Borderline Personality Disorder in Young People: Are We There Yet? Andrew M. Chanen Orygen, the National Centre of Excellence in Youth Mental Health Although borderline personality disorder (BPD) usually has its onset in young people, its diagnosis and treatment is often delayed. The past 2 decades have seen a rapid increase in evidence establishing that BPD can be diagnosed before 18 years of age and that BPD in young people is both continuous with BPD in adults and more notable for its similarities than for any differences. This knowledge has led to the first wave of controlled treatment trials, which have established that early intervention through appropriate BPD diagnosis and treatment leads to clinically meaningful improvements for patients. However, there is still much work to do in terms of treatment development and innovation and overcoming challenges to successful translation of evidence into practice. To advance early intervention for BPD, access to evidence-based treatments needs to improve, the variety of available treatments (including novel pharmacotherapies) needs to increase, treatments need to be matched to individual development and to the phase and stage of disorder, and workforce development strategies need to update knowledge, C 2015 Wiley Periodicals, Inc. J. Clin. Psychol.: culture, and practice in relation to BPD in young people.  In Session 71:778–791, 2015. Keywords: borderline personality disorder; treatment; prevention; early intervention; adolescent

The past two decades have seen the development of a broad, evidence-based consensus that borderline personality disorder (BPD) is both a reliable and valid diagnosis and a severe but treatable mental disorder. In fact, BPD is among the most common problems seen in psychiatric practice, affecting one in five psychiatric outpatients (Zimmerman, Chelminski, & Young, 2008). Although BPD usually has its onset in the period between puberty and emerging adulthood (young people), diagnosis is often delayed and specific treatment is rarely offered at this early stage. Commonly, clinicians and services avoid offering treatment until pressured to do so, when they can no longer ignore the patient’s pleas or behavior or the remonstrations of others that something must be done. When treatment is finally offered, it typically occurs late in the course of the disorder, when functional impairment and iatrogenic complications are already entrenched, limiting the effectiveness of treatment, especially upon functional outcomes (Bateman, Gunderson, & Mulder, 2015; Gunderson et al., 2011). In this article, I briefly highlight some key clinical advances in the early detection and treatment of BPD in young people. I then discuss implications of these advances for current clinical practice and some key challenges for future clinical care, clinical research, and research translation in this age group. Some of these issues are also relevant to BPD among all age groups.

Early Diagnosis of BPD in Young People The past two decades have also seen a rapid increase in evidence establishing that personality pathology is a common and important form of psychopathology among young people, and that personality disorder (PD) diagnoses can be made before 18 years of age (Newton-Howes, Clark, & Chanen, 2015). This is especially so with regard to BPD, where numerous reviews (e.g., Chanen, Jovev, McCutcheon, Jackson, & McGorry, 2008; Kaess, Brunner, & Chanen, 2014; Miller, I thank Drs. Katherine Thompson, Jennifer Betts, and Louise McCutcheon and Professors Eoin Killackey and Henry Jackson for comments on parts of this manuscript. Please address correspondence to: Professor Andrew M. Chanen, Orygen, the National Centre of Excellence in Youth Mental Health, Locked Bag 10, Parkville, Victoria, Australia 3052. E-mail: [email protected]  C 2015 Wiley Periodicals, Inc. JOURNAL OF CLINICAL PSYCHOLOGY: IN SESSION, Vol. 71(8), 778–791 (2015) Published online in Wiley Online Library (wileyonlinelibrary.com/journal/jclp). DOI: 10.1002/jclp.22205

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Muehlenkamp, & Jacobson, 2008) have concluded that BPD in young people is both continuous with BPD in adults and more notable for its similarities in terms of phenomenology, structure, stability, validity, and morbidity than for any differences. This knowledge has sanctioned the diagnosis of BPD in young people and this has now been integrated into national guidelines for the management of BPD (National Collaborating Centre for Mental Health, 2009; National Health and Medical Research Council, 2012), Section III of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5; American Psychiatric Association [APA], 2013), and will likely enter the International Classification of Diseases 11 (Tyrer, Reed, & Crawford, 2015). I highlight three important corollaries of this evidence below, regarding diagnostic labels, differential diagnosis, and early intervention.

