[MUSIC PLAYING] We are the Association for Child and Adolescent Mental Health, or ACAMH for short. And this is ACAMH Learn. Hello, everyone. It's a pleasure to speak with you today about a structured, generalist approach to treating borderline personality disorder in adolescents, known as good psychiatric management for adolescents, the GPM-A. In our previous lecture, we explored the 10 myths surrounding the early diagnosis and intervention for BPD, discussing the rationale behind these myths and the supporting evidence. You can watch it on the ACAMH Learn platform as well. Today we will provide a brief overview of GPM-A, which is a treatment designed to empower mental health and healthcare professionals in general who are not specialised in personality disorders. GPM-A offers foundational knowledge and practical training in clinical management, equipping providers to treat this condition pragmatically, confidently, and competently. I have no conflicts of interest to declare. Let's begin with two statements. Patients with BPD should be able to assume that professionals who treat them have been trained to do so. And patients with BPD should also be able to assume that early detection and intervention are possible, and BPD treatment is not a last resort. Due to stigma surrounding the diagnosis, many health professionals, when possible, actively avoid treating BPD, which as you will see, is highly prevalent condition. But we know through research that when clinicians receive adequate training to treat BPD, bias decreases and empathy increases. The prevalence of BPD in adolescence is high and comparable to adults. It is between 1% and 3% in the community, 11% to 22% in outpatient units, and 33% to 49% in inpatient units. So early diagnosis and intervention are extremely important, since when care is delayed, the chances of negative outcomes are higher. And as we discussed in the previous lecture, a lot of myths around the BPD diagnosis in teens, such as the belief that it is not allowed before 18 years of age, while both DSM-5 and ICD-11 allow the diagnosis in adolescents when symptoms are present for at least a year. And in fact, since DSM-III, you can diagnose BPD in adolescents. And due to this high prevalence, it is unfeasible to refer all adolescents with BPD to clinicians specialising in personality disorders. So generalist and scalable approaches are necessary. So the top reasons for early intervention for BPD are that it occurs with other disorders that usually will not remit if BPD is not addressed. And BPD predicts continued self-injury and increased suicide risk. Also, BPD is associated with poorer relationships and a financial burden on families. And it predicts lower school related and adult occupational outcomes. And it is a misconception that it's not advisable to give patients and families the BPD diagnosis. BPD patients benefit from informed treatment that includes psychoeducation about the diagnosis. However, it's still many clinicians refrain from making or informing patients about the diagnosis. The past decades of research show that BPD diagnosis is a valid and reliable in adolescents, as it is in adults. And BPD traits are especially flexible and malleable in youth, and there are effective treatment interventions to it. Usually, clinicians consider only the BPD diagnosis for a subset of the most severe cases due to what is called the Berkson bias. Patients who are more severe tend to seek more treatment or stay in it longer. And clinicians, especially those who work in hospital settings, tend to see these patients more frequently and assume that all BPD patients are that severe. One of the rationales for early intervention is to begin appropriate treatment to intervene before adolescents or young adults reach this point. As we will see, we lower the threshold for early detection and to start treatment. The main objective of early intervention for BPD is to put the adolescent back on track for normal development. There is a normative increase in BPD symptoms during adolescence, with a peak around 14 years, and a decrease through by age 18. But for a subset of teens, the peak is higher, and BPD traits remain persistently high, fluctuating depending on life events. The goal with treatment is to reduce the gap from their peers and improve functioning. And you will see in a moment that the main strategies used to achieve that. From ages 9 to 28, average levels of BPD traits decrease by 59%. And they leave out from ages 28 to 38. And fortunately, since highly specialised treatments for BPD in adolescents is scarce, most trials show that structure and manualized treatments for BPD have comparable efficacy to specialised treatments. So what are the key takeaways of what we discussed so far? Early intervention for BPD is feasible and effective. Intensive and specialised treatments can be superior in facilitating self-harm reduction in trials, but it is unclear if the advantage persists over time. And overall brief, structured, and manualized generalist approaches produce comparable results to specialised treatments, leading to substantial improvement. And they are scalable. One of the largest randomised clinical trials for DBT, if not the largest, compare its efficacy to GPM in adults. And both GPM and DBT, which stands for dialectical behavioural therapy, were effective in decreasing hospitalisation, self-harm, and depressive symptoms. But GPM was superior for patients with more comorbidities. And when considering treatments for BPD that are cost effective and scalable within