Associate Professor Michael Kaess Hello,  ladies and gentlemen, dear colleagues. My   name is Michael Kaess and I’m a Professor  of Child and Adolescent Psychiatry working   at the University of Bern in Switzerland. And  today, I’m going to talk to you about the topic,   “Early Detection and Intervention of  Borderline Personality Disorder.” So,   first of all, although I have a strong interest  in the topic, I do not have a conflict of   interest with regards to pharmaceutical  or industrial funding. All funding for   the research that I’m going to tell you about  was provided by research funding agencies only. I’m going to start to introduce you, quickly, to  the topic of personality disorders, in particular   with regards to the new ICD-11. So, in the ICD-11,  personality disorders will be classified on the   continuum of severity, mainly including the two  big domains, self and interpersonal functioning. In the self domain, we distinguish  between identity and self-direction,   whereas in the interpersonal domain, we can  then also distinguish between the basis of   empathy and intimacy. And this will be a  very new concept of personality disorders   which includes dramatic changes compared to  the categorical diagnostic classification   system that we have in personality disorders  to date. However, and that is very important,   there will be one diagnostic entity as  a categorical classification that will   still be available in the ICD-11 and that’s the  diagnosis of borderline personality disorder. Borderline personality disorder is one  of the, also, most important personality   disorder types because it is what we would  call a disorder that fits best on a general   personality pathology factor, which also  means that individuals suffering from   borderline personality disorder can be regarded  as those with most severe personality disorder.  Borderline personality disorder, as it is  still described today in the Diagnostic and   Statistical Manual of mental disorders, the  DSM-5, comprises nine diagnostic criteria   fear of abandonment, instable interpersonal  relationships, identity disturbances,   a pattern of impulsive and risk-taking  behaviours, repetitive non-suicidal   and suicidal self-injury, affective  instability, chronic feelings of emptiness,   irritability and anger and transient,  paranoid or dissociative symptoms. There’s been an ongoing debate about  the diagnosis of personality disorder,   in particular borderline personality  disorder in adolescence, but it is nowadays,   in the classification systems and also in  most international guidelines, acknowledged   as a reliable and valid diag – disorder in  adolescence. And I will show you throughout   the talk why we should acknowledge and also  diagnose borderline personality disorder in youth. The prevalence of borderline personality disorder  in the normal population ranges between 1-3%,   depending on the type of studies,  but it is a very common disorder in   inpatients. Almost 50% – up to 50% of  inpatients fulfil diagnostic criteria.   And borderline personality disorder is  a very severe and enduring disorders. It   ranges among the most important causes  of disability-adjusted life years. The diagnosis of borderline personality  disorders was very controversial during the   last decades and still remains controversial,  particularly among many Clinicians and also,   in the general public. And this was mainly  due to a few false beliefs that were related,   or that are related, to the diagnosis of  borderline personality disorder in this age group. One of those beliefs is that there is a lack  of validity of the diagnosis in adolescence,   because borderline personality disorder  includes some features that indeed,   we often find in adolescence as very common  features, such as mood swings or a tendency   to act impulsively and engage in risk-taking  behaviour. Nonetheless, I’ll be able to show   you that borderline personality disorder in  adolescence is far away from being usual puberty. The second false beliefs is that there is a  lack of stability of personality and personality   pathology in adolescence because personality  is not yet mature. It’s still under maturation   and because of this lack of stability, diagnosis  of personality disorder should not be made. And   a second belief – a third belief, excuse me,  that – maybe I start again with this. And the   thir – sorry, and the third belief that is still  very common among Clinicians is that personality   disorder is uncurable, and many Clinicians just  want to prevent their young clients from the   stigma of an uncurable personality disorder,  such as borderline personality disorder. So, let’s talk a little bit about what borderline  personality disorder is and how it differs from   usual adolescence and also, from other disorders  that are very common in adolescence. First of all,   it is very important to state that adolescent  borderline personality disorder is not similar to   self-injury. Of course, most of individuals with  borderline personality disorder present with a   pattern of suicidal and non-suicidal self-injury,  but as you can see