Evidence-Based Treatments The past decade has seen the publication of the first wave of randomized controlled trials (RCTs) for BPD in adolescents (Chanen & Thompson, 2014), comprising four psychosocial treatments and one pharmacotherapy. These studies have challenged fears about diagnosing and treating personality disorder in young people by establishing that appropriate diagnosis and treatment lead to clinically meaningful improvements for patients. I briefly discuss their implications here. Cognitive analytic therapy (CAT) is a time-limited, integrated therapy that uses an object relations informed approach to cognitive therapy. The Helping Young People Early (HYPE) program (Chanen, McCutcheon, et al., 2009) in Australia compared the effectiveness of adding up to 24 sessions of CAT or manualized good clinical care (GCC) to the comprehensive HYPE service model of care in 15–18-year-old outpatients with two or more DSM-IV BPD criteria. At 24 months, there was no significant difference between the outcomes of the treatment groups on the prechosen measures but patients allocated to CAT improved more rapidly (Chanen, Jackson, et al., 2008). In a subsequent quasi-experimental study comparing the effectiveness of the two treatment groups in this RCT with historical treatment as usual (TAU; Chanen, Jackson, et al., 2009), both HYPE treatments were more effective than TAU, with HYPE plus CAT being the most effective. A second pilot RCT (Gleeson et al., 2012) investigated the safety and feasibility of HYPE plus specialist first-episode psychosis (FEP) treatment versus FEP treatment alone for patients with FEP and BPD features (ࣙ4 DSM-IV criteria). Specialist FEP treatment HYPE was an acceptable and safe treatment and showed an encouraging pattern of improvement on outcome measures for the combined treatment group. Emotion regulation training (ERT) is a 17-session, adjunctive, group-based skills training and individual and family psychoeducation program that is based upon Systems Training for Emotional Predictability and Problem Solving (STEPPS) for adult BPD (Blum et al., 2008). Two RCTs have been published comparing ERT plus TAU with TAU alone in 14–19-year-olds. The first included individuals with ࣙ2 DSM-IV BPD criteria (Schuppert et al., 2009) and the second included individuals with ࣙ3 DSM-IV BPD criteria (Schuppert et al., 2012). TAU was not manualized. Posttreatment there was a significant reduction in BPD features in both treatment groups but no significant difference in improvement between groups. Mentalization-based treatment for adolescents (MBT-A) is a psychodynamic psychotherapy with its origins in attachment theory and is delivered as a year-long program involving weekly individual MBT sessions and monthly mentalization-based family therapy. An RCT comparing MBT-A with nonmanualized TAU for 12–17-year-olds with self-harm and comorbid depression (73% with BPD) reported significant reductions in self-harm and risk-taking behavior, with MBT-A being more effective than TAU in reducing self-harm and depression (Rossouw & Fonagy, 2012). This superiority was explained by improved mentalization and reduced attachment avoidance and reflected improvement in BPD features. Dialectical behavior therapy for adolescents (DBT-A) synthesizes behavior therapy with mindfulness-based strategies to target the emotional dysregulation, distress tolerance, and interpersonal problems in BPD. It is delivered over 19 weeks and comprises weekly individual therapy, weekly multifamily skills training, family therapy sessions, and telephone coaching. An RCT