health systems or services, a stepped care model allows GPM-A and other generalist treatments to target most individuals with BPD while preserving, I'm sorry, while reserving specialised and intensive approaches require extensive training for patients who do not respond to well-conducted generalist approaches. And here are the basic GPM-A structure. It is once weekly with the team. Parent work is a vital component, which varies in frequency and form, depending on the age of the adolescent and other particularities of the case. Its duration depends on the progress. For example, in our outpatient unit at the University of Sao Paulo, we currently offer a minimum of six months of weekly sessions that can be extended to another six months, depending on the necessity and the progress. Adjunctive or split treatments are desirable when available. We will discuss that at the end of the lecture. And participation in schools teams, clubs, or other extracurricular activities is encouraged. And consultations and peer discussions are desirable as well. The GPM-A approach is eclectic and borrow from both psychodynamic and behavioural strategies, such as from dialectical behavioural therapy. We borrow homework assignments, focus on day-to-day life, and dialectical dilemmas, such as dependency and autonomy. From transference-focused psychotherapy, we borrow attention to anger and addressing devaluation of the clinician, others and the patient themselves, and the use of interpretation in the GPM-A in a more parsimonious way. And from mentalization-based treatment, we borrow the not knowing instance. We try to promote reflection and curiosity, and pay attention to attachment. The GPM-A menu is currently available in three languages English, Portuguese, and French, with more to come. And the main theoretical model of GPM-A, which guides many of its interventions, is the interpersonal hypersensitivity. Both in adults and youth with BPD, psychopathological decompensation or improvement usually follows interpersonal events. And this is even more pronounced in teens due to the particularities of this developmental stage, where they are dealing with learning how to navigate in the complex landscape of relationships. Here is the interpersonal hypersensitivity or also named BPD interpersonal coherence model. And we can see in the first balloon, when the patient is compensated in a connected state, you can miss the BPD diagnosis if you only look at the case cross-sectionally. The adolescent is idealising others, too dependent on the likes of few and others for their emotional well-being, and hyper vigilant to rejection. When the patient perceives interpersonal stress, such as separation and criticism, patients feel threatened, insecure, or disorganised, presenting disorganised or insecure attachment styles reactions, and the patient shifts to devaluating themselves and others. They can engage in self-injurious thoughts and behaviours and display intense anger, anxiety, and help-seeking behaviours. If they feel supported by others, they can return to the first stage of a connectedness. But if they feel further withdraw from others, they can decompensate even further and experience dissociation, paranoia, engaging even more desperate impulsive behaviours and reject help. We try to avoid these two more decompensated stages, because at this point, words can be ineffective. The teen has lost their mentalizing capacity. And we may have to refer them for hospitalisation or residential treatment. The clinical implications of the interpersonal hypersensitivity are that being connected explains phenomenology. Emotional or behavioural dyscontrol is secondary, and it's our job during sessions or appointments to proactively help the team connect symptoms to adverse interpersonal events, which at the beginning, due to dissociation or difficulty in perceiving and labelling emotions, can be difficult for them. Actions or inactions of important others will trigger apparently sudden, unexpected responses that reflect the oscillations in symptom stages. You can print, for example, the previously showed four bubble chart and explain it to them. In our experience, patients feel very understood and validated when we do that. And GPM-A is a principle-based approach, meaning there is no prescriptions for what we do in every possible situation, but general rules and strategies that guide the treatment. We will discuss briefly its eight principles. The first principle is to include the BPD diagnosis in routine clinical assessment. To begin treatment, we lower the threshold from five to three BPD criteria, since research shows that adolescents with 3 to 5 criteria have practically the same level of impairment, and teens with three or more criteria benefit from treatment. The second principle is psychoeducation for families, patients, schools, and peers. We inform the patient and their parents about what BPD is, what its multifactor causes are, its natural course, which is usually one of remission, and how the treatment works, emphasising how commitment to it will aid in functional recovery. We usually contact the patient's school to coordinate interventions when necessary. There are various online resources for families, such as the family guidelines available for free in six languages on the NEA BPD website. And there are also resources for clinicians, families and schools, for example, in the Anna Freud Institute website and Project Air. The third principle is be active, responsive, curious, and not reactive. Adolescents may require more