here from this study,   the prevalence of self-injury among adolescents  in many countries in Europe is enormously high. It’s around 20-30% for single incidence  of self-injury and it ranges around 5-10%   for the DSM-5 diagnosis of non-suicidal  self-injury. Whereas the prevalence of BPD,   as we learnt before, ranges around 1-2%. So, only  a minority of self-harming teenagers really suffer   from borderline personality disorder. However,  within the group of individuals who self-harm,   BPD has some very prominent features and  individuals with BPD differ from those   who do not present with borderline  personality disorder, for example,   with regards to their load and to their  severity and complexity of childhood adversity. We can here see the slide from the study  that we investigated in Heidelberg in   Germany. It’s a study comprising of more than 500  help-seeking teenagers with self-harm behaviour,   where we investigated severity and complexity  of their experience of childhood adversity.   And as you can clearly see, the number of  borderline personality disorder criteria met,   correlate very well with their severity and  complexity of childhood adversity. Which   means that the more borderline personality  criteria the adolescent patients fulfil,   the higher their risk of having a  history of severe childhood adversity. Now, as we already know that personality disorder  is dimensional in nature, we also know that this   is true for borderline personality disorder. This  is the same sample, more than 500 individuals who   self-harm, where we investigated two different  constructs. One is health-related quality of life,   and the other one is psychopathological burden  or distress. And we investigate that with well   validated instruments, with the advantage  that there is also enough data in healthy   individuals. And as you can see here is that  with regards to health-related quality of life,   the self-harming individuals here in the black  line who do not suffer from borderline personality   disorder at all, show lower quality of  life compared to healthy individuals. But you can also see that once individuals fulfil  that threshold borderline personality disorder,   which means that they meet three or four criteria  of the disorder, but do not just reach the full   diagnostic threshold. And then, obviously, those  who meet diagnostic criteria for borderline   personality disorder show significantly lower  health-related quality of life. And we find the   same pattern with regard to psychopathological  burden or distress. The self-harming individuals   have higher psychopathological burden  compared to the healthy individuals,   but again, those with sub-threshold, or full  syndrome borderline personality disorder,   show a much and significantly  higher psychopathological burden. So, borderline personality disorder is  an important driver of comorbidity. We   know that individuals with borderline  personality disorder often suffer from   this characteristic combination of  both internalising and externalising   psychopathology. And as you can see  here in this graph, it’s, again,   the same study of more than 500 self-harming  individuals, we can show that those who suffer   from borderline personality disorder have very  strong comorbidity in many other ICD categories. For example, here, affective disorders, anxiety  disorders, eating disorders, or conduct disorder   or ADHD. Whereas those who self-harm but show  no borderline personality disorder, show much   less comorbidity. So, then we can also conclude  that those individuals suffering from borderline   personality disorder very commonly, have a set  of diverse comorbid mental health problems.  Other important aspect of mental health  problems is that mental disorders often   come with a loss of psychosocial functioning. We  know that psychosocial functioning is reduced in   many of our patients and that particularly  inpatients are often the group with high   severity of the disorder and particularly low  psychosocial functioning. So, in this study,   we investigated individuals with full diagnostic  threshold of borderline personality disorder,   and we compared them with a healthy control  group, but also, with a clinical control   group which was consecutively recruited  from adolescent inpatient units of child   and adolescent psychology. And again,  you can see here that the individuals   with borderline personality disorder showed  significantly lower psychosocial functioning,   not only compared to the healthy controls, but  also compared to the mixed clinical control group. Now, if we try to dive a little bit deeper into  the phenomenology of borderline personality   disorder, it is very important that the disorder  mainly includes three domains of instability,   the affective instability, the interpersonality –  the interpersonal instability and the instability   of self. And this is a study that was done with  what we call ecological momentary assessment. It’s   a smartphone-based technology where individuals  are asked about their mood states, in this case   12 times a day, in approximately hourly intervals.  