Management Of Borderline Personality Disorder Research Articles

A Narrative Systematic Review of the Effectiveness of Repetitive Transcranial Magnetic Stimulation (rTMS) in the Treatment and Management of Borderline Personality Disorder

Background: Borderline Personality Disorder (BPD) is a psychiatric condition that affects approximately 2% of the population worldwide. It can present many challenges and can therefore be difficult to treat successfully by mental health professionals. Aim: The aim of this systematic review was to detect whether repetitive Transcranial Magnetic Stimulation (rTMS) is an effective intervention for the management of BPD to the point where there would be a reduction of the BPD symptoms and challenging behaviour. Methods: A literature search was conducted systematically using the following databases: PROSPERO, PUBMED, GOOGLE SCHOLAR, WEB OF SCIENCE, COCHRANE LIBRARY, SCOPUS, EMBASE and CLINICALTRIALS.GOV. Included studies were primary research studies of adult patients with a diagnosis of BPD who received rTMS treatment. Results: Nine studies were identified which ranged from a case report to a randomised controlled trial (RCT). While rTMS improved certain symptoms of BPD patients, such as affective instability, impulsivity and outbursts of anger; overall, some results lacked statistical significance and, due to the lack of robust evidence, it is uncertain if rTMS is an effective intervention for BPD. Conclusions: rTMS treatment showed some promising results in reducing the severity of symptoms for a number of patients. Studies varied with regard to the location of the target stimulation site, including different prefrontal brain regions and the cerebellum, as well as other rTMS protocol characteristics. These methodological differences in the application of the intervention and their impact on BPD symptomatology need to be explored more systematically in future research. Higher quality studies with larger sample sizes are needed in order to assess further the effectiveness of rTMS interventions on BPD symptoms.

Gulf between research evidence and clinical reality in relation to prescribing in EUPD

There appears to be a gulf between the evidence generated from quantitative research and clinical practice in relation to prescribing of psychotropic medications (antipsychotics, sedatives, antidepressants and mood stabilisers) in the group of challenging patients who are diagnosed with EUPD (emotional unstable personality disorder). Javed, et al's qualitative research article captures clinicians’ views and experiences pertaining to prescribing medications for EUPD within the context of NICE guidelines. The findings suggest that clinicians not only consider medication during periods of crisis but also when there is sparse access to psychological services. The article highlighted that the relational aspect of prescribing is not considered in clinical guidelines. The recommendations are for developers of guidance to design effective interventions to guide practice; and develop future recommendations on the role of pharmacological interventions in the treatment of EUPD.1 Given the stance by NICE and other relevant guiding bodies across the continents that there is limited evidence for prescribing of psychotropic medications in EUPD, I am cautious about your attempts to influence changes in future clinical guidelines and policies. And the gulf between research findings (that there is limited evidence for prescribing psychotropic medications in EUPD) and clinical practice (where drug prescription and polypharmacy are commonly seen in the management of borderline personality disorder [BPD] and the ‘placebo effect of medications’ in BPD patients is considerable) will probably remain. The recent 2022 Cochrane evidence2 points to the same – that not much has changed since the last review in 2010. The review had 18 more trials than the 2010 review on the topic. It supports the continued understanding that no pharmacological therapy seems effective in specifically treating BPD pathology.3 In my article on prescribing in this complex group of patients, I highlighted that if the treating clinician and the patient jointly discuss the proposed benefit and harm from psychotropic medications, then this would hopefully lead to ethical prescribing in BPD.4 My article aimed to support improvement in one of the four core ethical principles, namely, nonmaleficence – non-harming or inflicting the least harm possible to reach a beneficial outcome. It could be beneficial to highlight to patients with BPD that many experts on BPD recommend psychological therapies as the first-line treatment, in line with the ethical principle of nonmaleficence. Training for all prescribing clinicians on judicious use of psychotropic medication in this patient group is advised. Medications are used as an adjunct to psychological therapy, rather than as primary therapy; and when medications are considered, they are prescribed for a time-limited period, for specific symptoms.4 User perspective highlights an urgent need to narrow the gap between research and what is done in policy and clinical practice. The author of this study reflected that the emergence of clinical guidelines has not resulted in optimal care for those with BPD. The suggested recommendations include early intervention, educating the workforce to improve their attitudes on ‘deep rooted beliefs and prejudices on BPD’, enhancing ‘clinician training’, awareness campaigns for BPD and developing more rigorous studies and analysis of processes.5

