Dr Marcelo Brañas Hello, everyone, it’s  a pleasure to speak with you today about   the importance of early intervention  for borderline personality disorder.   We will explore this topic by addressing  ten common myths held by Clinicians who   work with adolescents. I have no  conflicts of interest to declare. And as you can see in this chart, the amount of  research on BPD in youth has steadily increased   in the past decades, alongside books  and online resources for professionals,   patients and families, which has helped  increase awareness and education on the topic.   Nevertheless, we still see  many misconceptions about BPD,   especially in teens, among mental health and  other health professionals. Here are the ten   – are ten common myths about BPD that we  will – that will drive our discussion today. The first, and probably the most important myth,   since it has a direct impact on  indicating appropriate treatment,   is that BPD cannot be diagnosed in adolescents.  And current manuals and guidelines,   and actually previous ones, as well, are very  clear that BPD can be diagnosed in adolescents. In the DSM-5 only one personality disorder,  which is antisocial personality disorder,   can’t be diagnosed until 18-years-old.  For all the others, including BPD,   you can reliably diagnose it if its features  cause significant foc – functional impairment   and if they have been present for at least a year. In the new ICD version 11, also – it also  allows the diagnosis in this age range   and it states that “Personality disorders  manifests in similar ways in adolescents   and adults.” But you have to take into account,  of course, developmental typicalities. And it   also cautious that personality disorders is “not  typically diagnosed in pre-adolescent children.”  In line with that, the very recently  published 2024 APA Guidelines it state   there is a misconception that “BPD only occurs in  adults.” And in their review of the literature,   they included studies with participants aged 13  years and older and this is a common lower bound   for diagnosing BPD. And it’s also the minimum age  for inclusion we use in our outpatient programme. The second myth is that all teens are  somewhat borderline and therefore,   this would be a reason not to diagnose BPD  in adolescents. And this is also not accurate   for a series of factors. The prevalence of BPD in  adolescents is practically the same as in adults,   ranging from .9 to 3% in the community and as  – is the cause – and is the cause – as is the   same in adults. Which is, like, much higher,  as you can see here, in clinical populations,   ranging from 11 to 22% in outpatient  units and 33 to 50% in inpatient units. Also, in fact, there is a normative increase  in borderline symptoms during adolescence,   but for a significant subset of individuals,  as you can see here in the red line,   the symptoms persist into adulthood.  The symptoms that best predicts if BPD   diagnosis will persist are identity  disturbance, affective instability   and inappropriate and intense anger, which is  similar to what we found in adults. And also,   it is worth mentioning that usually, BPD also  remits in adults, as we will see in myth nine. The third myth is that adolescents are still  developing their personality, making them too   unstable to diagnose with BPD. Although it is  true that adolescence is a critical period of   identity formation, for the development of  interpersonal skills and autonomy, and this does   not impede the accurate diagnosis and subsequent  early intervention for BPD, as we will see.   As demonstrated in various research, the BPD  diagnosis in adolescents compared to adults   has similar structure phenomenology, aetiology,  rates of adverse childhood experiences, validity,   instability and internal consistency. And,  as in adults, the BPD should remit over time. One worry that precludes Clinicians from  diagnosing BPD in youth is that would be   a life sentence for their personality,  when this is not the case. The long-term   prognosis for the majority of individuals  is favourable for both teens and adults.   The BPD diagnosis in adolescents and young adults  demonstrates significant rank-order stability,   meaning that an individual’s relative severity  of BPD symptoms compared to their peers tend   to remain consistent over time, even if there are  fluctuations in symptoms at the individual level. And the fourth myth is that diagnosing an  adolescent with BPD is stigmatising. However,   as you will see, there is no evidence to  support this claim, as well. The main problem   is that BPD is still discriminated against by  healthcare professionals and some Researchers.   