 Okay, borderlines and borderline nets, today we are going to discuss your chances. Are you ever going to heal? Is it possible at all? Borderline personality disorder is a mental health issue that comes with stigma. But stigma is half the problem. The other half is myths, misinformation. And as usual, loads of unmitigated rank nonsense propagated by self-styled experts and borderline personality disorder patients themselves. So let us review the facts. Facts is what we do in Akadem and I and Sam Vaknin, a professor of psychology and the author of Malignan Self-Love, Narcissism Revisited. I love my voice. Okay, let us start with a bibliography. So I recommend that you try to find the article, The Lifetime Course of Borderline Personality Disorder, Canadian Journal of Psychiatry, July 2015. It was authored by Robert Viskin, B-I-S-K-I-N, but don't hold his name against him. The article is well written and a reasonable summary of what we know. So let's start with some facts. Borderline personality disorder is not as widespread as people would have us believe. The community prevalence in the general population is something like 1-2%. But the problem is that borderlines present in treatment much more than their share in the general population. In other words, they hit above their weight. They are frequently in crisis and whenever they are in a crisis they go to therapy, they go to inpatient clinics, they go to mental institutions, etc. So there is this optical illusions that borderline is everywhere. Borderlines account for 10% of outpatients, 20% of inpatients and 6% of patients presenting for family medicine. Now the fact is that there are equal numbers of borderline men as there are borderline women. Yeah, that's a fact and this also applies to narcissism lately, by the way. But borderline women are three to four times more likely to frequent clinical settings. No one is sure, no one knows why. We can only speculate and guess, perhaps grandiosity. Male grandiosity is more kind of in tune with culture and society than female grandiosity, perhaps an issue of empathy. I suggested a new diagnosis, covert borderline. Covert borderline is actually an amalgam, a hybrid, a cocktail between borderline personality disorder and narcissistic personality disorder. That might explain why borderline men refuse to attend therapy. And so again there is this optical illusion, there is this myth, there is this misinformation that there are more borderline women than men. Wrong. Now we have been studying borderline for decades. It's one of the oldest mental health issues to have been studied repeatedly. There are even studies that are still ongoing, 20 and 30 years after they had started. I will touch upon these later. When borderline patients present themselves in clinical settings, they are always in some mayhem, in some mess, in some chaos, in some crisis. Help me. So they trigger the rescuer savior instincts and reflexes of every therapist, especially if he happens to be a man. Borderlines are irresistible, I must admit. So borderlines suffer intensely. And they do so publicly, in open view of the treatment community and other practitioners. Their family, their friends, they make a spectacle. The drama queens, they convert their suffering into a spectacle. And this gives them a bad name. But actually, the prognosis for borderline personality disorder is not bad at all, as we will see. By age 45, a sizable portion of patients with borderline personality disorder will have healed spontaneously and miraculously. We will not be able to diagnose the disorder anymore in these people. And the other half respond very well to dialectical behavior therapy, DBT. So if you put the two together, theoretically, we can heal, cure, whatever word you want to use, something like 90% of borderline patients. This is, I mean, in narcissism, for example, you can forget about it. No one heals from narcissism. No one ever recovers from narcissism. Don't listen to the online nonsense about recovered narcissists. These are con artists masquerading as experts. There's no such thing as a recovered narcissist. It's total unmitigated trash. Borderlines, however, do heal and do remit. Technical term is remit. They do remit. Okay. Borderline, according to the diagnostic and statistical manual, is a pervasive, inflexible, impairing and non-normative behavior outside the cultural and societal background. And it's important to understand that in most borderline cases, the unusual, atypical, non-normative, sometimes even antisocial behavior, the socially unacceptable misconduct in every field, sexually, by way of property, with family members, with friends, with other people, people, all these types of misconduct start actually in most cases in adolescence. Borderline personality disorder is one of a few mental health disorders where we can safely diagnose at a very early age. Now, for example, psychopathy cannot be diagnosed in children and adolescents. Instead, we have something called conduct disorder. But borderline can, we theoretically can diagnose borderline personality disorder pretty safely at age 12. And this is unique. The diagnostic and statistical manual says if the symptoms of a pervasive, persistent and unlikely to be limited to a particular developmental stage or another mental disorder, as long as these symptoms have existed or present for one year or longer, that's borderline. Never mind the age. So we are faced with something that starts in late childhood, early adolescence, that is intimately linked to anxiety, disorders, depression. And so we tend to believe that borderline personality disorder is somehow associated with brain abnormalities. Possibly hereditary brain abnormalities. Studies tend to support this. Functional magnetic resonance