And we did this investigation in individuals with   non-suicidal self-injury, one type of adolescent  self-harm and also, with healthy controls. And what you can see here is what we call a  heat map. You see here the four days in a row   where we did this examination, and you  can see here the current affect in each   hour across the day. And the colour of  red shows a particularly low affect,   whereas the green colour shows  a particularly high affect. So, what we – what can we see here on this graph?  First of all, and I think this is very important,   is that healthy adolescents are far away from  being affective instable. You can see here that   most of the healthy controls show pretty high  affect across all the four days and there’s   very little fluctuation of the current mood.  The picture is completely different in those   individuals who self-harm. You see this, kind  of, moderate picture with the emotions or current   affect of the individuals changing from hour to  hour, showing this characteristic mosaic picture,   which shows us a very visualised picture  of emotion or affective instability. So, this is a group of self-harmers which we can,  again, distinguish into the group of self-harm   with borderline personality disorder and without  borderline personality disorder and this is what   we did here in this next graph. You can see  here the co-efficient of affective instability   of the healthy controls and you can see here  the self-harm group, again distinguished into   those with self-harm, but no borderline  personality disorder and then, again,   with much higher affective instability, those with  self-harm and borderline personality disorder. So, in the same study, we  did not only ask for affect,   but we also asked the individuals whether  they felt close or loved by their mother   or by their best friend. And indeed, you can  see the same characteristic picture. Those   individuals without any pathology showed  very little interpersonal instability,   whereas those with self-harm and in particularly  those with borderline personality disorder,   showed significantly higher levels  of interpersonal instability. So, there is other groups worldwide who also  investigate the topic of adolescent borderline   personality disorder. Here is the slides  from the group in Basel, in Switzerland,   who investigated identity disturbances or  identity instability in borderline personality   disorder. And they investigated, again, a group  from the normal population, but then also,   individuals with predominantly externalising  disorders, internalising disorders and a group   with personality disorder. And what you can  see here is that the same picture applies.   The individuals with personality disorder, most  of them with borderline personality disorder,   showed a much higher and significantly  higher level of identity disturbances   compared to the healthy controls, but  also compared to the two clinical groups. We have talked a lot now about the concept of  borderline personality disorder, but I would   briefly like to show you how these data relate  to the new concept, to the Alternative Model   of Personality Disorder, which will also  be more or less introduced in the ICD-11,   as I told you before. What we have done here  in Bern, is we have investigated a large number   of patients and with the two constructs, DSM  diagnostic criteria for borderline personality   disorder and Alternative Model, impairment of  personality functioning. And then these were   all patients from our outpatient or inpatient  department and what you can see here is that   almost two thirds of the patient population do  not fulfil criteria for personality disorder,   neither in the old categorical way, nor in the new  dimensional loss of personality functioning way. Then you can also see that there is  a group of individuals, it’s 16.9%,   who show impairment in personality functioning,   but not borderline personality disorder. Which  is not very surprising because this is the group   of patients who would fulfil other types of  personality disorder according to the old   classification system and will now be  summarised in the new dimensional model. We have then the group who will be the  new diagnostic group of personality – of   borderline personality disorder, because  in the new classification system,   they will need to fulfil diagnostic criteria  for impairment in personality functioning,   so impairment in self-domain and in the  interpersonal domain. And they will additionally   need to fulfil the diagnostic criteria for  borderline personality disorder according   to the new borderline personality disorder  qualifier, which is introduced in the ICD-11. And then there is a interesting small group of  at least almost 10% and that is an interesting   group because this group does currently fulfil  criteria for borderline personality disorder   according to the DSM-5, but they do not meet the  criteria for impairment in personality functioning   according to the new model. Which means that  technically, in the ICD-11, they will not meet   criteria for a diagnosis of borderline personality  