Antisocial traits and neuroticism as predictors of suicidal behaviour in borderline personality disorder: A retrospective study

IntroductionThe spectrum of suicidal behaviour (SB) is nuclear in the clinic and management of borderline personality disorder (BPD). The pathological personality traits of BPD intervene as risk factors for SB in confluence with other clinical and sociodemographic variables associated with BPD. The objective of this work is to evaluate the specific personality traits of BPD that are related to SB. MethodsA cross-sectional, observational and retrospective study was carried out on a sample of 134 patients diagnosed with BPD according to DSM-5 criteria. The Millon-II, Zuckerman–Kuhlman and Barrat questionnaires were used to assess different personality parameters. Variable comparisons were made using the χ2 test and the Student’s t-test. The association between variables was analysed using multivariate logistic regression. ResultsStatistically significant differences were observed between SB and related factors and the neuroticism-anxiety dimension in the Zuckerman–Kuhlman test. It is also significantly related to the phobic and antisocial subscale of the Millon-II. Impulsivity measured with the Zuckerman–Kuhlman and Barrat tests does not appear to be related to SB. ConclusionsThe results presented raise the role of phobic, antisocial and neuroticism traits as possible personality traits of BPD related to SB, suggesting an even greater importance within the relationship between BPD and SB than that of impulsivity. Looking to the future, longitudinal studies would increase the scientific evidence for the specified findings.

Epicardial adipose tissue and adrenal gland volume in patients with borderline personality disorder

Borderline personality disorder (BPD) is associated with an elevated mortality risk that is partially attributed to suicide, but few studies examined other possible causes of premature death. The present study compared epicardial adipose tissue (EAT) volume as a known early predictor of premature cardiovascular morbidity, cardiovascular risk indices, and adrenal gland volume (AGV) as an indicator for chronic hypothalamus-pituitary-adrenal (HPA) axis activation in females with borderline personality disorder (BPD), major depressive disorder (MDD) and in healthy individuals. Twenty-eight patients with BPD comorbid with MDD (BPD/MDD), 22 MDD patients and 26 healthy females (CTRL) of comparable age were included. EAT and AGV were assessed by magnetic resonance tomography; 10-year cardiovascular risk and diabetes risk were determined by PROCAM and FINDRISK score; metabolic syndrome was defined following National Cholesterol Education Adult Treatment Panel III R (NCEP/ATP III) criteria. MADRS was used to assess depression severity. After adjustment for age, body mass index (BMI), and physical activity, EAT and AGV were significantly increased in BPD/MDD compared to MDD and CTRL. EAT and AGV displayed a positive correlation. Finally, diabetes risk in BPD/MDD was elevated compared to CTRL and MDD. The present study highlights the increased cardiometabolic risk of BPD patients. We identify EAT accumulation as an early predictor and potential mediator of cardiovascular disease in BPD that appears to be driven at least in part by HPA axis dysregulation. Therefore, interventions that reduce EAT volume (i.e. exercise and diet) should be considered in the clinical management of BPD.

Application of Transference Focused Psychotherapy in Borderline Personality Disorders

Borderline Personality Disorder (BPD) is a condition that is currently commonly found in daily psychiatric practice, and causes serious psychiatric disorders because it has an impact on the emergence of various other comorbid psychiatric disorders. The management of BPD is a challenge, because it is quite difficult and complex. Psychotherapy is an effective first-line therapy for BPD. Transference Focused Psychotherapy (TFP) is psychodynamic based psychotherapy that is specifically designed for BPD and is considered effective based on the specific psychopathology of BPD, namely the lack of identity integration. TFP focuses on the relationship between patient and therapist in sessions which have the aim of facilitating better behavioral control and increasing reflection and influencing regulation so as to produce identity integration that leads to a more coherent identity, better regulatory abilities, less self-destructive behavior. forming a more balanced and constant relationship, and increasing overall functioning.Keywords : Borderline Personality Disorder, Psychodynamic Psychotherapy, Transference Focused Psychotherapy.