BPD has historically been interpreted negatively  and personali – and personally by professionals,   who often see symptoms such as uncontrolled  anger and swings between idealising and   devaluing and other people through a pejorative  lens, than – rather than a diagnostic one. So, fortunately, this can improve and research  shows that bias decreases and empathy increases   for Clinicians who receive education about BPD,  such as with GPM Workshops. There are guidelines   and recommendation for Researchers, Reviewers  and Editors, such as the one written by Masland   and colleagues. And in many recent scientific  meetings, such as the last ESSPD, for example,   in Europe, and during the design phase of  research, individuals with lived experience have   been included. Improving the stigma among health  professionals, which can also lead to improvement   in stig – in self-stigma by patients, through  proper psychoeducation, which is an essential   part of the treatment. Additionally, patients can  benefit from peer support groups and BPD literacy,   such as those that you can find in  Emotions Mater and BorderlinerNotes. So, disclosing the diagnosis facilitates  the therapeutic alliance and hope,   decreasing stigma, blame, alienation  and anger, providing relief to patients   and family. And there is no evidence that  adolescents have a negative experience of   the diagnosis disclosure when delivered  in the context of offering treatment. Moving on, another myth is that BPD  is much more prevalent in females,   and although many studies find a preponderance  of females in clinical settings, that is not   the case in the community. Data from, for  example, the National Epidemiological Survey   on Alcohol and Related Conditions show a very  similar prevalence of BPD in females and males,   of three and 2.4% respectively. And data from the  National Comorbidity Survey Replication did not   find a difference in the prevalence for males  and females. So, if both genders use similar   rates of mental health services, the difference  in the prevalence in clinical settings may be   due to various reasons, such as bias in how the  symptoms are interpreted in males and females,   their different presentations, comorbidities  and what is prioritised in their treatment. For example, men with BPD have higher  rates of substance abuse and anti-social   personality disorder, also more intense and  inappropriate anger and impulsivity and more   impulsive behaviours and outbursts of anger. While  women tend to present more with mood, anxiety,   eating disorders and somatoform disorders. Also,  display more chronic feelings of emptiness,   affective instability, suicidality and  self-harm, higher degrees of affective   instability, identity disturbance, chronic  feelings of empathy and unstable relationships.   And we know that males use more drug  and alcohol rehabilitation services,   while females receive more psychotherapeutic and  psycho – sorry, pharmacotherapy interventions. So, there are many problems that arise  from this. Like most trials used almost   exclusively white female samples. Much is less  know about BPD in the LGBTQ and gender minority   stress and we know that this can  be mistaken for BPD symptoms,   and also, feminised views of BPD may also  discourage men with BPD from seeking help. The sixth myth is that BPD is only caused by  adversity and trauma, which is actually an old   myth, but still prevalent with some Clinicians.  And in a great book about the role of sexual abuse   in the aetiology of BPD, Mary Zanarini wrote  this cautionary note that you can see here,   stating that “Childhood sexual abuse is being  suggested as the main aetiological factor in   many disorders common in women.” And of course, we  know that abuse is highly prevalent and associated   with serious psychopathology and consequences,  but psychiatric diagnosis are multifactor and we   have to be cautious of simple developmental views.  Also, Joel Paris also elaborated on this subject,   saying that “The idea that all cases  of BPD are associated with adversity   and trauma has influenced clinical thinking  and the relationship is far from consistent.” So, one adverse effects of this reductionist  view is that when parents read about BPD,   they may become apprehensive about trauma’s  role as a supposedly necessary causal factor.   Child abuse and neglect are indeed  important risk factors for BPD,   but there are neither necessary nor  sufficient for BPD to develop. For example,   there is a 46% rate of irritability with the  remaining variance explained by environmental   factors. And as we mentioned, the aetiology of  BPD is multifactorial. Besides maltreatment,   there are broader social factors, family factors,  parenting styles, other trauma, such as bullying,   child – and child factors related to cognitive  function, attachment and temperament, and also,   internalising and externalising disorders  that serve also as risk factors for BPD. And the relationship between child BPD symptoms  and parenting styles is reciprocal. There is   a bidirectional association, such as child BPD  symptoms predict harsh punishment by caregiver and   low warmth, and also, caregiver harsh punishment  and low warmth predict child BPD symptoms,   with child BPD symptoms being the stronger  predictor. And the BPD symptoms most strongly   associated with harsher parenting practors  – practice, sorry, are impulsivity, negative   affectivity and ODD and conduct disorder severity.  