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comparing DBT-A with nonmanualized enhanced usual care (EUC) for 12–18-year-olds with a history of nonsuicidal self-injury (NSSI) and two or more BPD criteria found that DBT-A was superior to EUC in reducing self-harm, suicidal ideation, and depressive symptoms (Mehlum et al., 2014). The only randomized controlled pharmacotherapy trial for BPD in adolescents is a post hoc subgroup analysis of a double-blind, randomized controlled trial of long-chain omega-3 polyunsaturated fatty acids (PUFAs; fish oil) for youth who met ultra high-risk criteria for psychosis (Amminger et al., 2013). Nonpsychotic individuals with BPD (mean age 16.2 years, standard deviation = 2.1) were randomized to receive 12 weeks of either 1.2 g/day omega-3 PUFAs or placebo. At baseline, erythrocyte omega-3 PUFA levels correlated positively with psychosocial functioning and negatively with psychopathology. By the end of the intervention, omega-3 PUFAs significantly improved functioning and reduced psychiatric symptoms, including a proxy measure of BPD pathology (suspiciousness, tension, poor impulse control), compared with placebo. The magnitude of group differences was large (d = 0.91–1.59). Side effects did not differ between the treatment groups. In interpreting these studies, it is important to note wide variation among the comparison treatments. It cannot be assumed that TAU or EUC means the same thing or has the same effect across all studies and in all of these studies, TAU and EUC were neither manualized nor checked for treatment integrity. The choice of control intervention is likely to lead to different effect size estimates. Moreover, there is evidence that TAU might act as a “nocebo,” whereby potentially harmful effects arise from a placebo (Chanen & Thompson, 2014). In addition, it is difficult to know whether the patient samples in these studies are comparable. Not all treatment with young people is “early intervention” (see below) and it is possible that participants were enrolled at different phases of illness (first-presentation patients through to those with enduring disorder). A key point of difference among the studies is that the HYPE/CAT and ERT studies were primarily focused upon early intervention for BPD, whereas the MBT-A and DBT-A studies were primarily focused upon suicidal and self-harming behavior. Another key issue is the unacceptably low consent rates and high dropout rates for all interventions. Even among the best performing studies, more patients decline to consent or cannot participate in treatment than enroll in the RCTs, and one quarter to one half of participants do not complete the intervention. Nonetheless, overall, these studies suggest that psychosocial treatment is effective for adolescents with BPD features or full-syndrome BPD. All interventions, including TAU and EUC, resulted in improvement on the primary outcomes. However, the structured interventions (CAT, GCC, MBT-A, DBT-A) appear to outperform TAU or EUC. HYPE, MBT-A, and DBT-A are systematized interventions with individual and family components, and these might be necessary elements for superior treatment outcome. Chanen and colleagues have outlined some of the common features of structured early intervention for BPD (Chanen & McCutcheon, 2013) and these might be applicable to a variety of treatments and clinical settings (see Figure 1). The role that specific interventions or “brands” of psychotherapy might play in treatment for young people with BPD remains unclear. This issue is not unique to treatments for young people with BPD (or even to BPD for that matter). In the treatment literature for adults with BPD, various specialist treatments seem to have similar effects despite distinct theories and interventions (Bateman et al., 2015). Importantly, structured, generalist interventions (similar to GCC for young people) perform almost as well as these highly specialized treatments. These findings among RCTs for adolescents and adults with BPD also raise the provocative idea that individual psychotherapy might not be the sine qua non of treatment for BPD. Although the above pilot study suggests that long-chain omega-3 PUFAs should be investigated as a feasible treatment strategy, overall, there is an absence of evidence for pharmacotherapeutic intervention for young people with BPD, including RCTs of treatments for common mental state problems, such as depression, anxiety, or psychotic symptoms among young people with BPD. Given the limited evidence base for pharmacotherapy for BPD in adults (Stoffers & Lieb, 2015), pharmacotherapy cannot be recommended as a primary treatment for young people with BPD. Moreover, polypharmacy, metabolic complications, and intentional overdose using prescribed medication are common clinical risks among this patient group.

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Figure 1. Key elements of a team-based, integrated early intervention for BPD (Chanen & McCutcheon, 2013).

Clinical and Research Challenges Overall, these data represent “proof of concept” that early detection and psychosocial early intervention and standard treatment (as defined by the Institute of Medicine framework (Mrazek & Haggerty, 1994) for BPD in young people is effective in reducing psychopathology and deliberate self-harm and improving global functioning. There is still much work to do in terms of treatment development and innovation and there are significant challenges to successful translation of this evidence into practice. Below I outline some of these key clinical challenges.

BPD is a Unitary Construct Across the Life Course Not only can BPD be reliably and validly diagnosed prior to age 18 years but also terms such as “adolescent BPD” or “emerging BPD” are misleading and are best avoided because they can imply discontinuity with BPD as it is seen in older patients. BPD is now understood to be a unitary construct across the life course, with a rise in pathology in the pubertal period that subsequently wanes from early adulthood onwards, partly due to maturational or socialization processes (Chanen & McCutcheon, 2013). There is nothing developmentally special about the age of 18 years with regard to BPD and no point of rarity with BPD in adults. Nonetheless, recent surveys among Dutch psychologists and British child psychiatrists highlight persisting reluctance and even outright hostility to the diagnosis of BPD among adolescents (Griffiths, 2011; Laurenssen, Hutsebaut, Feenstra, Van Busschbach, & Luyten, 2013). Reasons cited in defense of this include the mistaken beliefs that personality pathology is transient or normative among young people, or that the diagnosis is not allowed in adolescence. While these concerns can be assuaged by evidence, concern that the diagnosis is stigmatizing is supported by evidence and stigma remains a key barrier to the widespread acceptance of the BPD diagnosis in young people (Chanen & McCutcheon, 2013). However, above and beyond the general stigma associated with mental disorder, the most negative beliefs and attitudes about BPD tend to occur among our clinical peers. Delaying the diagnosis of BPD because of fear of stigma risks colluding with the ignorance, prejudice, and discrimination that nourishes stigma (Thornicroft, Rose, Kassam, & Sartorius, 2007). The evidence now supports challenging such forms of bigotry among the health workforce in the name of timely access to evidence-based care. Delaying the diagnosis and treatment of BPD is