Persistent idiopathic facial pain associated with borderline personality disorder: a case report

IntroductionBorderline personality disorder may be associated with persistent facial pain since its relationship with different pain syndromes has been reported. Persistent idiopathic facial pain is commonly unilateral, pulsating, burning, or profound and challenging for clinicians. Therefore, excluding underlying organic causes by appropriate clinical investigation and complementary tests is essential to diagnose this disease.Objective This case report aimed to provide evidence of the relationship between idiopathic persistent facial pain and borderline personality disorder.Case report A 24-year-old woman reported severe pain in the left hemiface for ten months, three to six hours per day, five days per week. No abnormalities were found in dental and neurological assessments. A psychiatric evaluation was performed, and the patient met the criteria for borderline personality disorder. Pharmacological treatment consisted of daily lithium carbonate (900 mg) and venlafaxine (150 mg). Weekly sessions of cognitive-behavioral therapy with emotional regulation and tolerance to stress were performed. The patient was evaluated every 30 days and showed improved pain intensity and frequency over six months. Conclusion Proper management of borderline personality disorder can modify the evolution of persistent idiopathic facial pain when both pathologies are comorbidities.

Audit of pharmacological management of borderline personality disorder as per NICE clinical guidelines CG78

AimsTo audit the current practice of pharmacological management of Borderline Personality Disorder with NICE Clinical guideline [CG78]: Borderline personality disorder:Objectives:23 patient records were analysed in the last 18months with a diagnosis of EUPD to compare current practice against NICE clinical guidance. (2009)Standards:When prescribing 1)Use a single drug.2)Use the minimum effective dose.3)Agree with the person the target symptoms, monitoring arrangements and anticipated duration of treatment. Antipsychotic drugs should not be used for medium, long term treatment.Indication:4)Drug treatment should not be used specifically for borderline personality disorder or for the individual symptoms or behaviour associated. (Repeated self-harm, marked emotional instability, risk taking behaviour and transient psychotic symptoms).5)Short-term use of sedative medication may be considered cautiously as part of the overall treatment plan in a crisis. The duration of treatment should be no longer than 1 week.6)When considering drug treatment, provide the person with written material about the drug. This should include evidence for the drug's effectiveness in the treatment of borderline personality disorder and for any comorbid condition, and potential harm.Review:7)Review the effectiveness and tolerability of previous and current treatments.8)Discontinue ineffective treatments.BackgroundBorderline Personality Disorder is common in psychiatric settings with a reported prevalence of 20%.As per NICE Guidance (CG 78), no medications have been found effective for the longer term treatment of personality difficulties.This audit was carried out to review if patients were offered psychiatric reviews to discuss the medications they are using, the effectiveness of these, and any potential side effects.ResultGood practice compliance of 90-100% was noted where >90% compliance was seen in areas where the effectiveness and tolerability of current and previous medication was reviewed by the clinicians under Structured Clinical Management. Also was noted that antipsychotics were not used for medium to long term in patients with Borderline Personality Disorder in the cohort.The following areas were non-compliant with the NICE recommendations where a compliance <79% has been achieved.When prescribing, use a single drug (avoid polypharmacy), agree target symptoms, monitoring and duration, provide written information, discuss evidence for effectiveness in treatment of borderline personality disorder.Partial compliance was achieved (80-89%) with use of sedatives for less than 1 week and discontinuation of ineffective treatment.ConclusionDistribute key cards to clinicians.Provide written information to patients.Re-audit in 6 months.

Rasgos antisociales y neuroticismo como predictores de conducta suicida en trastorno límite de la personalidad: un estudio retrospectivo

IntroductionThe spectrum of suicidal behaviour (SB) is nuclear in the clinic and management of borderline personality disorder (BPD). The pathological personality traits of BPD intervene as risk factors for SB in confluence with other clinical and sociodemographic variables associated with BPD. The objective of this work is to evaluate the specific personality traits of BPD that are related to SB. MethodsA cross-sectional, observational and retrospective study was carried out on a sample of 134 patients diagnosed with BPD according to DSM-5 criteria. The Millon-II, Zuckerman-Kuhlman and Barrat questionnaires were used to assess different personality parameters. Variable comparisons were made using the χ2 test and the Student's t-test. The association between variables was analysed using multivariate logistic regression. ResultsStatistically significant differences were observed between SB and related factors and the neuroticism-anxiety dimension in the Zuckerman-Kuhlman test. It is also significantly related to the phobic and antisocial subscale of the Millon-II. Impulsivity measured with the Zuckerman-Kuhlman and Barrat tests does not appear to be related to SB. ConclusionsThe results presented raise the role of phobic, antisocial and neuroticism traits as possible personality traits of BPD related to SB, suggesting an even greater importance within the relationship between BPD and SB than that of impulsivity. Looking to the future, longitudinal studies would increase the scientific evidence for the specified findings.