And caregiver psychopathology is associated with   more severe parenting behaviours, but does not  directly predict the trajectory of adolescents’   BPD symptoms. And it is important to highlight  that these findings do not justify inadequate   parenting, but underscore the reciprocal dynamics  within the parent-child relationship. While   exceptions exist, in most cases, both children  and parents are struggling and doing their best. And that seventh myth is that BPD is better  explained by the former Axis I disorders,   such as bipolar disorder,  depression, anxiety or ADHD.   And besides the BPD diagnosis being valid  and reliable, as already demonstrated,   it is useful since it accounts for a  substantial portion of these patients’   poor outcomes that cannot be explained solely by  internalising and externalising comorbidities. Here, you can see in the middle column, Model  B, after adjusting for other behavioural and   emotional problems, BPD still remains  a significant predictor of various poor   outcomes. And here in the same sample, you can  see again that subjects with higher borderline   symptoms had worse mental health, functional  outcomes and victimisation across the board. The eighth myth is that BPD and non-suicidal  self-injury are synonyms, and undoubtedly,   there – BPD represents a very considerable  proportion of individuals with NSSI,   but non-suicidal self-injury is also  present in adolescents with depression,   PTSD, anxiety and other internalising and  externalising disorders with or without BPD. Conversely, in adolescents – in adolescent  BPD samples, a larger majority report NSSI.   For example, here in this recent Danish  study, more than 90% of teens with BPD   reported NSSI. Most used more than one  method, such as cutting and burning,   and the majority experience a decrease  in self-harm when they reach adulthood. So, 70 to 95% of adolescents with BPD engage  in non-suicidal self-injury, most commonly to   decrease negative emotions, handle dissociative  experiences, self-punish – push – self-punishment,   such as to cope with feelings of guilt, shame  or anger directed at oneself. And although the   immediate intent of NSSI is not suicide,  it considerably increases the risk of it.   And in teens with BPD, interpersonal stressors  trigger self-harm. And here you can see a recent   network analysis of NSSI and BPD symptoms  that were interconnected via loneliness,   impulsivity, separation anxiety,  negative affect prior to self-harm,   and frequent thoughts about NSSIs. So,  we can see shared psychopathology here. And the nine myth is that BPD does not  improve over time, which is not the case,   neither in adolescents or in adults. In this  study by Dr Carla Sharp, for example, after 18   months post-discharge, as you can see here in the  plot, BPD features both reported by the child and   the parent decreased significantly, and this is  the same for adults. In ten years of follow-up,   more than 80% of subjects with BPD remit  and the chance of relapse is low, around 12%   in ten years. And here, it – we’re using another  sample, The McLean Study of Adult Development,   also show that more than 80% of  patients remitted after ten years,   and although the proportion of them who also  achieved good functional recover was lower. And the tenth and last myth is that there are  no effective treatments for BPD, which is also   untrue. There are several effective treatments  for BPD, both in adults and adolescents, as you   can see here in the table which was compiled  by Dr Sharp and colleagues. And treatments were   able to reduce BPD symptoms, depression,  suicide attempts, self-harm, ER visits,   hospitalisations, substance use, improved  quality of life, among many others. And so,   the authors recommended the integration of  evidence-based treatments into standard clinical   practice for adolescents, the development  for – of early intervention strategies,   and since – as we know the availability of  specialised treatment is scarce, the generalist   treatment incorporate high quality strategies  to treat BPD from evidence-based treatments. So, in summary, to – the research on treatments  for BPD in adolescents shows that early   intervention is feasible and effective. Intensive  and specialised Psychotherapists may be superior   in facilitating reduction of self-harm, but in  general, the overall improvement is comparable   to brief manualised generalist approaches focused  on BPD, which produce comparable and substantial   clinical improvement and are more scalable and  more available. And this is actually a seg into   our next lecture, in which we will offer  a brief overview of one of these structure   generalist approaches, named “Good Psychiatric  Management for Adolescents with BPD, the GPM-A. Here are the references, and thank  you very much for your attention and   see you in the next lecture. Thank you very much.