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not a trivial matter, as evidence is accumulating that many of the harms associated with BPD emerge early in the course of the disorder and delay is likely to lead to worse outcomes. This will be discussed below.

BPD is a Legitimate Differential Diagnosis of Many Common Disorders Encountered in Young People Although personality pathology can be identified in young people, there are also other precursor signs and symptoms that are prospectively associated with BPD in young people (Chanen & McCutcheon, 2013). These include the disruptive behavior and disturbances in attention and emotional regulation typically found in childhood or adolescent conduct disorder, oppositional defiant disorder (ODD), attention deficit hyperactivity disorder (ADHD), substance use disorder, nonsuicidal self-injury (NSSI), anxiety, and depression (Chanen & Kaess, 2012). The robustness of the relationship between these disorders and BPD suggests that similar or identical phenomena are perhaps misleadingly characterized as mental state pathology in children and later relabeled as personality pathology in adult life (Chanen & Kaess, 2012). For prevention and early intervention for BPD, it would be beneficial to recognize that many aspects of these childhood or adolescent psychopathologies are actually trait-like, such as impulsivity, affective instability, or hyperaggression (Moffitt et al., 2008). For example, impulsivity in ADHD and substance use, NSSI, and ODD might be relabeled as the BPD features of impulsivity, self-harm, and inappropriate anger, respectively. Therefore, borderline personality pathology should be considered among the differential diagnoses in youth presenting with these common disorders, especially when there are multiple “comorbidities.”

Not All Treatment That Occurs Among Young People is “Early Intervention” The influential Institute of Medicine report on the prevention of mental disorders (Mrazek & Haggerty, 1994) set out a framework for prevention and early intervention for mental disorders and this has been applied to BPD (Chanen & McCutcheon, 2013). In this framework, early intervention denotes treatment of subthreshold disorder or treatment shortly after reaching diagnostic threshold for a disorder. It is quite possible (and not uncommon in specialist services) for individuals younger than 18 years of age to present with a clinical picture of enduring illness, including chronic deliberate self-harm, that is identical to that found in BPD among adult populations. The significance of this is that treatments need to be matched to the phase of the disorder, not just the chronological age or developmental stage of the individual. This will be discussed in detail below.

Improving the Effectiveness of Treatments Overall, the improvements arising from the current wave of treatments are modest. Persisting psychopathology and functional impairments remain clinically problematic. One way to improve effectiveness might be for treatments to focus more directly upon practical outcomes that matter to patients (Katsakou et al., 2012), such as functioning, distressing symptoms, and premature mortality due to physical ill health, substance use, and suicide.

Functioning Changing the focus of treatment for BPD from symptoms and behaviors to functioning is a priority that patients have identified (Katsakou et al., 2012). Severe and persistent functional disability is an underrecognized and devastating hallmark of BPD (Gunderson et al., 2011) and should arguably be the primary outcome for all RCTs of treatments for BPD. Vocational impairment is present early in the course of BPD and BPD prospectively predicts poor vocational outcome. Higher levels of BPD features at age 14 predict lower academic and occupational attainment and greater reliance on welfare benefits 20 years later (Winograd, Cohen, & Chen, 2008). Among 15- to 34-year-olds, BPD is the fourth leading cause of