Pharmacotherapy for borderline personality disorder: A review

IntroductionBorderline personality disorder (BPD) is characterized by instability of interpersonal relationships, self-image, and emotions, and by impulsivity. Although patients with BPD are misdiagnosed, some of them receive mental health treatment. Even if the first-line treatment of this disorder is psycotherapy, the patients with BPD may be highly symptomatic and are often prescribed multiple medications in a manner unsupported by evidence.ObjectivesThe aim of this study is to study the available evidence about the pharmacotherapy for borderline personality disorder.MethodsA review of the available literature about the management of borderline personality disorder and de pharmacotherapy for personality disorders was performed.ResultsFirst-line treatment of the personality disorders is psycotherapy. The treatment plan for BPD may include individual and group therapy, medication, self-education, specialized substance use disorder treatment, partial hospitalization, or brief hospitalization during times of crises. Medications are generaly used only as adjuncts to psychotherapy and the adjunctive use of symptom targeted medications has been found to be useful. There is limited information to guide pharmacotherapy; preliminary evidence limits the practice of polypharmacy. Sympton-domain focused medication treatment is recommeded by some guidelines: cognitive-perceptual symtoms (low-dose antipsychotic drugs), impulsive-behavioral dyscontrol (mood stabilizers), affective dysregulation (mood stabilizers and low-dose antipsychotic drugs) and self-harm (omega-3 fatty acids).ConclusionsBPD cause significant distress and impariment of social, occupational and role functioning. The first-line treatment for BPD is psychotherapy; however symptom-focused, medication treatment of BPD is generally considered to be an adjunct to psychotherapy. The data support the efficacy of low dose antipsychotic drugs and mood stabilizers.

What you see is not what you get: multiple states and dialogues in borderline presentations

The recently revised NICE guidelines on treatment and management of borderline personality disorder (BPD) (NICE, 2018) presents new evidence on psychological therapies being effective treatments for patients diagnosed with BPD. This article will describe some of the challenges we face as clinicians working with complex co-morbid presentations in a healthcare setting. It will briefly discuss the different modalities as suggested by NICE guidelines and expand on the implications of this guidance in relation to service development and constant restructuring, often acted out as an organisational procedure to avoid the harsh reality of limited resources within the NHS. The impact of this on patient care, organisational dynamics, the need for joined-up thinking, and contextual formulations will be discussed using case scenarios. Clinical examples will be used to highlight that pseudo hallucinations, core thoughts, self-to-self dialogues, which trigger "state shifts", can be understood and formulated using dialogic sequence analysis (Leiman, 1998) and concepts from cognitive analytic therapy (CAT). This article will offer some pointers as to how we as clinicians can build resilience, survive the powerful projections and countertransference reactions, recognise the importance of self-care, supervision, and personal therapy in order to be effective, minimise harm, and develop compassion for our patients.

White matter pathology in patients with borderline personality disorder: A review of controlled DTI studies.

Neuroimaging, especially diffusion tensor imaging (DTI), has emerged as a helpful tool in assessing and characterizing white matter (WM) integrity. The resultant early treatment from early diagnosis is crucial because treatment is often more efficacious. Borderline personality disorder (BPD) is a challenging disorder to diagnose and treat, and has been reported to have various neurobiologic abnormalities. We conducted a search of the literature to review WM pathology findings in BPD. A search was conducted to identify systematic reviews and meta-analyses published from January 2000 to September 2019 that assessed WM integrity in BPD. Four studies were included. One study demonstrated no difference in WM between BPD and healthy controls. Another study found decreased fractional anisotropy (FA) within the corpus callosum (CC) and orbitofrontal regions. A subsequent randomized controlled trial reported a decrease in FA within the fornix, CC, and right superior/anterior corona radiata with associated increase in radial diffusivity in the left anterior thalamic radiation. The fourth study found a decrease in the axial diffusivity within the cingulum, inferior longitudinal fasciculus, and inferior frontoccipital fasciculus. Our review concludes that BPD is associated with measurable WM pathology. Methods such as DTI might emerge as useful tools in the management of BPD. More controlled studies are needed to validate our conclusions.

