 Some some good upheaval in the world of borderline personality disorder Many things we thought we knew were disproven lately and others have emerged all in all More optimistic news If I had to choose between borderline personality disorder and narcissistic personality disorder as a diagnosis I would choose borderline. There's spontaneous remission After age 40 or 45 There is DBT, which is a very effective treatment strategy And there is growing hope day in and day out The more we believe or the more we convince ourselves that borderline personality disorder is actually a form of hereditary brain abnormality The more treatment horizons medical interventions open But even in the classical field of psychotherapy There are mega developments Stay with me for this right a literature review of the most recent studies in the world of Borderline personality disorder My name is Sam Vaknin. I'm the author of Malignant self-love narcissism revisited and a professor of psychology And let's delve right in and review a new study This study Upsends our perception of borderline personality disorder Before I go there. There is enormous ignorance Enormous ignorance even among people who are supposed to know better I just returned from a trip in July to Vienna where I've met 13 13 psychologists and psychiatrists 12 of whom had insisted that borderline personality disorder is actually bipolar disorder not Borderline personality disorder as the name implies is a personality disorder Bipolar disorder has absolutely nothing to do with it. It's a mood disorder And yet these top-notch professionals didn't know the difference In another country, Hungary, I've heard of the most credentialed prestigious Diagnostician there Misdiagnosing borderline personality disorder or actually the absence or lack thereof egregiously He hands down Diagnosis to people telling them they do not have borderline personality disorders because they don't self mutilate or self harm This is a level of profound Ignorance in every civilized country these men would have lost his license Let me elucidate a bit The absence of self harm Does not preclude a diagnosis of borderline personality disorder There are new findings and they have enormous implications when it comes to the diagnostic criteria for this disorder And so there's a study a recently published study and It's titled the hidden borderline patients Patients with borderline personality disorder who do not engage in recurrent suicidal or self suicidal or self-injurious Behavior it was published by Cambridge University Press in July 2022 and the authors are Mark Zimmerman and Lena Becker I will summarize the study for you and then as is my habit. I will read to you the abstract So what they what these people are saying but these investigators or scholars are saying is that You don't need to self harm or self mutilate or cut In order to gain The diagnosis of borderline or qualify for the diagnosis of personal borderline personality disorder They chose they selected 400 psychiatric outpatients diagnosed with borderline personality disorder About half the participants Were suicidal And they engaged in recurrent self injury self mutilation and self harm The other half didn't Then they studied these two populations and the results showed no difference between the two groups in the degree of impairment in occupational functioning social functioning comorbidity of psychiatric disorders history of childhood trauma severity of depression existence presence of anxiety Anger emptiness Etc. Etc. In other words, these two populations were identical Diagnostically and psychodynamically the only single difference between them is that the people in the first group Self-injured self-harm and self-mutilated Intended to have suicidal ideation and people in the second group didn't When yet clearly Both members both members of both groups Qualified abundantly for a diagnosis of borderline personality disorder Mark Zimmerman Who is an md and a professor of psychiatry and human behavior at Brown University Providence, Rhode Island Said just because a person Doesn't engage in self-harm or suicidal behavior Doesn't mean that the person is free of borderline personality disorder Clinicians need to screen for borderline personality disorder in patients with other suggestive symptoms Even if these patients do not self harm Just as they would for similar patients who do self harm Zimmerman is also the director of the outpatient division at the partial hospital program in Rhode Island Hospital Anyhow, he publishes findings in Psychological in the journal psychological medicine The problem with borderline personality disorder and with all other personality disorder Disorders is that they are Polythetic at least in the diagnostic and statistical manual four three and two this approach of Making a list of diagnostic criteria Prevailed over the alternative approach, which was which is descriptive and dimensional So we ended up having lists each diagnosis had its own list of criteria And in the case of borderline personality disorder and narcissistic personality disorder It was sufficient to meet five of the nine criteria In order to be diagnosed with the disorder But this created a major problem Because for example, you could be diagnosed with criteria one two three four and five And then I could be diagnosed with criteria five six seven eight and nine And both of us would qualify To receive the diagnosis of borderline personality disorder yet. We have almost nothing in common Your borderline personality disorder relies on diagnostic criteria one to five My borderline personality disorder relies on diagnostic criteria five to nine We have extremely little in common And this is called the polythetic problem So there were risk there were scholars and researchers and experimenters and psychologists all over the world who have spent past two decades Trying to find the single criterion Which would apply to all Patients with borderline personality disorder regardless of which other