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disability-adjusted life years (DALYs) in females and the sixth leading cause in males (The Public Health Group, 2005). Most costs attributable to BPD are due to work-related disability. International studies indicate that the majority of the high costs attributable to BPD are due to indirect costs, chiefly work-related disability (Salvador-Carulla et al., 2014; van Asselt, Dirksen, Arntz, & Severens, 2007), with even the lowest estimate indicating that 25% of the total societal cost of BPD is due to work disability (Wagner et al., 2014). Although early detection and intervention for BPD is effective in reducing psychopathology and deliberate self-harm, in common with other severe mental disorders, vocational recovery for people with BPD has not automatically followed symptomatic recovery. Completing education and training and transitioning into employment are defining and normative experiences for emerging adults in all industrialized societies. BPD can severely disrupt normal vocational development and transition into work (Chanen & McCutcheon, 2013; Newton-Howes et al., 2015), and individuals with BPD experience incomplete education, few qualifications, and disproportionately low levels of employment (Sansone & Sansone, 2012; Winograd et al., 2008), despite a strong desire to work (Katsakou et al., 2012). Unemployment in this group comes at a high economic and personal cost, and contributes significantly to their social marginalization (Scott et al., 2013). It is known that, even among the general population, periods of unemployment while young have “scarring effects,” increasing the likelihood of future unemployment and this is even more pronounced in BPD (Winograd et al., 2008). The most effective early intervention would be to prevent the establishment of long-term vocational disability. However, improving vocational outcomes represents one of the major clinical and social challenges in BPD treatment. Among all PDs, BPD has the strongest association with lost days of role functioning (Jackson & Burgess, 2004). Compared with remitted BPD patients, nonremitted BPD patients are more likely to have quit or lost their jobs due to their impaired state of health (Frankenburg & Zanarini, 2004). Two population-based studies (Knudsen et al., 2012; Ostby et al., 2014) show that having any PD is strongly associated with receiving disability benefits (odds ratio (OR) = 4.69), more so than having either anxiety (OR = 2.3) or depression (OR = 1.3). After adjusting for co-occurring traits of other PDs, BPD traits have the strongest positive association with receiving disability benefits (OR = 1.63; Ostby et al., 2014). BPD also has additive negative effects with regard to unemployment. A recent psychological autopsy study (Pompili et al., 2014) found that unemployed people who had committed suicide (compared with living unemployed controls) were 22 times more likely to have a diagnosis of BPD, suggesting that unemployment and BPD might be a lethal combination. High impulsivity upon entry to the HYPE early intervention program is associated with poor 12-month vocational outcome (Sio, Chanen, Killackey, & Gleeson, 2011). Compared with patients with depression, significantly more BPD patients are disabled and significantly fewer are employed (Skodol et al., 2002). Moreover, when BPD co-occurs with mental disorders such as unipolar depression, patients are significantly more likely to have been persistently unemployed (Zimmerman, Martinez, Young, Chelminski, & Dalrymple, 2012). Compared with patients with no DSM-IV BPD criteria, patients with only one BPD criterion missed significantly more work due to psychiatric illness and had lower global functioning (Zimmerman, Chelminski, Young, Dalrymple, & Martinez, 2012). Compared with those with another or no PD, individuals with BPD also find employment more stressful and more difficult to cope with (Jovev & Jackson, 2006). Employment outcomes in BPD are poor. Although people with BPD want to work in the open labor market (Katsakou et al., 2012), a review of 11 longitudinal studies of employment outcomes in patients with BPD (Sansone & Sansone, 2012) over periods from 1 to 27 years found that approximately 45% of people with BPD remain unemployed at follow-up. In addition, among those who are employed, only a fraction appears to be genuinely self-supporting and 20% to 45% of patients with BPD were on disability benefits at follow-up. Ten-year longitudinal data (Zanarini, Jacoby, Frankenburg, Reich, & Fitzmaurice, 2009) show that BPD patients are three times more likely to be receiving social security disability benefits than patients with other PDs. Of the patients with BPD on such payments at baseline, 40% were able to get off disability benefits but 43% of these patients subsequently went back on benefits. Additionally, 39% of borderline patients who were not on disability benefits at baseline commenced benefits over

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this period. By 10-year follow-up, only 55% of BPD patients had worked or gone to school at least 50% of the last 2 years. These data suggest that, in the absence of targeted intervention, vocational impairment is a chronic and costly feature of BPD.