Developments in diagnosis and treatment of people with borderline personality disorder.

Borderline personality disorder (BPD) attracts significant attention from clinicians and researchers alike. Despite increased recognition and willingness to diagnose BPD, most effective treatment approaches remain inaccessible to most. We consider recent developments in the diagnosis and treatment of BPD. A literature search of EMBASE and PsychINFO, using the search terms 'borderline personality disorder,' 'diagnosis' and 'treatment' for publications since October 2018, yielded over 300 articles and reviews. The literature highlights the increasing awareness of the diagnostic complexity of BPD as well as the emerging significance of 'common factors' and stepped care approaches for managing and treating the disorder. Clinical practice is evolving to embrace more holistic diagnostic approaches, generalist treatment frameworks and stepped-care models that can be tailored to fit individual needs and service resources. The new frontiers in this field include expansion of timely treatment options, improved knowledge regarding the expression and management of BPD in men, adolescents and the elderly, and bridging cultural divides to create a worldwide population approach.

Emergency psychiatric management of borderline personality disorder: Towards an articulation of modalities for personalised integrative care

Building on existing literature, the authors draw the landscape of psychiatric emergencies, and focus on borderline personality disorder, frequently encountered, and strongly linked to death by suicide. A review of knowledge in terms of diagnosis, prognosis, etiology, and treatment, as well as their own experiences, lead them to propose areas of progress that would secure the patient's care pathway. The evolution of society has led psychiatric emergency departments to play the role of a safety net and an entry point to the mental health system. Borderline personality disorder is one of the most common pathologies encountered in psychiatric emergencies. It represents a major concern, long characterized by an often dramatic evolution, and by the human and economic stress it generates. However, since the 1990s, knowledge of this disorder has been refined, and today there are various means of evaluation, good clinical practices and psychotherapeutic treatments, thanks to which significant and lasting improvement is possible. Recent studies highlight the crucial role of hospital caregivers, and the benefit of consolidating their skills by providing them with the knowledge and tools specific to this disorder. They also converge on the interest of setting up specific emergency treatment modalities, particularly highly structured, safe and empowering for the patient, in order to improve their effectiveness. The authors suggest that a case formulation model for persons with borderline personality disorder in emergency would make it possible to activate these two levers of progress, while improving collaboration between hospital and outpatient care. This would also address their main concern of optimizing the patient's therapeutic pathway and reinforcing adherence to treatment that could bring remission, and should be supported by data from empirical research.

Prescribing in borderline personality disorder – the clinical guidelines

Drug prescription and polypharmacy are commonly seen in the management of borderline personality disorder (BPD) in clinical practice, and the ‘placebo effect of medications’ in BPD patients is significant. However, it is to be noted that ‘no drug’ has a UK market authorisation or Food & Drug Administration approval in the USA for BPD. Here Dr Yadav reviews the guidelines.

Management of Borderline Personality Disorder

The management of borderline personality disorder (BPD) can be difficult, and specialized psychotherapy remains the core component of treatment with the most robust evidence. Dialectical-behavioral therapy and mentalization-based therapy are the most studied and commonly used among the specialized psychotherapy treatment options. Pharmacotherapy has more limited evidence and should be used primarily to address specific symptom alleviation. Inpatient hospitalization should be used cautiously to minimize unintended, unproductive consequences. Day hospital or intensive outpatient programs are good alternatives between hospitalization and routine outpatient visits for many patients. Because the rate of nonsuicidal self-injury is high among people with BPD, safety assessments by clinicians are an ongoing part of treatment and often involve family and loved ones. [ Psychiatr Ann . 2020;50(1):24–28.]

ASENAPINE: PHARMACOLOGICAL ASPECTS AND ROLE IN PSYCHIATRIC DISORDERS

Schizophrenia and bipolar disorders are serious psychiatric disorders with substantial health risks. Asenapine is a new second-generation antipsychotic, available as a sublingual tablet, approved in Europe for the treatment of moderate-to-severe manic episodes in adults, and in US for manic or mixed episodes of bipolar I disorder in adults and adolescents. In this review, we searched the available literature to appreciate the role of asenapine in the management of psychiatric conditions such as bipolar disorders and schizophrenia and describe its mechanism of action, efficacy and tolerability. Asenapine has demonstrated efficacy in the management of bipolar disorders and schizophrenia, while a possible role in the management of borderline personality disorder and agitation needs further research. Asenapine has favourable side effects profile and combining with other pharmacological treatment in post-traumatic stress disorder has shown promising results. Asenapine fulfils important requirements of efficacy and tolerability as an anti-psychotic. These findings should support psychiatrists and pharmacists in the care of their patients while on asenapine.