imaging, other types of studies tend to support this conjuncture. Not conclusively, not rigorously at this stage, but we are getting there. There is a body of evidence that psychopathy is actually a brain abnormality. And this body of evidence is building for borderline as well. One of the reasons we now consider borderline to be a form of secondary psychopathy, especially among women. Zanarini and allies, they have demonstrated that patients with borderline personality disorder start treatment on average at age 19, 18, I'm sorry. Many of them start much earlier, like 16 or 15 or 14. Her team, Zanarini's team, demonstrated that over 30% of patients with borderline personality disorder started to self harm, to self mutilate. When they were 12 years of age or less, another 30% initiating self harm between the ages of 13 and 17. And this is bodily self harm. This does not include reckless behaviors. For example, sex, especially sex with much older people, which is a pretty common occurrence and phenomenon in borderline personality disorder. The diagnostic and statistical manual permits the diagnosis in patients earlier than 18. Again, if they persist for one year. And so we are beginning to conceive of borderline personality disorder as essentially a childhood or adolescence disorder. Indeed, in many cases, the disease is present in childhood and adolescence and vanishes as the person grows up. We'll talk about it a bit later. Are there any, is there any way to diagnose borderline personality disorder in very, very, very young people? Like I don't know, six or seven. Paris, a scholar by the name of Paris and her colleagues, they suggested a syndrome called borderline pathology of childhood. Borderline pathology of childhood is a combo, is a cocktail of effective, impulsive and cognitive impairments, cognitive problems. And so what they did, they used a kind of a tool, an instrument, a test, a psychological test. They rebuilt it as a kind of diagnostic criteria and then they applied the diagnostic criteria. We'll not go into it, into all this right now. The authors found, Paris and allies found that children from ages seven to 12 who met the criteria for borderline pathology of childhood were more likely to have experienced abuse, neglect. There were also neuropsychological findings suggesting executive dysfunction similar to that found in adults with borderline personality disorder. But five years later, when these kids were 15, the mean was 15, five years later, only very few of them actually developed borderline personality disorder. They were borderline in childhood and yet in extremely few of them, the disorder had survived. They function poorly as adolescents, but they did not have BPD, borderline personality disorder. There was a first clue that actually borderline personality disorder is a cyclical disorder with some features reminiscent of bipolar disorder. It seems to wax and wane. There seem to be period in life where borderline is more pronounced, more manifested, takes over, overwhelms the individual, causes the individual to decompensate and act out and even becomes psychotic. And there are other periods with borderline personality disorder where the disorder remits. There are relapses and remissions. And when the disorder remits, it vanishes altogether. The person functions totally normally and normatively. There was another study and they studied a cohort community sample of high-risk girls between the ages of 6 and 12. They reported some interesting findings. They asked the parents to participate, the teachers to participate, to rate and rank these girls. They found a lack of control. They found aggression. And they discovered that these features, lack of control and aggression, remain stable six years later. It seems that children and early adolescents with borderline personality disorder carry forward some of the features of the disorder, but not all of them. So while they don't merit the diagnosis, some elements of borderline behavior, some borderline traits, problems of impulse control, problems of aggression, they remain well into adulthood. So we tend to begin to think that borderline personality disorder symptoms may appear in childhood in some patients, but we don't know what's going to happen to them. In the majority of people, majority of children, these symptoms are going to vanish. In a minority of them, they're going to persist into adulthood. In adolescents, borderline personality disorder probably can be diagnosed reliably and validly. We call this adolescent onset borderline personality disorder. And borderline personality disorder in adolescents, let's say ages 12 to 17, is indistinguishable from borderline personality disorder in adults. And that includes promiscuous sex, drinking and substance abuse, aggression, recklessness, problems with impulse control and so on. The borderline adolescent is already a borderline adult in effect. There are many studies that followed the outcomes of patients diagnosed with borderline personality disorder in adolescents. The course of BPD in adolescents is not very stable. There was a study of clinical population between the ages of 15 and 18, and they found that only 40% of patients with borderline personality disorder met the criteria two years hence. A two-year follow-up. But this sample only included a small number of adolescents with BPD because it looked at the course of all personality disorders. There was another community study of self-reported symptoms in adolescent twins. And they also, this study also found a decrease in the rates of BPD diagnosis between the ages of 14 and 24. With significant reductions of symptoms in every two-three-year intervals through the 10-year follow-up. So perhaps adolescents BPD while on the surface appears