criteria They had met And they found that the only criterion which applies to 90 percent. That's nine zero percent Of all patients with borderline personality disorder Is effective instability Also known as emotional dysregulation Zimmerman says that effective instability had a very high negative predictive value Meaning that if you didn't have effective instability, you didn't have the disorder Given the clinical and public health significance of suicidal and self-harm behavior in patients with bpd An important question is whether the absence of these criteria Which might attenuate the likelihood of recognizing a diagnosis of this disorder And they identifies a subgroup of patients with borderline personality disorder Who are less borderline than patients with bpd who do not manifest this criteria In short The issue is this We know that 90 percent of patients with borderline personality disorder Have emotional dysregulation Aka effective instability We these scholars wanted to find out whether self-harm Self-injury self-mutilation Occupies the same hallowed space in other words whether it was also present in the vast majority of borderline cases And what they found is no the answer is no You could definitely be borderline without any hint or trace of suicidal ideation Self-harm self-injurious behavior or self-mutilation Similarly There was no difference between any specific axis one or personality disorder And borderline personality disorder in other words The comorbidity of borderline personality disorder with other mental health disorders Did not have a predictive diagnostic value You couldn't say if this person doesn't have depression If this person doesn't have I don't know some other issue for example Grandiosity if this person doesn't self harm and self mutilate and doesn't have suicidal ideation This person is not borderline. You can't say this It's wrong The only two comorbidities which have some predictive value when it comes to borderline personality disorder are generalized anxiety disorder in patients under age 45, especially very young patients And histrionic personality disorder Both were more frequent in the patients who did not meet the suicidal self-injury criterion So it seems that there are two groups of borderline Borderlines who are suicidal and self-injurious These borderlines would tend to have anxiety and histrionic personality disorder And borderlines who are self-destructive self-harming And these borderlines would not have usually or normally or would have less lower frequency of histrionic personality disorder The patients who met the suicidality self-injury criterion Were significantly more likely to have been hospitalized And reported more suicidal ideation at the time of the evaluation wrote the researchers There were no between group differences On severity of depression Anxiety or anger at the initial evaluation There were no differences in social functioning Adolescent social functioning Likelihood of persistent unemployment or receiving disability benefits Childhood trauma or neglect Both all these parameters were identical in the group Who of people who were of patients who were suicidal And self-harming And in the group of patients who were not suicidal Who were not suicidal and were not self-injuries All these parameters I repeat them Social functioning adolescent social functioning Likelihood of persistent unemployment or receiving disability benefits Childhood trauma or neglect Zimmerman says I suspect that there are a number of individuals whose bpd is not recognized Because they don't have the more overt feature of self-injury or suicidal behavior He he calls this hidden bpd hidden borderline personality disorder Repeated self-injurious and suicidal behavior. He says Is not synonymous with borderline personality disorder And clinicians should be aware that the absence of these behaviors Does not rule out a diagnosis of borderline personality disorder Monika Karski Is the assistant professor of psychology In psychiatry and a senior fellow of the personality disorders institute in wild cornell medical college new york city She has a very long list of credentials. She is also a postdoctoral Manager of the postdoctoral program in psycho analysis psychotherapy, et cetera, et cetera Karski suggested to stop using the Model the diagnostic and statistical manual edition four text revision model In other words, she says don't use the list of nine diagnostic criteria This list is very misleading It's very misleading. It's also culture-bound. It includes gender bias and it's polythetic It it leads equally to comorbidity with other disorders. It's a mess The diagnostic and statistical manual edition four Including the text revision are a bloody mess And they are a mess Because they rely on lists and categories where it's the human psyche and the human mind are not categorical They are dimensional and they are on a spectrum So karski suggests to use the alternative model or the alternate model for personality disorder In the diagnostic and statistical manual fifth edition text revision In the alternative model or alternate model of borderline personality disorder First you rate the severity level of personality You assess identity Relationship problems intimacy issues Self-regulation You note you note specific traits of personality disorders And she says this will help clinicians who dread telling patients that they are borderline I concur wholeheartedly the alternative model in the dsm five Is vastly superior to anything dsm four has to offer It is regrettable that the insurance industry and the pharmaceutical industry have both Intimidated the diagnostic and statistical manual committee into including the outdated and defunct language of the diagnostic and statistical manual edition four In the fifth edition and in the text revision Summary of this part You don't have to self harm. You don't have to self mutilate And you don't have to be suicidal to qualify for a diagnosis of borderline personality disorder If you are