disorder anymore. This is an interesting group   that probably we’ll need to deal with in more  and future studies in the next ten years. So, the interesting question now is, does the idea  of personality disorder, particularly borderline   personality disorder, as one of the most severe  and enduring and impairing disorders that we have   in adolescence, also apply to those diagnosed with  the new model? And you can see this here in this,   a little bit complicated graph, but I’ll  talk you through. You see the different   diagnostic groups in the different colours. The yellow group is the new borderline personality   disorder group. The green group is the group who  suffer from personality functioning impairment,   but not borderline personality disorder. The  red group is the group that I told you is a   little bit difficult at the moment, and we  have the blue group which is all patients of   a university child and adolescent psychiatric  hospital, but not with personality disorder. And here, you see different measures of  psychopathology, self-harm and burden,   also reduced functioning. This here is the  number of comorbid diagnoses. This here,   for example, is quality of life measured by the  KIDSCREEN. Here we have psychosocial functioning.   We have suicidal ideation, suicide attempts.  We have self-harm. We have psychotic symptoms,   depressive symptoms, current stress level, emotion  dysregulation, and load of traumatic experiences.   And the overall pattern, actually, is pretty  clear. Those diagnosed with borderline personality   disorder, the yellow line, they are, in most  constructs, far above all the other patients   and also, above those with personality  disorder but not borderline personality. So, to sum up, if we talk about validity  of borderline personality disorder, we have   today sufficient data to say that borderline  personality disorder clearly demarcates a group   of mentally ill adolescents with commonly,  adverse childhood, with high morbidity, with   extreme levels of instability and dysregulation  and a particularly low psychosocial functioning. So, let’s get to the next topic, the stability  of personality disorder. Like, first of all,   I want to talk to you not about personality  disorder but about personality development.   Many decades we thought about personality as  a very stable construct that is more or less   not changing over the lifespan. Maybe after a  period of maturation, which we consider to be in   childhood and adolescence. However, what I show  you here is data from a huge meta-analysis that   included all the longitudinal data that we know,  or have, worldwide on personality development.   And in this graph, you see the degree of change  in each of these personality phases in different   age groups. And yes, there’s quite a bit of  personality change going on in adolescence   between ten and 18-years-old. But interestingly,  in the age group from 18 years to 22 years,   there is even more change in personality. And  if you have a look at the group 22 years until   30-years-of age, there’s tremendous change in  personality development, and even between the   age of 30 and 40 years, tremendous change in  personality dis – in personality development. There’s a little bit less change in  the decades from the 40s until old age,   but still, some changes going on. And what I  want to tell you is that personality is not   as stable as we maybe thought. Personality  is developing and changing and adapting to   our life circumstances throughout the  lifespan, and this is important. It’s   probably also important from an evolutionary  perspective. It makes us more resilient. It’s   important that our personality develops with  our different steps that we take in life. So, let’s now go to the topic of borderline  personality disorder. If we assume that   personality is not stable, this may also be true  for borderline personality disorder. And in 2011,   there was one of the first studies that did a  ten-year follow-up from a group of individuals,   adult individuals with borderline personality  disorder who were treated in a DBT,   a dialectical behaviour therapy programme.  And what you can see here was a very unique   new finding at the time, around  15 years ago, because suddenly,   we saw that borderline personality disorder, at  least if it is treated, is not stable at all. After two years, more than 50% of the individuals  suffering from borderline personality disorder   did not meet criteria for the disorder anymore.  And it was less than 20% who still met criteria   at the end of the ten-year follow-up period.  