to be identical to adult BPD is actually not the same. Because in the vast majority of cases, it remits to oblivion, it vanishes, living behind vestiges of aggression and impulse control problems. So in each follow-up in this study, there was a 50%, 50% reduction in diagnosable BPD, which raises a fundamental question about the validity of the clinical entity of adolescents' onset BPD. Is it a real clinical entity? There was a large longitudinal community study of adolescents with two and eight-year follow-up. They found that BPD symptoms tended to persist even when formal diagnostic criteria were no longer met. Again, the same result. Some behaviors, some traits, some problems and impairments persist into adulthood, but not the totality of the diagnosis. When a sample of adolescents previously diagnosed with BPD were followed up four years later, 65% remitted from the diagnosis. And this is consistent with many other studies. There was a research group that tried to identify risk factors for the development of BPD in a community sample of adolescents. And they found that maternal child discord, maternal BPD, when the mother has BPD, paternal abuse of drugs and substances, paternal abuse of drugs and substances, as well as depression and suicidality in the adolescent, they all predict later development of BPD symptoms. And these risks may moderate the improvement of the patients during this phase of development. In other words, it seems that what we call adolescent onset BPD is actually, in large part, reactive to familial context to the family unit. If a family unit is disrupted, dysfunctional, if the mother has mental health problems, if there is conflict between mother and child, if drugs and alcohol are used and abused, if the child herself is depressed and anxious, there's a tendency, suicidal ideation or even suicidality, she's likely to develop BPD symptoms in adulthood. But if these factors, contextual factors, family factors are missing, she is not likely or he is not likely to develop BPD later. BPD begins in adolescence, is not necessarily a lifelong disorder. Many patients retain residual symptoms later in life, and these are not predictable. And we simply don't know enough about this. Okay, but what about adulthood? In adults, there's been a lot of research, especially over the last two decades, numerous meta-analysis and longitudinal studies and so on. Two of the most important studies are known as MSAD, MSAD and CLPS. MSAD is still ongoing. 20 years later, it's by far the largest, most thorough and substantive study of borderline personalities. It's a prospective longitudinal study. They've been following a group of 290 patients who were hospitalized, so they used to be inpatients, and they were diagnosed with BPD. And they compared these 290 people to 72 patients, initially hospitalized with other personality disorders. There was a reassessment every two years. They measure symptomatology, functioning, comorbid, psychiatric and medical conditions, you name it. And the other study... I'm sorry. No, it's not COVID. You're not infected. The other study, CLPS, they recruited 668 patients, and mostly outpatients. And these patients met criteria for BPD, but also comorbid avoidant personality disorder, obsessive-compulsive schizotypal or major depressive disorder. There were no other comorbid personality disorders, but I would say that the CLPS muddied the water. By accepting cases which were not pure BPD, we are left wondering which artifacts come from the other diagnosis. At any rate, these patients were reassessed six months after baseline, then annually for 10 years. Massive serious study. Again, they focused on symptomatology, comorbidity, functioning, but there were also several assessments of dimensional personality traits. Both studies, the MSAD and the CLPS, both studies found that most patients with borderline personality disorder, and these are the good news. You know, it's almost religious. I bring you the good news, the Evangelion. Most studies, these studies found that most, I repeat most patients with borderline personality disorder, improve with time. The CLPS provided clear evidence that even when followed up two years after the initial assessment, about one quarter of patients experienced a remission of the diagnosis during the prior two years, within two years. And during the 10 year follow up, 91%, a whopping 91% had at least a two months remission and 85% shocking number, 85 miraculous number, 85% had remitted for 12 months or longer. In other words, they didn't have BPD. That BPD was not diagnosable in them for a year and longer. The MSAD had similar results, found similar results. And if the MSAD found these results consistently over a period of 16 years, the MSAD's definition of remission was even much more rigorous than the CLPS. The MSAD defined remission as no longer meeting diagnostic criteria for a period of two years or longer. The MSAD found that by 16 years later, 99% of patients, 99% of patients had at least a period of two year remission. 78% had a remission that lasted eight years. Now, for example, in cancer, in oncology, if you are cancer free for five years, you're cured. 