help with tolerating difficult situations and emotions. And research shows that long and excessive silences are usually not welcomed by teens with BPD, and are counterproductive. The fourth principle is to focus on life situations. We know from longitudinal studies that the natural tendency of BPD is of remission, meaning symptomatic improvement. However, functional recovery rates are lower than remission rates. Therefore, we focus on being pragmatic in collaboratively problem solving with the team than on aiming for significant intrapsychic changes. We know that school non-attendance is linked to poor socioeconomic outcomes. So we put a lot of effort in coordinating with schools, families, and the adolescent on strategies to mitigate this. Additionally, teenagers in general, but especially teens with BPD, tend to focus a lot on romantic relationships, to the detriment of school and other extracurricular activities. And instead, this link BPD symptoms to having more dating partners, prioritising romantic relationships over other commitments, and experiencing higher levels of insecurity, intensity, and conflict in relationships. And teens with BPD are more likely to date than their peers without BPD. When they lack other sources of self-esteem, such as mastering daily activities or school work, this tendency, coupled with their interpersonal hypersensitivity, can considerably decompensate the clinical picture. Here are examples of what we pragmatically discuss during sessions, such as restructuring relationship with parents and siblings, working on health and appearance, making sense of free time, intimacy and sexuality, relationship with peers, and social media use. As you can see, we are very focused on the life of the adolescents in a pragmatical way. The fifth principle is that the therapeutic relationship is real, dyadic, and professional. So we use selective self-disclosure if and when it is appropriate, such as to normalise feelings, decrease shame, show that their behaviour affect us, and demonstrate that we care. For example, we might say, you scared me. That would make me angry. And in the manual, there is a detailed table explaining how self-disclosure is used. We also explain the professional side of the relationship and the value of limit setting. And limits should not be administered in an automatic procedure way, but with the adolescents in mind. And the sixth principle is that change is expected. A lack of change is an indicative of treatment failure, even more so in adolescents with BPD. And we don't want to prolong a treatment that is not working. Here are usual milestones that indicate progress in treatment. For example, for the majority of cases, after a month of weekly treatment, the patient's acute distress diminished. The patient is actively participating. And you like each other, which usually means you are understanding the case, and the patient is actively engaging in treatment. After 2 to 3 months, self-injury or risky behaviours decrease. The patient remembers and apply lessons learned during sessions, and your empathy and understanding of the case increase further. After 3 to 6 months, the patients resumes their social roles and activities, and the patient can relate behaviours to emotions and interpersonal events. And the patients trust you as a reliable, well-intentioned, caring clinician. And the seventh principle is accountability, which involves explaining and working with the patient to help them become active collaborators in treatment, and assuming control of their lives. We can say, for example, I will depend on you to tell me what kind of help you need, or your parents will not be needed to be so much involved when you show more reliability. And we construct with the team a personalised safety plan with strategies to identify a crisis, it's triggers, symptoms, and how to act and get help. It can be used, for example, for self-harm behaviours. And the eighth and last principle is family involvement, which is crucial, as we mentioned. And we use a hierarchy of family interventions, beginning with psychoeducation and incorporating other strategies if needed. Family therapy, when available, is reserved for patients and parents who can discuss conflicts without interruption or angry outburst, and it's usually not advisable in the early stages of treatment. And it's not necessary for every case. We can also construct a parent coping plan to help patients with how to act during crisis. And here is an example of it. Lastly, we will briefly discuss examples of multimodal treatments. When available, GPM-A is compatible with and encourages group treatment. Here are examples of BPD group types, such as self-assessment, DBT skills training, mentalizing, and interpersonal groups. And for example, there is even a published book on how to integrate GPM and DBT. Also, we encourage a lot participation in groups that occur naturally in school or as extracurricular activities, such as sports, drumming schools, bands and others. And finally, besides the GPM-A manual for adults, there are adaptations of GPM for various settings, including for comorbidities, such as alcohol use disorder. And for teens, there is an adaptation of how to treat BPD and eating disorders together. So if you are interested in having the full GPM-A workshop, or other GPM trainings, you can find information on the Gunderson Personality Disorders institute at Harvard Medical School website. Here's a link for that. And again, thank you very much for your attention. It was a pleasure. [MUSIC PLAYING]