emotionally dysregulated and your effect is unstable You probably have borderline features and in all likelihood a borderline personality disorder So this is the article Go to the description for a bibliography. I'm going to read to you what the authors said in the article itself Background despite the significant psychosocial mobility associated with borderline personality disorder It's under recognition. It's a significant clinical problem BPD is likely under diagnosed in part Because patients with bpd usually present with chief complaints associated with mood anxiety and substance abuse disorders When patients with bpd do not exhibit self-harm behavior We suspect that bpd is less likely to be recognized An important question is whether the absence of these criteria Which might attenuate the likelihood of recognizing and diagnosing the disorder Identifies a subgroup of patients with bpd who are less borderline than patients with bpd who do not manifest this criterion The results are this Approximately half of the patients with bpd Did not meet the suicidality self injury diagnostic criterion for the disorder There were no differences between the patients who did and did not meet this criterion in terms of occupational impairment likelihood of receiving disability payments impairment in social functioning level of educational achievement comorbid psychiatric disorders history of childhood trauma or severity of depression anxiety or anger upon presentation for treatment and just Correcting one thing the only exceptions are generalized anxiety disorder in patients under age 40 And histrionic personality disorder throughout the lifespan these two are Are correlated with borderline personality disorder the comorbidity is significant statistically speaking The conclusions of the study Repeated self-injurious and suicidal behavior is not synonymous with borderline personality disorder It is critical for clinicians to be aware that the absence of repeated self-injury and suicide threats or gestures Or attempts does not rule out the diagnosis of borderline personality disorder Onward to the next article It identified a new treatment modality for borderline personality disorder Either to we have had mostly dialectical behavior therapy dbt dbt has been extremely efficacious Well over 50 percent of patients lost the diagnosis within one year A dbt involved a group element an individual therapy element To this very day dbt dialectical behavior therapy is the gold standard for treating borderline personality disorder And here comes another possibility Another possibility I'm referring to an article titled the effectiveness of predominantly group Schema therapy and combined individual and group schema therapy for borderline personality disorder randomized clinical trial the lead author is agnud ounce ar n t z and I will read to you the key points and findings from the study itself, but I want to discuss it a bit beforehand What the study shows is that if you were to combine Individual schema therapy with group schema therapy You would accomplish a reduction of symptoms a substantial reduction of symptoms in patients with borderline personality disorder That's a new tool in our arsenal Schema is a form of psychotherapy that focuses on the experience on experiential approach It's not so focused on behavior change It teaches you how to manage your experience in ways which render you more functional and definitely more self-aware This study Again, the lead author was dr. Arnud ounce this study was an international randomized control trial And what the study found was that it's not enough to offer individual Schema therapy you need to couple it with group schema therapy and so What dr. Arn says is in the Netherlands There's a big push from mental health institutes to deliver treatments in group therapy only Because people think it's more cost effective But these findings question this idea the findings were published in a very prestigious academic journal journal of american medicine association medical association psychiatry The study characterizes borderlines a borderline personality disorder a bit idiosyncratically I must say There many scholars would disagree with some Of the characteristics of borderline personality disorder as incorporated in this study The study says that patients with borderline personality disorder Exhibit extreme sensitivity to interpersonal slides This kind of hyper vigilance is actually much more typical in narcissistic personality disorder Not in borderline personality disorder The study says that patients with bpd have intense and volatile emotions, which is true as we've seen in the previous study Impulsive behaviors also true. Many of them abuse drugs self-harm or attempt suicide Wrong, it seems About half of them do not many of them At any rate borderline personality disorder Is by and large Captured appropriately in the study. So we can't disqualify the study as having as having Explored other mental health disorders is people patients in the study were clearly borderline And when we look at evidence-based recommendations by various psychiatric and psychological associations around the world The usual first venue or first resort is psychotherapy Psychotherapy is a primary treatment for people presenting with what appears to be borderline personality disorder And so we need many more therapies Classical therapies such as psychoanalysis or cognitive even cognitive behavioral therapy Have proven to be inefficacious with borderline. Hence the modification of dbt Schema therapy uses techniques from traditional psychotherapy, but it focuses as I said on an experiential strategy It delves into early childhood experiences And in the case of borderline personality disorder, this is very relevant Because in the vast majority of patients with borderline personality disorder, we do find adverse childhood experiences trauma Abuse and neglect in early life That is not to say that borderline personality disorder is not a brain abnormality It's