPD. And I have to do a lot of education about, like, yes, just because this person you don't like was diagnosed with BPD doesn't mean that you don't have it. You know, it's, there's a lot of bias and stigma work we have to do with our own patient population as well. But for them to come in and say, I think this is me, I would listen. I really would. So one of the questions here is, what is the connection between attachment disorders and the development of personality disorders? So that's a very nice question. If we had time, we could have gone into the etiology of personality disorders. But most of the developmental models of personality disorders, somewhere in the model, attachment would feature. And so if we do think about personality disorder in its essence as a disorder of maladaptive self and interpersonal functioning, we do think about the disorder as living in the serve and return between us and other people. And so attachment, the attachment context is the first environment, the first laboratory where we learn the serve and return, where we practice the serve and return. And if there is a poor fit, those skills, those metacognitive skills of learning how to read other people, how to read myself in the context of other people, that development goes awry. And so we absolutely, in most of the models, the Fonagy model, the Marsha Linehan model, Kernberg, all of the models do refer back to the attachment context. And what you do then in psychotherapy, which is, of course, attachment relationship, is you are resetting that serve and return and helping the patient learn a different way of reflecting on self and reflecting on other in the context of this attachment relationship that they can then generalize outside of the therapy room. Next, please. Hi, I really enjoyed your presentation, number one. Although I have no real expertise, I had experience with borderline personality disorder patients in two settings. One, ironically, was in psychoanalytic training, which had horrible outcomes. A lot of the patients regressed to infantile states, became psychotic, had to be hospitalized. It was a big mistake to try to treat those patients with psychodynamic psychotherapies. So I want your opinion on that, number one. Number two, then I did modified DBT later on and also had bad outcomes. Even though I had a good therapeutic alliance, multiple suicide attempts, a lot of sexual acting out. So I never used medication with these patients, which probably would have been, but this was a long time ago, probably would have been helpful. But I just like your thoughts on someone who's had, I enjoyed working with them, but I just wasn't very successful. So I'd like your opinion. I can't tell from here. Is the microphone working? Yes. Good. So, yes. One of the ways that the understanding of personality disorders as being identified as access two versus access one was this sense that in the paradigm, treatment paradigms of the time, they were less responsive to treatment or less successful in treatment. So it's important to identify when that pattern is present because you wouldn't necessarily use the same psychoanalytic or psychodynamic treatment frameworks in the same way if it's more of the personality construct versus a so-called access one construct. I really appreciate the APA moving forward with removing those diagnostic axes because it's a step closer to the reality that there's no such thing as a treatable and an untreatable diagnosis that we have to essentially understand how to best treat disorders and study that scientifically. Psychodynamic, modern psychodynamic frameworks, mentalization is a psychodynamic framework. So there are more structured BPD specific psychodynamic frameworks that are evidence based to be effective. So it's clear that the more, that the less structured or treating the BPD patient like any other analytic client, that didn't work. But there are modern psychodynamic frameworks that are effective. The key is really kind of this nonjudgmental stance and then boundaries and skill building within the context of the therapy. But as I mentioned before, it does tend to be two steps forward, one step back kind of pattern as with any other kind of developmental process. It's not always going to be linear in the right direction. And I would ask was the patient on benzos or alcohol at the time because the best therapy is going to not be as effective in the context of medications or other substances that actually impede learning and growth and long term potentiation of neurons and learning, that kind of thing. So I would, or if there's ongoing abuse, if somebody is in the context of a traumatic or a harmful setting, therapies that rely on growth and learning and psychological safety are going to be less effective. So there are barriers to recovery certainly that we see and try to identify. Can I just add that many of them had OCD and many of them also had eating disorders. Yes. Which confounded the treatment as well. Yes. Can you comment on that? Yes. The question is about the kind of intersection with OCD and eating disorders. So