78% of BPD patients lost their diagnosis, did not have BPD anymore. For eight years, definitely cured. This study has demonstrated that BPD is slower to remit than other personality disorders and depression, but it remits much more. There was a study that followed patients for 27 years, and this study found that 92% of them no longer met criteria for borderline personalities. These are staggering numbers. It means everyone heals spontaneously. All BPD patients heal. Now, we don't know why. Is it hormonal balances as people age? Is it something to do with the brain, neuroplasticity, rewiring? We have no idea, but it's nothing short of miraculous. This borderline is a really, really bad problem. It's a serious mental health disorder, and it's a sibling of narcissistic personality disorder, and yet narcissistic personality disorder is utterly resistant to any change, any meaningful change. While borderline personality disorder inexorably, glacially, but surely, slowly, but surely, people with borderline personality disorder heal day by day, year by year, until finally it's gone. And no one knows why. A major topic of study. The rates of recurrence, so remission and relapse, the rates of recidivism, recurrence, were not quite consistent. It's the only point where most major studies disagree with each other, probably because of how they define relapse or remission. In the CLPS, the recurrence rates for patients with BPD were 11% at a 10-year follow-up. In those who had achieved at least 12 months remission. This was significantly lower for other personality disorders and also significantly lower than the recurrence rate for patients with major depression. So people with borderline personality disorder take longer to remit. They take longer to spontaneously heal, but the healing stands. The healing is forever. It's resilient to any remission, resistant to any remission. The MSAD found that recurrence rates decreased the longer the remission lasted. 36% of patients experienced a recurrence if their remission lasted only 2 years. But this number declined to 10% if their remission lasted 10 years. These numbers are amazing. They compare extremely favorably with rates of relapse and remission among, for example, alcoholics and drug users. Anyone in rehab, anyone who's ever worked in rehab will tell you that something like 80% of alcoholics remit or relapse within the first year after rehab. Compete the numbers. The BPD group was slower to heal, faster to remit, by the way. They remitted faster, but the rate of remission was much lower. This results suggest that patients with BPD are able to achieve remission of symptoms and that the longer the remission lasts, the lower the risk of relapse. When we study the course of individual symptoms, not the entire diagnosis, the borderline personality disorder affects every trait, every behavior, every area of functioning, everything. That's why Otto Kernberg and others suggested that it borders on psychosis. That's why it's called borderline between neurosis and psychosis. It's that bad. It's like almost one abyss schizophrenia. So borderline is bad. And it's a panoply. It's a colloquium. It's a cornucopia in a way of symptoms. So if you study these symptoms separately, there is an overall decrease in all symptoms. But symptoms that relate to impulsivity and behavioral manifestations of BPD, they remitted at a quicker rate than internal, primarily effective experiences. In other words, the internal experience of the borderline changes dramatically as the borderline ages. As she grows older, her inner experience changes. For example, dysregulation almost disappears, emotional dysregulation, moodlability disappears. But behaviorally, impulsivity, aggression, recklessness, defiance, what you could call secondary psychopathy, these things remain. They no longer reflect an inner reality, but they have become probably habituated or entrenched and it's difficult for a patient to get rid of them. It's like a reflex, automatic response. In general, the behavioral symptoms of personality disorders are less stable than the personality traits associated with borderline personality disorder over time. So despite early reductions in symptoms of self-harm, for example, suicidality, the risk of completed suicide remains. So suicidal ideation decreases. The inner landscape changes, but the behavior remains. It's a mystery, by the way. It's difficult to understand this disconnect between behavior and internal interiorizing, internal view. After 27% of follow-up, about 10% of the patients completed suicide, typically when the patients were in their 30s and after multiple failed treatments. The MSAD found a suicide rate of about 5%, an identical rate of death, by all other causes. In this sample, there were issues with the factors, because there was a question of how to deal with suicide attempts, how to deal with comorbid depression, substance abuse, post-traumatic stress disorder, family history of suicide, and so on and so forth. So it's not a clean result, but it does seem, based on these and previous studies, that the rate of suicide in BPDs falls to between 8% and 10%, but then mysteriously stabilizes. Even as the disorder remits and disappears, suicide remains as a risk factor. We don't know why. We have no idea what's going on. Now, in borderline personality disorder, it's very common to find in the same patient mood disorders, substance abuse, anxiety disorders, eating disorders. It's very common. Comorbidity and dual diagnosis are very common, much more common than in other personality disorders. After six years of follow-up, over 60% of borderline patients meet the criteria for mood disorder and similar disorders, like anxiety disorders, 60%. The presence of a BPD diagnosis is associated with a longer duration to recovery from some psychiatric illnesses, such as major depression. And so comorbid personality disorder are more frequent in patients with borderline personality disorder, and so we have comorbid avoidant, dependent, self-defeating, or passive-aggressive. If the patient has this disorder, in addition to borderline, the remission rate is lower. Strangely, if there is a comorbidity of borderline and narcissistic personality disorder, there's no effect on the remission rate. But avoidant, dependent, and passive-aggressive or self-defeating, these have an impact. Comorbid