not to say that there is no genetic or hereditary component in borderline It seems that people who go on to develop borderline personality disorder As early as childhood in childhood or adolescence are people who have a propensity A proclivity a predilection to develop borderline personality disorder Genetically or cerebrally in the brain In other words, these people are somehow predisposed to develop borderline personality disorder because they have defective genes or brain abnormalities But the trigger Is environmental nurture not nature In the absence of abuse, trauma and neglect in early childhood You're very unlikely to develop borderline personality disorder Even if you have all the genes and all the brain abnormalities So schema therapy seems to be very relevant With this approach Therapists take on a kind of parenting role And they try to meet the needs of these patients That were not met in early childhood The patient is perceived as a frustrated child And the role of the therapies is to help the patient grow up and mature by acting the parent Previous research had suggested that both individual and group schema therapy helped to reduce BPD symptoms But what this study shows is that if you if you had to combine individual and group schema therapy The the benefit is becomes exponential Treatment retention is also higher when you combine the therapy Improvement in multiple secondary outcomes happiness quality of life Patient report patient reports an enhanced sense of well-being Still just to put things in perspective Outcomes In society or in work Are more improved in dbt than they are in this combined approach I want to be clear combining individual schema therapy group schema therapy Does improve societal and work functioning patterns and outcomes, but not as much as dbt Um So aren't says that group therapy seems to offer something that is important for learning to cooperate with other people At work you often have to collaborate with people who are not necessarily your friends It's the same approach in dbt by the way There's a very very strong dominant group element there The number of suicide attempts Among patients exposed to combined schema therapy The number of suicide attempts declined over time The combination Proved to be significantly superior to treatment as usual During the study period Three patients died of suicide one In each treatment hour Another third one Was not it wasn't clear that it was suicide So these are three out of hundreds It's a major improvement in in the statistics of suicide in typical borderline groups Overall, the results suggest that group and individual sessions address different needs of patients said the investigators While patients may learn to get along with others in a group setting They may be more comfortable discussing severe trauma or suicidal ideation or thoughts in one-on-one sessions with the therapist So let me read to you From the study and again Go to the description. There's a bibliography with a list of all these studies. They went to find them Let me read to you the key points of the study The question was Is group schema therapy for borderline personality disorder more effective than optimal treatment as usual And is predominantly group schema therapy or combined individual and group schema therapy more effective the findings In this randomized clinical trial, which included 495 adult participants with borderline personality disorder in five countries Combined individual and group schema therapy was significantly more effective than optimal treatment as usual And predominantly group schema therapy So the combination was much more effective in reducing bpd severity The findings add to the evidence for the effectiveness of schema therapy for borderline personality disorder And indicated the combination of individual and group schema therapy is the more affect effective schema therapy for month Okay Let's go on to the next study And the next study Kind of challenges The common orthodox wisdom In all the treatment guidelines that I'm aware of all over the world If this study is replicated and supported by other studies We have been doing things wrong for decades According to this study and in a minute I'll read to you the title of this study. Give me a minute Effect of three forms of early intervention for young people with borderline personality disorder The mobby mobby randomized clinical trial The lead author is andrew chanen chanen And as usual I'll first analyze the study and then read to you from the study What the study says is that Early interventions that focus on clinical case management and psychiatric care And not on individual psychotherapy Are more effective For young patients with borderline personality disorder. Now you remember that we can diagnose and do diagnose Borderline personality disorder as early as 12 years old It's not the case with narcissistic and antisocial personality disorder Which are diagnosed only after age 18 or sometimes 21 Borderline can be diagnosed very very early on in life And so we have patients they're underage and we need to treat them somehow and hitherto All the treatment guidelines all over the world Said that what you do with such a young patient is give him or her psychotherapy And what this study says it's a wrong approach. You should focus on Case clinical a clinical case management. You should focus on psychiatric care, including medication And there is this trial big trial called monitoring outcomes of borderline personality disorder in youth The mobby trial a mobby trial It showed improved Psychosocial functioning and reduced suicidal ideation Up with early psychiatric intervention and case management So the results of this study suggest That psychotherapy is not the only or even first effective approach for early bpd Dr. Chainan is the director of clinical programs and services and head of personality disorder research at origin Melbourne, australia And he told he said We can say that early diagnosis and early treatment is effective And