there is a subtype of BPD that's discussed that's kind of the overcontrolled, is that the term? Overcontrolled subtype that does have treatment. It is more difficult to treat with those comorbidities. Yep. The overcontrolled subtype. There are some emerging psychotherapeutic studies looking at how do we best treat this subpopulation within the BPD population. Radically open DBT is one such methodology that's being looked at. I'll just add to that, you know, there are many reasons why classic psychoanalytic treatment doesn't work for people with personality disorders. Peter Fonagy developed mentalization-based treatment specifically because classic psychoanalytic treatment is seen as iatrogenic. There are two big problems. It's not transparent. Transparency in working with people with BPD or personality disorder is really, really important. And then, interestingly, not taking an authoritative stance. If there is one population in which the clinician and the patient are on equal footing and the one is not the trained, competent person and the other one is the incompetent patient, it is personality disorder. So I'll just say at the core of all of the treatment approaches is this sort of non-authoritative, transparent stance. We always talk about, you know, in working with personality disorder, you put your mind on the table, you say what you're thinking, and it becomes in DBT a dialectic. My view is as valid as your view. It's a very transparent, very active, structured therapy in all cases. So is there any good evidence for naltrexone or N-acetylcysteine for the reduction in cutting behaviors? Not at the level of evidence base that we would like. Naltrexone has been theorized to be effective in repetitive, self-injury-focused behaviors because the idea is that there's a function to the behavior that's somewhat rewarding. So in the same way we would use naltrexone for alcohol use, for example, perhaps with cutting there would be less of a reward that would then decouple the behavior as a functional behavior in the setting of emotional distress. In some people it has been helpful. This is anecdotal. But very importantly, the concern is actually cutting deeper or more in order to elicit the same function. And so you really just can't sort of prescribe it or inject it and think, okay, the self-injury is going to go down. It really has to be paired with a very transparent commitment on the part of the patient to understand that, yes, this might be helpful, but a potential risk is actually worse injury because of how this could potentially impact your experience of self-injury. And then the other medication was? N-acetylcysteine. Oh, N-acetylcysteine, yes. I was involved in some early research on N-acetylcysteine for self-injury at the University of Minnesota. It ends up being multiple large supplement pills three times a day. And it's a lot of supplement. And it's unclear whether taking a large dose of a supplement three times a day actually, you know, the placebo effect from that may actually obscure the actual effect from the N-acetylcysteine. And so the question is, ethically, is this something we do? Or, you know, how transparent are we about the actual effect of this versus being a kind of an intentional self-treatment three times a day, which on its own would have benefits, a kind of a mindfulness activity around self-injury. So it's sort of, that's what I know about that. Next, please. The slide listed mood stabilizers as having large effects. How do you think about the different class of mood stabilizers, like anti-epileptics versus second-generation antipsychotics versus lithium, especially lithium with overdose toxicity? So regarding mood stabilizers and some of their potential effects, lithium is really not studied in borderline personality disorder, if you can believe it. I still consider it a mood stabilizer when I look at that chart. Again, just sort of anecdotally in my own practice. And I use lithium, and I actually use it at lower doses, 300 or 600 milligrams. I don't necessarily need to get to 1.0 blood level. We're not treating mania. We're treating essentially mood reactivity. So you can, in my mind, get away with a little bit lower doses, which is safer. Now, if this is someone with a lot of overdosing, it is a concern in terms of safety. I let them know that it's likely to cause brain injury in the course of overdose more than death, and so that the main risk is actually brain damage. And that often is heard by people as a discourager for overdose. But if it's really a safety issue, you have to keep that in mind. And so it's primarily anti-epileptics in that category. But agents like aripiprazole that sort of function as a mood stabilizer slash antipsychotic agent, you can conceptualize that in a similar way. We've reached 930. Sorry. Your hunger for knowledge is not that good. Thank you so much.

Personality Disorders

Borderline Personality Disorder

BPD

Diagnosis

Treatment

Dr. Carla Sharpe

Kaz Nelson

Alternative Model for Personality Disorders

DSM-5

ICD-11

Psychopharmacology

Patient-centered care