However, in the same study, the authors made   another very remarkable finding, because they  did not only investigate the trajectory of   disorder symptoms, but they also investigated  the trajectory of psychosocial functioning. And this line looks completely different. There  is almost no change in psychosocial functioning,   which means that although patients were  able to mostly recover from borderline   personality disorder, their psychosocial  functioning, which means their ability   to work, to participate in social connections,  to found a family, to build a social network,   to, you know, care for themselves, was  much impaired and didn’t improve at all. If we conclude on what we know  about the stability of adolescent   borderline personality disorder at all,  we first need to conclude that borderline   personality disorder is not a stable  disorder, which also means it is treatable. There is, to date, I’ll show you a few data  later, and we have sufficient data on that,   there is, to date, no evidence that  borderline personality disorder is   less stable in adolescence compared to adulthood.  And it is very important that although borderline   personality disorder symptoms can be reduced  substantially during and after intervention,   there’s a high risk of enduring and stable  loss in psychosocial functioning. And this   is important because I’ll get to that later when  we talk about the potential of early intervention. So, let’s go to early intervention. The idea of  early intervention is that we treat individuals   with a new emerging disorder, either at  the very early onset of the full disorder,   which we call early treatment, but maybe we  can also go a little bit earlier and we treat   those individuals once they emerge with certain  symptoms of the disorder, but before they fulfil   full diagnostic threshold for the disorder,  which we then call indicated prevention. So, the range of treatment that ranges  from indicated prevention to early   treatment in case of full and new emerging  disorder, that is called early intervention,   across a whole range of mental disorders. And  early detection and intervention have potential   advantages compared to late intervention  and this is true for most disorders,   but is also true for borderline personality  disorder. So, first of all, what you can achieve   with early intervention is you can rechie  – achieve a reduced duration of illness,   and you might probably agree that it is different  from suffering from a mental disorder for a period   of one or two years or suffering from a mental  disorder over a period of ten to 20 years. If we reduce the duration of illness, we also  have the chance to reduce repetitive comorbid   disorders. In particular, since we know that  borderline personality pathology is an important   driver of both internalising and externalising  comorbidity. Particularly important for   individuals with borderline personality disorder  is that we may be able to achieve a reduction of   cumulative traumatic events. Because of the very  specific interpersonal instability and the way our   individuals with borderline personality disorder  tend to engage in unhealthy relationships,   they are at high risk of engaging in traumatic  relationships ever and ever again throughout their   lifespan. But if we treat the disorder, we might  be able to get our foot into this vicious circle. It is also very important that by labelling the  diagnosis and then, also, adapting our treatments   to the diagnosis of borderline personality  disorder, we may be able to reduce the iatrogenic   harm. Individuals with borderline personality  disorder have a high risk of iatrogenic harm   because they are often prolongly hospitalised.  They often get a lot of polypharmacy, despite   well knowledge that pharmaceutical treatment is  actually not very helpful in those individuals.   And I think here, the potential of reducing  these times of the iatrogenic harm is enormous.   And most importantly, we have the potential to  improve or maintain psychosocial functioning,   which we have seen before is hugely impaired and  is probably also difficult to recover. And that’s,   you know, not very difficult to  understand, because in adolescence,   there’s so many developmental goals  and milestones to achieve, you know. Individuals need to build their own social  network. They need to get their proper   education to build a professional career.  They often find partners for their life   to be able to found their own family. But if  all these developmental milestones cannot be   achieved due to a severe and ongoing and enduring  disorder, such as borderline personality disorder,   it is not very surprising that at the  age of 25 or 30, it is pretty hard to   achieve all these milestones which have  not been achieved during adolescence. So,   our idea is that if we intervene early enough,  we’ll be able to support young individuals to   either not lose their psychosocial functioning  or rebuild their psychosocial functioning   in a phase of life where psychosocial  functioning can be more easily rebuilt. So, what options do we have for early  intervention in borderline personality disorder?   There is not many studies on the topic  yet, but there is a few randomised   controlled trials that clearly show  that psychotherapy and in particular,   disorder-specific psychotherapy, has  advantages compared to treatment as usual.  