the treatment doesn't need to involve individual psychotherapy But does need to involve clinical case management and psychiatric care Patients with bpd have extreme sensitivity to interpersonal slides And exhibit all kinds of volatile emotions and impulsive behavior As we said many self harm abuse drugs attempt suicide The suicide rate among patients with borderline personality disorder to remind you Is anywhere between 8 and 11 percent depending on the country The condition is diagnosed in puberty or early adulthood and it affects about 3 percent of young people Luckily for for humanity Many of these young people grow out of their borderline personality disorder. There are two waves Where you can lose the diagnosis Between ages 12 and 21 and then after age 45 Only one third of young adults or adolescents Diagnosed with borderline personality disorder go on to become adults with the diagnosis of borderline personality disorder But these patients young patients They are volatile. They are labile. They're dysregulated. They're aggressive. They have enormous interpersonal difficulties And they are discriminated against by health professionals. They don't get treated Those that are treated Are often shunted off to some therapies once a month or something and they receive individual psychotherapy A very small percentage of them end up in dialectical behavior therapy program the and so In let me be clear individual psychotherapy is a good thing These therapies, especially dbt teach you Healthy ways to cope with stress and to regulate emotions. And so these therapies are highly effective But the mobi trial examined three treatment approaches not only one The first treatment approach is called the help young people early model hype The second is hype Combined with weekly befriending And the third was a general youth mental health service Y mhs modeling combined with befriending So a key element of hype is cognitive analytic therapy. It's a psychotherapy program focused on understanding problematic self-management and interpersonal relationship patterns The model also includes includes clinical case management. For example, housing vocational and educational issues other mental health needs Commobilities like depression and anxiety medication physical health needs in the second model psychotherapy Of the hype program Is replaced you have all the elements of clinical case management But instead of psychotherapy you have befriending befriending means chatting with the patients with a patient The chats are about neutral topics. I don't know sports Avoiding emotionally loaded topics avoiding actually not discussing interpersonal problems And the third approach was why mhs plus befriending it's when you the the experts trained Trained young people They they gave the young people therapy they managed the patients, but these Therapies were not specialists in bpd So the third approach is what we call what we call as usual treatment or treatment as usual approach Therapists ecologists who are not Experts and scholars of bpd, but but treat bpd as well all patients across all three groups Had marked and sustained improvements In ways you wouldn't expect for borderline personalities or Interventions have a true effect especially in childhood and puberty The results suggest that early diagnosis And not very complicated treatment or even just chatting to someone drastically improves the lives of these young people says chanon The results also imply that there are effective alternatives to mere treatment as usual psychotherapy The insistence on the field by many scholars and many institutions and many Treatment guidelines the insistence that only therapy works in bpd is wrong Chain and says this study turns things upside down And says actually that psychotherapy is not the single modality It's the basics of treatment that are important not which treatment When a patient presents at an emergency department following for example severe overdose Clinicians reflexively refer that person to a psychotherapy program But the problem is these programs Are not built to service the needs of suicidal borderline personality disorder patients They are kind of canvassing programs And most of the workers in these programs Or be it with academic degrees in psychology are not experts in the extremely Convoluted and complicated dynamic of borderline personality disorder The skills for clinical case management and psychiatric care Are very specialized so This is the this is the study John Oldham Who is a distinguished Emeritus professor In the manning the manninger department of psychiatry and behavioral sciences in Baylor College of Medicine Houston, Texas Oldham says The general standard approach in psychiatry and the diagnostic world Has been to not even consider anything until after somebody somebody is 18 years of age Which is a mistake because these kids can become quite impaired Much earlier than that. He says incorrectly Oldham was not involved in in this study Ironically He was one of the main contributors and authors of the very treatment guidelines Which are undermined by this study and yet Amazingly at his age and with his renome and track record. Oldham is an example of a good scientist A scientist who is open to new information Scientists who is capable of modifying his views very substantially When exposed to new findings Oldham says there is an emerging trend towards good psychiatric management That focuses on level of functioning rather than on a specific strategy Requiring a certificate of training that not many people out there have Oldham says You're not going to make much headway He concludes with these kids. You're not going to make much headway with these kids If you are going to be searching around for a dbt certified therapist What you need is to bring them in Get them to trust you and in a sense to be a kind of overall behavioral medicine navigator for them Let me read to you from the study As I usually do by the way the study comes with the beautiful graphic And