Borderline Personality Disorder (BPD): In the Midst of Vulnerability, Chaos, and Awe.

Borderline personality disorder (BPD) is a chronic psychiatric disorder characterized by pervasive affective instability, self-image disturbances, impulsivity, marked suicidality, and unstable interpersonal relationships as the core dimensions of psychopathology underlying the disorder. Across a wide range of situations, BPD causes significant impairments. Patients with BPD suffer considerable morbidity and mortality compared with other populations. Although BPD is more widely studied than any other personality disorder, it is not understood sufficiently. This paper briefly reviews the recent evidence on the prevalence, etiology, comorbidity, and treatment approaches of borderline personality disorder (BPD) by examining published studies, and aims to offer a more coherent framework for the understanding and management of borderline personality disorder.

Changes over the last 15 years in the psychopharmacological management of persons with borderline personality disorder.

To describe the pharmacological management of borderline personality disorder (BPD) in Spain from 2001 through 2016, the factors associated with prescriptions, and changes in pharmacotherapy over this time period. Retrospective, cross-sectional, observational study conducted in a sample of 457 patients with BPD consecutively admitted to a specialist BPD Program between January 2001 and November 2016. Data on sociodemographic and clinical variables, as well as pharmacological treatment upon the admission to the programme, were used to describe pharmacological prescriptions, the factors associated with these medications, and changes in prescription over the last 15 years. Most (88.4%) patients were on pharmacological treatment, with 53.8% of persons taking ≥3 medications. No significant changes in these percentages were observed over the study period. The use of tricyclic antidepressants and benzodiazepines decreased, while the use of atypical antipsychotics increased. Axis I comorbidity was the main factor associated with pharmacological treatment and polypharmacy. This study provides further evidence confirming the worldwide overuse of prescription medications for BPD and shows that there has been a shift in the prescription pattern in the last 15 years. These results suggest that real clinical practice only partially adheres to clinical treatment guidelines.

Letter: Prescribing and borderline personality disorder

Accurate diagnosis is fundamental to effective management of borderline personality disorder, but many patients remain undetected. The first-line management for borderline personality disorder is psychosocial treatment, not drugs. There are major prescribing hazards including polypharmacy, overdose and misuse. Drug treatment might be warranted for patients who have a co-occurring mental disorder such as major depression. If a drug is prescribed for borderline personality disorder, it should only be as an adjunct to psychosocial treatment. There should be clear and collaborative goals that are regularly reviewed with the patient. Use single drugs prescribed in limited quantities for a limited time. Stop drugs that are ineffective.

Inpatient management of borderline personality disorder at Helen Joseph Hospital, Johannesburg.

ObjectiveThe aim of this report was to establish a profile of patients with borderline personality disorder (BPD) admitted to the acute inpatient psychiatric assessment unit at the Helen Joseph Hospital, in Johannesburg, over the course of 1 year.MethodsA retrospective record review was conducted to investigate the prevalence, demographics, reasons for admission, treatment, length of stay and follow-up of a group of inpatients during 2010 with a diagnosis of BPD, based on DSM-IV-TR diagnostic criteria, allocated on discharge.ResultsConsidering evidence retrospectively, the quality of the BPD diagnosis allocated appeared adequate. Statistical analysis revealed findings mainly in keeping with other reports, for example, that patients with BPD are above-average users of resources who make significantly more use of emergency services and that they generally do not adhere well to their scheduled outpatient follow-up arrangements. The longer average length of inpatient stay of this group with BPD, however, exceeded the typically brief period generally recommended for acute inpatient containment and emergency intervention.ConclusionImplementation of targeted prevention and early intervention strategies, based on systematised programmes such as dialectical behavioural therapy and mentalisation based therapy, may be useful in addressing these problems experienced with integrating the in- and outpatient management of BPD.