medical conditions are also significant problems for patients with BPD, including irritable bowel syndrome, osteoarthritis, diabetes, obesity, and others. Patients with BPD also experience more frequent, more intense pain with increased use of opiate medications, opioids. In general, the rates of psychiatric and medical treatment, the rates of usage of psychiatric medications are much higher in patients with BPD. And though there's always a decline in addictions and misuse in essence of medications and medical treatment, although there's a decline in the eighties of each study, in the eighties of follow-up, treatment use is relatively elevated and unchanged after that. So there's a slight decline in its stabilizes. In other words, the borderline patient continues to attend therapy and continues to abuse medications long after the borderline is gone. We see in borderline something very strange. The behaviors persist. Suicidality, impulse control, defiance, reactance, recklessness, consumatiousness, substance abuse, alcoholism, drug abuse, medication abuse. And overuse of treatment, medical treatment. All these are behaviors associated with borderline. But when the borderline is gone, in the majority of patients, as you've heard, and the borderline is gone, these behaviors don't. Why would someone without borderline personality disorder commit suicide? We don't know. We don't know why these behaviors persist. It's one of the greatest enigmas of psychiatry. Because they persist as though in vacuum. They're like a floating cloud. They're not tethered and they're not grounded in any underlying mental health condition. It's like the borderline had vanished but left behind a trace, a ghost. The ghost of the borderline remains with the patient for life. Perhaps as I said, it's habit. Habit-forming or habituation. Perhaps it's these are coping strategies that the ex-patient is loathe to give up on. The patient doesn't know any better. That's how she had coped with life all her life. So, you know, she doesn't, is not aware of other options. We are not sure because, for example, in dialectical behavior therapy, we teach the patients how to cope, how to better cope. We introduce them to new coping strategies, but it doesn't help. It doesn't help with the behaviors. It helps with the disorder, but not with the behaviors. The inner experience changes and becomes much better. There's a lot less dysregulation and mobility and the patient feels empowered and in control and optimistic and looking forward and everything. But the behaviors remain. So, this is a normal simplification for treatment and clinical management. First of all, there's the issue of diagnosis. How to properly diagnose the behavior in adolescents, especially adolescents, young adults. Should we differentiate between symptoms because they persist in the disorder? Or is the disorder the symptoms? Or are the symptoms connected to behaviors or behaviors? We don't know. Borderline personality disorder is like a huge black Friday sellout in a warehouse. It's everything and every item from the world of mental health is there. But we don't exactly see how they all fit in. There's no coherent view of the disorder. The disorder itself appears to be unstable during adolescence and the long-term course is essentially identical to that seen in adults. So, we have treatments, some of them work wonderfully, as I said, like dbt. But we don't really know what we're doing and we don't really understand borderline personality disorder. And stigma doesn't help because there is this myth, misinformation, that BPD is untreatable. That it has bad prognosis, that these women are going to end up like cat ladies and these men are going to end up in jail, in prison or derelict, homeless. This is nonsense. Actually, the vast majority of people with borderline personality disorder are high-functioning. They occupy positions of power and they are accomplished in their fields. It's nonsense. The stigma is not based on reality. It's fear. It's based on fear because these people are really sometimes frightening in a way. When the borderline switches to the secondary psychopathy state, to her self-state of secondary psychopathy, she can be very frightened and she does a lot of damage. She harms. She hurts. She destroys. She misbehaves recklessly, promiscuously and so on to the great detriment of those who love her. So, there's a lot of pain in borderline personality disorder and there is nothing more painful. Let me tell you from personal experience. There's nothing more painful than loving a borderline. It's an excruciating descent to hell. I read to you a poem I'd written recently. But the prognosis is optimistic because the disease remits even spontaneously, even without treatment. And if you add treatment to this, literally everyone can be cured, can be totally healed. There are dysfunctional behaviors that remain, but you know, behavior modification is a well-developed field in psychology. What we need to do, which we are not doing, we treat the disorder, but then we need to teach these people the healed, the recovered borderlines. We need to teach them how to behave themselves. We need to reintroduce them into the process of socialization. For more is acceptable, not acceptable. We need to teach them to sublimate, to self-control. I mean, they need to learn. They started in late childhood or early adolescence. They lost touch with society and family and community and so on. They drifted. They did horrible things to themselves and to others. They didn't have a chance to be socialized. No one taught them how to control impulses, how not to act recklessly, how to protect themselves sexually and otherwise. They fall prey to predators. It's a bad thing to have borderline personality disorder