so the study the key points are Question what combination of treatment components is sufficient for early intervention for young people with borderline personality disorder And the findings in this randomized clinical trial with 139 youth with borderline personality disorder A dedicated bpd service model and a specialized bpd psychotherapy Were associated with superior retention in care But not a superior rate of change in psychological functioning by 12 months And this is compared with general youth mental health care and a psychotherapy controlled condition Effective early intervention for bpd is not reliant on availability of bpd psychotherapy In This is a major change in orientation. It means that when we are confronted with the young bpd patient We should immediately take care Of all the aspects of his functioning and his life We should befriend him and which we should offer offer and we should offer a complete or total solution Not focus on psychotherapy, which often Doesn't work Or works less effectively and there are very few people Qualified to administer it And so now I want to review six studies of psychosocial interventions It is an article titled borderline personality disorder Six studies of psychosocial interventions by Sy Atezas Saeeden And angela calis k a l l i s is published in the journal of current psychiatry in 2002 So the first study Is by zanarini conchi and temis but before we go there A reminder of what is borderline personality disorder borderline personality disorder is a serious impairment In on multiple levels and in multiple areas of life Starting or with emotional dysregulation and affect instability But psychosocials functioning is severely affected There's an ongoing pattern of mood instability or ability cognitive distortions problems with self image Impulsive behavior that often results in problems in the workplace and in relationships Patients with bpd tend to utilize more mental health services than patients with any other mental health disorder Or even with major depressive disorder Many clinicians believe that bpd is very difficult to treat This is no longer true. This hasn't been true for decades, but the stigma lingers on Historically there's been little consensus on the best treatments for these disorders And currently we use pharmacologic and psychological interventions in combination And so I want to review six studies very briefly So again, the first one is titled randomized control trial of web based psycho education for women with borderline personality disorder It was published in the journal of clinical psychiatry in 2018 the authors are zanarini conchi and temis I'm reading the abstract Research has shown that bpd is a treatable illness with a more favorable prognosis than previously believed Despite these patients often experience difficulty accessing the most up-to-date information on bpd, which can impede their treatment A 2008 study by zanarini at allies of younger female patients with bpd Demonstrated that immediate in-person psycho education Improved impulsivity and relationships Wild spread implementation of this program proved problematic. However, due to cost and personnel constraints To resolve this issue research has developed an internet based version of the program In a 2018 follow-up study zanarini and his collaborators examined the effect of this internet based psycho education program on symptoms of bpd And the outcomes were pretty astonishing In the acute phase treatment group participants experience statistically significant improvements in all 10 endpoints and outcomes It seems that in patients with bpd internet based psycho education reduce symptom severity and improve psychosocial functioning With effects lasting up to one year treatment group participants Experience clinically significant improvements in all outcomes measured during the acute phase of the study Most improvements may were maintained over one year So this is pretty pretty a pretty interesting um A pretty interesting study the next study is a randomized trial of brief dialectical behavioral therapy skills training in suicidal patients suffering from borderline disorder was published in acta psychiatry Scandinavia 2017 the authors were mccain and gimo and bound heart So they said standard dialectical behavioral therapy dbt is an effective treatment for bpd However access is often limited by shortages of clinicians and resources Therefore, it has become increasingly common for clinical settings to offer patients Only the skills training component of dpd, which requires fewer resources While several clinical trials examining brief dpd dbt skills Only treatment for bpd So while several clinical trials Examining this shortened or condensed version of dpd For bpd these studies have shown promising results It is unclear how effective this kind of intervention is introducing suicidal or non suicidal self-injury episodes So the study explored the effectiveness of brief dpd dbt skills Only a junctive treatment on the race of suicide and in his nssi Episodes in patients with bpd I'll summarize this for you dpd is expensive dbt is cost dbt is costly dbt dbt requires Training dbt is not available everywhere to everyone So there's a short of zipped a sort of zipped or condensed version of dbt Which offers only skills training The authors try to find out if bpd patients subjected to a bridged dbt the skills training component of dbt if these patients Responded favorably to the treatment by reducing rates of suicide and self-injury, which was not suicide And so the outcomes were That the dbt group showed statistically significant greater reductions in the frequency of suicidal and nssi episodes So the dbt group experienced statistically significant improvements in distress tolerance and emotion regulations But no difference on mindfulness The dbt group achieved greater reductions in anger over time So it seems that Yes, uh, there are impacts Even if we use only a single component of dbt it already has Massive effects on multiple