Distressing Symptoms Depressive symptoms are frequent and often persistent among young people with BPD (Chanen, Jovev, & Jackson, 2007). The DSM-5 includes suicidal ideation or attempts in the diagnostic criteria for both BPD and major depressive disorder (MDD) and this can contribute to diagnostic confusion in young patients with BPD (Chanen, Thompson, & Berk, in press). This subject has received comparatively little attention in young people, especially in clinical samples. It is possible that the nature of affective symptoms is different in young people with BPD than their adult counterparts. For example, girls with BPD appear to use aggression as a strategy to cope with the overwhelming experience of intense negative affect associated with stressful peer interactions (Banny, Tseng, Murray-Close, Pitula, & Crick, 2014). Nonetheless, among adults with BPD, symptoms relating to chronic dysphoria and abandonment are relatively stable compared with other BPD symptoms, taking over 8 to 10 years to remit (Zanarini et al., 2007). It has been suggested that the chronic nature of these symptoms and their resistance to change might lead to poor psychosocial adjustment in BPD. Although auditory verbal hallucinations (AVHs) occur in up to 50% of patients with BPD (Kingdon et al., 2010), they have been clinically contentious and often ignored by clinicians (Yee, Korner, McSwiggan, Meares, & Stevenson, 2005). Until recently, psychotic symptoms in BPD were believed to be brief, less severe, and qualitatively different from those in “true” psychotic disorders, such as schizophrenia (Slotema et al., 2012). However, recent empirical studies have demonstrated convincingly that AVHs in BPD and schizophrenia are phenomenologically indistinguishable (e.g., Kingdon et al., 2010; Slotema et al., 2012; Tschoeke, Steinert, Flammer, & Uhlmann, 2014), leading to confusion about whether or not these are psychotic experiences. This is especially important in young people, which is the age when both BPD and psychotic disorders have their onset. In both BPD and schizophrenia, AVHs are commonly longstanding (Slotema et al., 2012) and commence at a young age (16 years BPD; 20 years schizophrenia; Slotema et al., 2012; Tschoeke et al., 2014). Rather than being an epiphenomenon or factitious psychopathology that might be dismissed, AVHs appear to be an indicator of more severe BPD. In clinical practice, AVHs in BPD are also widely assumed to be unresponsive to treatment with antipsychotic medication (Barnow et al., 2010). However, no RCT has tested whether pharmacotherapeutic or psychological treatments for AVHs in schizophrenia are applicable to BPD, or what might be the neurobiological mechanism of action of such treatments. Paradoxically, despite very limited evidence (Bateman et al., 2015), second generation antipsychotic medications (SGAs) are prescribed frequently off label in over one third of individuals with BPD, and polypharmacy is common, with almost half of patients taking three or more psychotropic medications (Zanarini, Frankenburg, Hennen, & Silk, 2004). It is important to clarify whether AVHs in BPD respond to conventional treatment for psychotic disorders. Currently, clinical practice guidelines for BPD recommend against the use of antipsychotic medications as first-line treatment for BPD, which places them in direct conflict with clinical practice guidelines for psychotic disorders. The absence of evidence does not allow proper evaluation of the risk-benefit ratio associated with delaying or rejecting conventional pharmacotherapeutic treatment for AVHs, or exposing patients to metabolic and other adverse effects of SGAs, or advocating for various psychological treatments (Thomas et al., 2014). Evidence indicates that BPD patients experience AVHs as highly distressing and disabling and there is a risk of colluding with the “soft bigotry” of having low expectations for recovery for this patient group.

Physical Morbidity and Premature Mortality This is highly relevant to early intervention for BPD, as the seeds of morbidity and mortality are sown early in the course of BPD. However, the issue is rarely discussed and none of the first wave of interventions for BPD in young people has addressed this issue.

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People with PD who use mental health services (i.e., those with more severe PD/BPD) have a substantially reduced life expectancy, with men losing 17.7 years of life and women losing 18.7 years (Fok et al., 2012). Mortality among this group is four times that of the general population but this risk is increased 10-fold among younger people with PD. Possible mechanisms include suicide, homicide, substance use, and poor physical health. Of the individuals with BPD, 8% die by suicide and this occurs early in the course of the disorder (Pompili, Girardi, Ruberto, & Tatarelli, 2005), making it a central issue for early intervention. Individuals who are at high risk for PD are also independently at increased risk of poor general health (Fok, Hotopf, et al., 2014) and BPD is specifically associated with physical ill health (Frankenburg & Zanarini, 2004), including cardiovascular disease among younger adults, and arthritis and gastrointestinal conditions among all ages (Quirk et al., 2014). Alcohol and drug use, physical illness, and functional impairment, even at mild levels, are predictors of mortality in individuals with personality disorder (Fok, Stewart, Hayes, & Moran, 2014). Among young people with BPD, 55% are nicotine dependent by mean age of 16 years (Chanen et al., 2007), making this is the key phase of the disorder for intervention to prevent downstream morbidity and mortality.