Two of those treatments should be named here. One  is dialectical behaviour therapy for adolescents,   which is a third wave behavioural therapy, and  the other very well investigated treatment method,   which is disorder-specific, is mentalised –  mentalisation-based treatment for adolescents,   which is more derived from the psychodynamic  psychotherapy tradition. And you can see here,   for both of these treatments, there’s  randomised controlled trials who show a   clear treatment infect – in favour of treatment  as usual, whereas in this graph you see that,   for example, for dialectical behaviour therapy,  there is not only self-harm which is reduced,   but it’s, basically, all the nine criteria, here.  Post-treatment is in yellow. The likelihood of   meeting all the nine criteria of borderline  personality disorder is significantly reduced. So, from our early intervention service, I’ve  brought you a few numbers on the efficacy of   dialectical behaviour therapy in adolescents, just  to show you what kind of response you can expect.   So, this is data from – published data from our  DBT-A programme, where you see in the first wave   of our programme, where we did this study, we  included almost 90% of individuals with full   syndrome, borderline personality disorder,  and another 10% with subsyndromal criteria. Today, we do more indicated prevention,  but at that time, we were still a little   bit of hesitant to do that. And you  see that after treatment with DBT-A,   only one third of the patients still fulfilled  criteria for borderline personality disorder.   There was another third of patients who  fulfilled subsyndromal criteria only and   there were almost 40% who did not show any  borderline personality pathology at all. So, if we have a look at this, we can  probably conclude that the response   rates for disorder-specific  psychotherapy in borderline   personality disorder among adolescents  is pretty good. It’s, in particular,   not worse compared to many other very common  disorders in adolescence, for example,   such as depression on the internalising side or  a conduct disorder on the externalising side. If we have a longitudinal follow-up, so in our  early intervention service we are also conducting   longitudinal follow-ups of our patients, you  can see here this is more than 500 individuals   at baseline and we follow them up annually,  here now for a duration of four years. And you   can see that the number or the average number  of borderline personality disorder criteria   is constantly declining, at least within  the first three years of follow-up,   with a significant reduction of  criteria. Which means that the   outcome with regards to a reduction  of psychopathology is pretty good. Interestingly, the age in which we start with  early intervention does moderate the treatment   effect. So, one of our research questions  was, is there may be a too early age for early   intervention? Yeah, and does early intervention  for borderline personality disorder, which we   start quite early, from the age of 12 years, does  that show similar efficacy or effectiveness at   different ages? And so, what I can show you  here is that there is indeed, an age effect   on the trajectory of borderline personality  disorder within our early intervention service. You can see that the older adolescents, 16  to 18-years-old, show large improvements of   BPD criteria, whereas the younger adolescents,  from 12 to 14-years-of-age, show only minimal   improvements of borderline personality disorder  pathology. However, what you can also see is   that those individuals who enter our treatment  service at an older age usually start on a much   higher level of borderline personality disorder  pathology. And that is not very surprising, given   that we know from population-based research, that  personality pathology, in particularly borderline   personality pathology, is on the rise during  adolescence. So, the load of personality pathology   usually increases until early adulthood and then  shows a small normative decline into old age. So, if we now, which we did with a sophistical  – statistical method, plot the intervention   effect against this normative rise, the  following picture results. We have here   the natural course of borderline personality  disorder with this characteristic increase   of borderline personality criteria into young  adulthood. And we have here the treatment effect,   so the deviation that our patients show from  this natural course. And what you can see here   is that still, the older age group shows a  stronger decline in personality pathology   compared to the younger age groups. But what  you can also see that in the end, all groups   show a strong benefit from early intervention and  that the benefit of intervention in younger age,   where we mostly do indicate that prevention is  more or less the prevention of the normative   rise and not so much the decline, or  the decrease, of personality pathology. So, let’s go back to the adult course, just  as a reminder that we see and in particular,   the – a little bit depressing finding of the  stability of loss in psychosocial functioning   in adults. We have investigated the construct of  psychosocial functioning within the longitudinal   follow-up in our intervention service, as well  and indeed, the picture is pretty different. You can see here that during the active  