and clinicians need to have a perspective on this. We need to parent the borderline patient after she had recovered from her primary disorder, from the primary problem. There are relapses, but the prognosis is wonderful, much, much better than alcoholics, for example. So we should not be deterred by relapses. For example, DBT focus primarily on self-harm and suicidality, which is these problems are serious, but they're serious early on in BPD. As these symptoms remit with time, patients who are older want to deal with other problems related to emptiness, fear of abandonment. These are not directly addressed by DBT. These are symptoms that are slower to remit. So we need to build a new psychotherapy founded on DBT. No question it's the most effective modality we have, but with a much wider spectrum. Not focusing on immediate dangers only, but teaching the patient to rebuild herself as a socially functioning unit, to become more self-efficacious, to regain agency and personal autonomy. There's a lifelong, long-term, poor functional status of these patients. The aforementioned Zanirini and her colleagues demonstrated that recovery is significantly less likely in patients with BPD than in an Axis II comparison group. Slightly more than one half of patients with BPD achieved recovery, which was defined as a remission from symptoms, as well as good full-time vocational and educational functioning. And at least one stable and supportive relationship with a friend or partner. So while the disease disappears, BPD disappears, when it comes to functioning, people who used to have borderline personality disorder are much more dysfunctional than, for example, narcissists and psychopaths. We need to teach them to functions. And so predictors of recovery are not being hospitalized. Higher IQ, prior good vocational functioning, absence of cluster C, comorbidity, like schizoid, and trait measures of high extroversion and high agreeableness. Recovery was also associated with both marriage and being a parent. Now most borderlines become parents at a much, much later stage. Ironically, borderline patients with active borderline, they become parents early on. Once the patient had lost her or his borderline diagnosis, they postponed parenting, they postponed fatherhood or motherhood to a much later stage. They feel more mature, they feel responsible, they act responsibly. There's a study that demonstrated that the global assessment of functioning scores were lower in the BPD group, and significantly fewer of these patients achieved levels that represent good functioning. These people seek social assistance, but they're getting the wrong social assistance. They're getting DBT, which focuses on emergencies, like suicide and self-harm. They're getting, or disregulation and liability, they're getting social, they're getting money. They're getting social workers who usually take away their children. They're mistreated in many ways. We must provide a one-to-punch treatment of borderline. First tackle the core disorder, get rid of it. It's possible to do it. Then focus on teaching, acquiring skills of functioning. Teach the borderline, or the former borderline, or the recovered borderline to function. This functional recovery is so difficult for patients with BPD to attain and maintain. I'm quoting now from the article that I started with. As functional recovery is so difficult for patients with BPD to attain and maintain, this becomes an important long-term goal for intervention. Currently the only long-term study to directly assess vocational or educational functioning indicates that mentalization-based treatment provided in an 18 months partial hospitalization setting is associated with a greater chance of being employed or in school up to eight years later. Other studies have also demonstrated improved social and global functioning, but these were not primary outcomes. They were not significantly different between the different treatments. Also, duration of follow-up was too short. Thus, says, concludes the article. Thus, there is evidence that while treatment is likely to lead to improvements in functional recovery, there is a notable absence of studies that focus on this as a primary outcome. Consideration should be given to providing patients with BPD as much support in attaining functional recovery as possible. This may include psychosocial programs aimed at returning to work and evaluation and involvement from occupational therapists, vocational counselors, or other specialists who can help patients develop the skills necessary for any sort of work. This is more or less the conclusion, the situation. Let me read to you the conclusions of this article. Research during the past two decades has clearly demonstrated that BPD has a positive trajectory over time. Although it is a disorder associated with many psychiatric and medical comorbidities, many of the most troubling symptoms remit during the first few years. Unfortunately, several of the underlying personality traits remain for longer periods, and these are the elements of the disorder that may not be fully addressed by current treatments. Many of the specialized psychotherapies help patients with BPD, but long-term functional recovery is difficult. One potential solution to this problem is in early identification of patients with BPD. Early intervention may allow these patients to resume a healthier trajectory early on in life and to attain the social and vocational functioning that is often challenging for somewhat older patients. The lives of patients with BPD have improved significantly with specialized treatments, and further refining these treatments for a younger population may lead to greater changes in the long-term course of borderline personality disorder. Amen to that.