Improving Access to Treatments Access to evidence-based treatments for BPD is poor internationally and is especially inadequate for young people with BPD (Chanen & McCutcheon, 2013). Patients with BPD are notoriously difficult to engage and retain in current psychosocial treatments, with high dropout rates (15%– 77%) reported even among specialist inpatient and outpatient treatment settings (De Panfilis et al., 2012). Dropout is positively associated with high impulsivity and pretreatment suicidal behavior (Barnicot, Katsakou, Marougka, & Priebe, 2011; De Panfilis et al., 2012), suggesting that those who have more acute or severe BPD might have even less access to treatment. The low consent and high dropout rates for all of the above RCTs suggest that, in reality, even help-seeking young people with BPD have little access to evidence-based treatments or clinical trials. Clinical experience suggests that this is often due to the severity of associated suicidal ideation and behavior, the chaotic nature of their lives, and the high level of commitment required to participate in psychosocial treatment. Current treatments appear to give insufficient recognition to the observation that the very nature of BPD militates against functional help seeking. Yet patients are often accused of being “unmotivated” or “difficult” if their functioning is too chaotic to attend office-based treatments or to fit in with strict institutional requirements. Future treatment systems will need to be more creatively designed around patients’ needs, rather than institutional constraints, or clinicians’ personal interests or theoretical orientation. Such treatments will have broader reach, catering to individuals’ current circumstances and current functional capacities. For example, integrating knowledge and treatment about BPD into schoolbased settings, youth support and child protection services, and alcohol and other drug services.

Increasing the Variety of Available Treatments We need to better understand what it is that patients and families actually want and need from services and to have them collaborate in the development of such services. To improve access to treatments, a range of treatment options need to be developed that do not rely so heavily on patients’ willingness to commit to relatively complex, skills-intensive, and often lengthy individual psychotherapy. Treatments also need to be proportionate to the problem at hand. Most people with BPD do not access specialist services for BPD and indeed, many young people with BPD are unlikely to need or want such complex or intensive interventions. The first wave of interventions for BPD in young people has already begun to recognize this. All are timelimited interventions, some significantly shorter than their adult BPD counterparts, ranging from 16 sessions to one year. Young people often do not want to commit to lengthy treatments and it is important not to set young people up for failure by routinely expecting commitment to long-term therapy at first presentation. However, at this stage, only the HYPE intervention

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(Chanen, McCutcheon, et al., 2009) has a deliberate focus on time-limited, intermittent treatment (including intermittent psychotherapy) as a desirable strategy for early intervention for BPD. A more sophisticated approach to this issue is to develop a clinical staging model for BPD (Chanen et al., in press; McGorry, 2010). (For a detailed description of this model, see Chanen et al., in press.) This cross-diagnostic approach integrates a range of risk syndromes, or warning signs for a variety of disorders, including BPD, combining traditional diagnostic categories and arbitrary age restrictions together, with a focus on the severity and persistence of symptoms, the need for care, and the proportionality of any intervention. This model outlines a response to each stage of disorder that is matched to the presenting clinical picture. Proposed interventions are simpler and more benign during early stages of disorder, increasing in intensity (and potential adverse effects) with disorder progression. In later stage disorder, the risk of more severe adverse effects becomes more justified when compared with the risk of not treating the disorder. This clinical staging model will necessarily evolve and become more sophisticated with evolving knowledge about developmental pathways for BPD and other disorders and with the development of novel interventions. It provides a starting point for both diagnosis and treatment development and a way of determining how to intervene early in the course of these disorders in young people.