intervention period, which takes place   in the first year, we have a strong and highly  significant increase in psychosocial functioning,   which then is followed by a steady further  increase in psychosocial functioning within   this cohort. And just for you as an information,  we have plotted the similar course from the adult   study from Gunderson et. al here. And you  see that, obviously, their potential for   improvement in psychosocial functioning in these  younger individuals who were pre – who presented   themselves to an early intervention service,  is much higher, which means that at this age,   we might have the option to change the trajectory  of psychosocial functioning, which is, in my   opinion, the main argument for early detection and  intervention in borderline personality disorder. We have shown a similar finding in a  control trial, where we investigated   a new psychodynamic treatment for adolescents.  It’s called Adolescent Identity Treatment. It’s   derived from Kernberg’s transference focused  psychotherapy and have compared that with   dialectical behaviour therapy for adolescents.  And as you can see here, this was the baseline,   this was after treatment and this were the two  annual follow-ups. We see the same picture.   The primary endpoint was global assessment  of functioning, and we see for both early   intervention approaches that the psychosocial  functioning is significantly improving. One last slide, before I come to my final  conclusions, is that I still want to show you   and remind you that the best treatment setting  for individuals with borderline personality   disorder is outpatient treatment. So, for  individuals with borderline personality disorder,   although they might sometimes need brief inpatient  crisis intervention, the outpatient setting is the   preferred way to treat. And you can also  see this in this analysis of our cohort,   because we had part of the patients who, for  several reasons, underwent inpatient treatment   for a longer period of time and one other part who  had outpatient treatment only. And this graph is   actually adjusted for all potential confounding  factors, which means that inpatient treatment may   have more suicidal behaviour. They may have  more illness severity. They may present with   lower psychosocial functioning. But even if you  adjust for all these factors, you can see here   that the trajectory for the decline of personality  disorder, but in particularly for the increase in   psychosocial functioning, is much better for  those who undergo outpatient treatment only. And the last slide is really a slide  dedicated to the topic of stigma of   borderline personality disorder. And yes, of  course, the diagnosis is still stigmatised,   and we will later, with our peer  that I’m going to talk to, again,   also discuss about the stigma of BPD and how  it is to live with the stigma of borderline   personality disorder. But I also want to – want  you to think about is it really the right way to   deal with stigma by not just saying the  word ‘borderline personality disorder’? It’s a little bit like in Harry Potter, where  nobody, in the first few books, is allowed   and is brave enough to say the name Voldemort.  And does that make Voldemort less threatening,   is the question? My opinion is it does not make  borderline personality disorder less threatening   if we consider it to be the diagnosis that  dare not speak its name. And I’m pretty   much advocating for detecting, diagnosing and  also, treating borderline personality disorder   as early as we are able to identify and treat  it properly, because I think that this will   graduately [means gradually] and remarkably  improve the outcomes of our young patients. Borderline personality disorder, indeed,  is a severe and valid mental disorder in   adolescents that is clearly distinguishable from  puberty and also from other mental disorders,   including self-harm. Early intervention  of borderline personality disorder,   because it has the best outcomes when it’s  disorder-specific, clearly requires early   detection. And early intervention of borderline  personality disorder is effective across   all ages during adolescence, but manifests  probably differently in younger individuals,   mostly by counteracting the normative  rise of borderline personality pathology. Most importantly, early intervention  has the potential to improve patients’   life and trajectories of psychosocial  functioning and that’s a real gain for   these young individuals, you will  certainly agree. And to date – and   that’s also important to realise is that  there’s no evidence of any pharmacological   treatment of borderline personality disorder,  neither in adults, nor in adolescents. So,   the treatment type of choice is psychotherapy.  And outpatient treatment should be the gold   standard treatment for adolescents  with borderline personality disorder. So, research is something that you  usually do not on your own. I have   many co-workers to thank and many collaborators  and mentors and I all wish to acknowledge them,   and I wish to thank you very much  for your attentions. Thank you.