very crucial dimensions of bpd The dbt group showed significant improvements In social adjustment symptom distress borderline symptoms But no significant Change in impulsivity Um clinical improvements Were the statistics the statistical measures are very significant. So it's pretty safe to say that these these outcomes are real the conclusions are brief dbt skills training Reduced suicidal and nnsi nssi self-injury episodes in patients with bpd Participants in the dbt group also demonstrated greater Improvements in anger distress tolerance and emotion regulation compared to the control group These results were evident three months after treatment However, any gains in health care utilization social adjustment symptom distress borderline symptoms Diminished or did not differ from the other participants at week 32 That time participants in the dbt group demonstrated a similar level of symptomatology as the control group So this is this was the second study. The next study is titled Combined therapy with interpersonal psychotherapy Adopted for borderline personality disorder a two years follower was published in psychiatry Research psychiatry research in 2016 the authors are bozatello and belino. I love italian how musical the study Was interesting It says that psychotherapeutic options for treating bpd bpd including dbt mentalization based treatment schema focused therapy Transference based psychotherapy and systems training for emotional predictability and problem solving All these are psycho psychotherapeutic options But they're not widely available More recently interpersonal therapy also has been adopted for bpd. It is known as ipt bpd However, thus far say the authors No trials have investigated the long-term effects of this particular therapy on bpd in 2010 belino at allies published a 32-week study examining the effect of ipt bpd on bpd They concluded that ipt bpd. In other words interpersonal therapy Adopted for bpd. They concluded that ipt bpd plus Prozac was superior to prozac alone in improving symptoms and quality of life The present study by bozatello at allies examined whether the benefits of ipt bpd plus prozac Demonstrated in the 2010 study persisted over a 24 month follower And so the outcomes were While the original study demonstrated that combined therapy had a clinically significant effect of a prozac alone on on bpd This advantage was maintained only at the six month assessment The improvement of the combined therapy provided over prozac monotherapy In with regards to impulsivity and interpersonal relationships As well as factors of social and psychological functioning at 32 weeks were preserved at 24 months No additional improvements have been seen The conclusions of the study are that the improvements in impulsivity interpersonal functioning Social functioning and psychological functioning at 32 weeks Seen with ipt bpd plus prozac compared with prozac alone persisted for two years after completing therapy But no further improvements were seen The improvements to anxiety And effective instability that combined therapy demonstrated over prozac monotherapy at 32 weeks when not maintained after 24 months So the next study is favorable outcome of long-term combined psychotherapy for patients with borderline personality disorder Six-year follow-up of a randomized study again in psychotherapy research 2017 the authors were Antonsen, Kvaustine, Stein and Urnes While many studies have demonstrated the benefits of psychotherapy for treating personality disorders, say the authors, there is limited research of how different levels of psychotherapy may impact treatment outcomes There is something called the uleval personality project It compared an intensive combined treatment program without patient individual psychotherapy in patients with personality disorders The combined treatment program consisted of short-term day hospital treatment followed by outpatient combined group and individual psychotherapy The outcomes evaluated included suicide attempts, suicidal thoughts, self-injury, psychosocial functioning, symptom distress and interpersonal personality problems A six-year follow-up concluded that there were no differences in outcomes between the two treatment groups However, the authors examined whether combined therapy, the combined psychotherapy produced statistically significant benefits over the outpatient therapy in a subset of patients with borderline personality disorder So you remember that the group included many types of personality disorders So these authors wanted to home in to focus on patients with borderline personality disorder and to see whether combined therapy was superior to outpatient therapy in the case of BPD only So they discovered that when it comes to BPD, borderline personality disorder compared to the outpatient group, the combined psychotherapy group demonstrated statistically significant reductions in symptom distress At year 6, in between years 3 and 6, the combined psychotherapy group continued to show improvements in psychosocial functioning So the outpatient psychotherapy group worsened during this time The scores of this group worsened during this time compared to the outpatient group Participants in the composite group also had significantly better outcomes on multiple domains of self-control and identity integration There were no significant differences between groups on the proportion of participants who engage in self-harm or experience suicidal thoughts or attempts There were no significant differences in outcomes between the treatment groups in all these domains Participants in the composite group tended to use fewer psychotropic medications than those in the outpatient groups over time But this difference was not statistically significant The two groups did not differ in the use of healthcare services over the last year Avoidant personality disorder did not have a significant moderator effect in this case Comorbid avoidant personality disorder was actually a negative predictor independent of