Pharmacotherapies There is a paucity of useful pharmacotherapies that might be used independent of or as a complement to psychosocial treatment programs. The Cochrane group has identified 33 RCTs of pharmacotherapeutic interventions for adults with BPD (Stoffers & Lieb, 2015; Stoffers et al., 2010) as well as second-generation antipsychotics, mood stabilizers, and omega-3 PUFAs as promising agents. Other agents of interest that have yet to be formally tested in RCTs include those targeting N-methyl-D-aspartate signaling, and neuropeptides such as opioids and oxytocin (Bateman et al., 2015). Although the findings in relation to pharmacotherapy for BPD are less conclusive than for the similarly sized psychosocial intervention literature, prescribing rates for BPD are paradoxically high (78% of patients for more than 75% of the time over a 6-year period) and polypharmacy occurs in 37% of patients (Zanarini et al., 2004), perhaps reflecting clinical needs and pressures. Clinical experience suggests that this is also a problem for young people with BPD, although the exact rates are unclear. Moreover, the inadvertent or deliberate underdiagnosis of BPD in young people can lead to inappropriate prescribing. Research in pharmacotherapy for BPD is hampered by small trials of numerous agents and infrequent replication of findings (Lieb, Vollm, Rucker, Timmer, & Stoffers, 2010), making it essential to systematically investigate promising agents using robust and adequately powered study designs. This is especially so for agents with few side effects and low toxicity in overdose, such as omega-3 PUFAs, that might be suitable for use in young people with BPD. Young people with BPD have been a neglected group in pharmacotherapy research. Researchers have been reluctant to include this age group in pharmacotherapy trials or to conduct specific RCTs and few centers have the clinical research infrastructure to support such trials. Additionally, there has been no framework within which to judge the proper place of pharmacotherapy in the treatment of young people with BPD or how appropriate pharmacotherapy might be as a response to the problems presented by BPD in young people. The clinical staging approach allows evaluation of the severity and persistence of symptoms, the need for care, and the proportionality of such an intervention and it is hoped that this might foster a broad range of treatment research, including novel pharmacotherapies.

Workforce Development This key issue is not unique to BPD in young people or even to adults with BPD. However, it must be addressed with BPD in mind if any real change is to be achieved at the national and international scale required for successful early intervention for BPD. The workforce skills shortage is due to both an essential undersupply of mental health professionals and a desperate

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need to update knowledge, culture and practice in the mental health workforce in relation to BPD in young people. Addressing this latter issue would reduce the likelihood of iatrogenic harm to young people who might be given a diagnosis of BPD. This would also be enhanced by encouraging greater participation by consumers with BPD and their families in the selection and education of the clinical workforce and in the design and implementation of treatments. Workforce development strategies will also need to reduce the emphasis on “brand promotion” of complex, skills-intensive psychosocial intervention. Instead, less complex interventions, such as Good Clinical Care (Chanen, Jackson, et al., 2008; Chanen, McCutcheon, et al., 2009), need to be developed and implemented within stepped care models. In such models, the complex, skills-intensive psychosocial interventions would be reserved for those not responding to simpler interventions or for those with later stage disorder.

Conclusion: Are We There Yet? It is perhaps self-evident from this outline that although there has been much progress toward early intervention for BPD, there is still much to achieve. The majority of the gains of the past two decades in understanding BPD in young people have been in the domains of descriptive, psychopathological, neuroscientific, and experimental research. This has led to a clear rationale for early diagnosis of BPD and it is hoped that this knowledge will lessen the preoccupation of many clinicians (and some researchers) with particular age restrictions in relation to BPD, leading to the greater recognition of BPD as a unitary construct across the life course. There is comparatively less treatment research. This is often logistically and practically more difficult to undertake but is the principal means of improving the lives of those who live with BPD. Overall, the data thus far represent “proof of concept” of the effectiveness of early diagnosis and treatment for BPD. However, there is still confusion in the field about what constitutes early intervention and what is simply conventional treatment of people with BPD who happen to be younger than 18 years of age. More importantly, treatments for young people with BPD are underdeveloped and available only to the small number of help-seeking individuals who manage to jump various motivational hurdles and meet particular institutional requirements. Treatment development and innovation need to focus on improving access to evidence-based treatments, more directly addressing patients’ needs, and increasing the variety of available treatments, including the potentially controversial area of novel pharmacotherapies. Such controversies might be allayed by more precise matching of new treatments to individual development and to the phase and stage of disorder. Finally, perhaps the greatest challenge is to develop a workforce capable of delivering early intervention at the scale required by the prevalence of BPD. This will require relatively straightforward strategies to educate the workforce about new knowledge in relation to BPD in young people. What is less clear is how to change the deeply rooted culture of enmity toward people with BPD and clinical policies and practices that are at best unhelpful and at worst harmful toward young people with BPD.

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