the group Both groups experienced a remission rate of 90% at six-year follower Compared with the outpatient group, participants in the composite group experienced significantly greater reductions in symptom distress and improvements in self-control and identity integration at six years So this is this is the this study The next study is eight-year prospective follow-up of mentalization based treatment versus structured clinical management for people with borderline personality disorder It was published in the Journal of Personality Disorders 2021 in the authors of Bateman, Constantinu and Fonagy They say the efficacy of various psychotherapies for symptoms of BPD has been well-established However, there is limited evidence that these effects persist over time In 2009, Bateman and others conducted an 18-month study comparing the effectiveness of outpatient mentalization based treatment, MBT, against structured clinical management for patients with BPD Both groups experienced substantial improvements But patients assigned to mentalization based treatment demonstrated greater improvement in clinically significant problems including suicide attempts and hospitalization In a 2021 follow-up to this study, Bateman and allies investigated whether the MBT group, the mentalization group, the gains in this group in the primary outcomes absence of severe self-harm, suicide attempts and inpatient admissions in the previous 12 months the gains in social functioning, the gains in vocational engagement, mental health service usage whether these gains were maintained throughout an eight-year follow-up period And so the outcomes were that the number of participants who met diagnostic criteria for BPD at the one-year follow-up was significantly lower at the mentalization base group compared with the other group. To improve participant retention, this outcome was not evaluated at later visits. The number of participants who achieved the primary recovery criteria of the original trial, to remind you, absence of self-harm, suicide attempts and inpatient admissions the number of patients who achieved this primary recovery criteria and remained well throughout the entire follow-up period was significantly higher in the mentalization group compared with the other group. The average number of years through during which participants failed to meet recovery criteria was significantly greater in the other group compared to the mentalization group. When controlling for age, treatment group was a significant predictor of recovery during the follow-up period. Overall, significantly fewer participants in the mentalization group experienced critical incidents during the follow-up period which was a very long follow-up period. The other group, the non-mentalization group, used mental health services for a significantly greater number of follow-up years than the mentalization group. The likelihood of using crisis services did not statistically differ between the groups but the first group, the non-mentalization group, used these services much more. MBT group participants spent more time in education, were less likely to be unemployed, were less likely to do social care interventions than the other group. People in the MBT group spent more months engaged in purposeful activity, etc. etc. They received, they had fewer months of psychotherapeutic medication compared with the other group and so on. The study demonstrated that patients with BPD significantly benefited from specialized therapies such as mentalization-based therapy. At the one year follow-up, the number of participants who met diagnostic criteria for BPD was significantly lower in the mentalization group. The number of participants who achieved the primary recovery criteria and remained well during the 80-year follow-up period was also significantly higher in the mentalization group. So mentalization is a third option after BPD and schema therapy. And finally, a sigh of relief. Finally, an article titled Effectiveness and Safety of the Adjunct Views of an Internet-Based Self-Management Intervention for Borderline Personality Disorder, in addition to care as usual, results from a randomized controlled trial. It was published in the BMJ Open Access, BMJ 2021. The authors are Klein, Howard and Bergen. They say fewer than one in four patients with BPD have access to effective psychotherapies. The use of internet-based self-management interventions developed from evidence-based psychotherapies can help close this treatment gap. Although the efficacy of internet for several mental health disorders has been demonstrated in multiple mental analyses, results for BPD are mixed. In this study, Klein and allies examine the effectiveness and safety of the adjunctive use of an internet-based self-management intervention based on schema therapy, in addition to care as usual in patients with BPD. So the outcomes were, there were large reductions in the severity of BPD symptoms, as measured in various ways. In people who used an internet-based intervention method, and this difference was statistically significant. There was not a statistically significant difference in the number of serious adverse events between the two groups. So the conclusion was that treatment with an internet-based intervention module did not result in improved outcomes over care as usual. Although the average reduction was greater in this group compared to the reduction in symptoms, was greater in this group compared to the control group, this difference was not statistically significant. The authors believe that because many of the patients were receiving psychotherapy, the study should be taken with a grain of salt. But it's interesting, it's interesting because many people resort to the internet as a first option, support groups, forums, even internet-based psychotherapy. This study seems to indicate that it's not working, many groundbreaking and earth-shattering discoveries. I thought I'd bring them to your attention. Thank you for surviving, and see you next time.