BPD In Adolescence: Early Detection and Intervention - Blaise Aguirre, MD

thanks so much everybody for showing up today I have a seven-year-old who knows the work that I do and he asked the question dad where are you going I said I'm going to Atlanta to talk about BPD he says they have BPD in Atlanta so I think it's it's so wonderful to see the NEA be PD here I mean they've just done an absolutely wonderful job and such wonderful friends with Jim and Perry and Trish and and the halls and I really encourage people to join the NEA BPD I'm sorry I'm doing a plug there Terry but the I think you know it's a seven year old ask that question and I think it's true I mean the the public acknowledgment of this condition just isn't there and so tremendous credit to to any a BPD okay three East so there I was at MacLaine in 2000 seeing a lot of what I thought were borderline patients and said I think that we need to do a dedicated treatment unit because the kids that were coming in who I thought had BPD were coming in on polypharmacy so here they had these lovely young people now overweight and with acne talk about self-esteem problems trying to deal with the motion regulation and a lot of these medications weren't helping and I thought you know we have dedicated eating disorders units dedicated psychotic disorders units etc we need to have dedicated adolescent BPD units so I proposed this for about seven years to the administration and there were jokes like you know what do you get when you put two borderlines on a single unit you know those sorts of things that it was going to be chaos that security would have to move into our building that people would be tearing each other apart so they said all right you can have a unit we expect an average daily census of two for the first year and see how that goes this is our fourth year we've just opened up our 26th bed and I think that they're going to get filled up pretty quickly we've also got a partial program that has 12 beds dedicated to the treatment of adolescent BPD we've had more than 400 patients come through our units and that's just the the residential unit okay so to me the idea that we had to wait until 18 to make the diagnosis made very little sense to me at many levels and John Gunderson in private conversations has admitted to me that he and people who developed the idea of BPD with him are really to blame for for for this misconception and it you know the whenever I spoke to adult patients with borderline personality disorder they recognized that their symptoms started in in adolescence and maybe even earlier than that so so what did we have to do wait until they turned 18 so you know you've been diagnosed with bipolar disorder and major depression ADHD and you're get a phone call from your psychiatrist happy birthday you're 18 now let me tell you you're borderline and then when you speak to clinicians in the community and they talk about people who present with symptoms of BPD and you know trying to come up with some things it was borderline personalities oh no we can't do that makes no sense anybody's got more than one child knows that personality evolves in childhood I mean you get you know kids and they're very very different doesn't it almost doesn't matter how you raise them you know they've got their own little personalities and they continue to evolve and our personalities continue to evolve they get a little bit more fixed the older we get but nevertheless and then the other thing was that the DSM was very comfortable diagnosing other psychiatric conditions and early childhood and adolescence so why not personality disorders okay now interestingly John Gunderson actually referred me an 11-year old and I was very happy that he'd done it at many levels first of all that he was recognizing you know to start to pay attention much earlier on so this is a young woman whose father has a diagnosed major mood disorder and mother is emotionally reactive although I don't know meets criteria for for BPD and the parents fight a lot and so what this girl has discovered is that when they fight she cannot stand it and what she's discovered is is that if she takes her skin and twists it and what she calls a monkey pinched never heard that term before but anyway a monkey pinch that it helps her to regulate her mood and it helps her to to stop or distract from what's going on in the in the house also so this is really interesting stuff already this child eleven years old has discovered a way of regulating herself that involves this monkey pinching well you can see where this is going to go okay well maybe the monkey pinching doesn't help so much and are there other ways to self injure they're going to they're gonna help her now I would not make the diagnosis of borderline personality disorder in this eleven-year-old girl but what we're seeing is early indicators of something of patterns of behavior that if they continue will go on to become something much more problematic and this is just an amalgam of many of the young women that we treat on our unit so this is not a specific case but I've just taken pieces from various histories so 17-year old Maria multiple hospitalizations many other kids who come to our unit have had multiple hospitalizations generally depression suicidal ideation self-injury often these really bright girls and I hate getting into conversations with them because they'll I'll think me and out and we've got to stick with the emotion regulation stuff let's leave Descartes out of this human but the probably it can be quite captivating oh my god this is really interesting you know so but they have it's often quite bright but yet fell out of school she feels that she has very few friends and that others can't possibly like her she's traded sex for drugs and alcohol and multiple occasions feels that sex with boys is the only way to get them to like her and many to some to many of the relationships have been abusive she feels she deserves it she's a bad person and she deserves to be treated badly she acknowledges that drugs alcohol sex and self-injury helped to regulate how she feels in the moment she cannot stand being in herself a lot of the times a lot of self-loathing she feels intense shame and guilt about doing what she does to provide relief so she does these things to provide relief a lot of sex self-injury and drugs but then in moments of clarity sort of feels very ashamed that she's done these things feels more of these emotions and goes back and do does what she knows best she's remarkably attuned to nonverbal communication and you know so she's able to read you know those faces the angry face that Brian had had showed us and just very exactly I kind of saw it as angry too a little bit makes you think but but they're very attuned but the problem isn't the attunement so often it's there is that then the attribution it's okay you're angry and you're angry because or even that you're you're angry when you're not tunes all right now historically clinicians so BPD as an extreme form of adolescence and somebody asked me once what's the difference between adolescence and BPD I don't know no but I but there's okay so so I I imagined identical twin children who are doing exactly the same things and one is BPD and one isn't so how can you tell the difference so they're both having lots of sex they're both having using drugs they're both driving fast what's the difference and to me the key difference is the function of the behavior so you know typical adolescent goes yeah I'm going to try out some weed and do a line of coke and drive a car fast and but you know what life is going okay but for the borderline adolescent often those behaviors are done to regulate how they're feeling in the moment so I mean they can also do typical adolescent things but for them often the function of the behaviors to regulate how they feel in the moment John Gunderson talked about this yesterday actually I was in Grand Rounds and they said that the the transaction between a child and a parent actually goes both ways so one of the things that happens is yes you can have parenting where you know you're yelling at your kid and all of that sort of thing but that a child who is irritable and who is angry and who's just whining and crying all the time is going to elicit reactions in parents so that there's a transactional piece to this and it's about 50/50 or they say insanity is inherited you get it from your kids the the abet but that there's this transactional piece that a child there's that is difficult to placate it's just going to elicit bad parenting in quotation marks in you ineffective parenting at times so historically adolescents were seen as promiscuous and manipulative now I'm gonna make a provocative statement I don't allow the word manipulation on our unit now this is very antithetical to the thinking of many many people who work with with with borderline patients because they are quintessentially seen as manipulative but I want you to start thinking about what the word manipulative means if I do the same thing over and over again I get the same result and it continued to do those things it's just learnt classically learned behavior so if I go to mom and say mom can I have $10 no dad can I have $10 yes oh she just manipulated you got $10 out of you well I'm gonna continue doing that if that's the way that it goes now so what happens is that often behaviors just repeated and learned it's throughout nature that is not to say that manipulation doesn't occur but the effect of feeling manipulated doesn't mean that the intention is to manipulate I could be saying something to you and you could all say well we're feeling manipulated by what you're saying is that well okay that's the feeling that you're having my intention may be to manipulate so there's the intention to manipulate the effect of feeling manipulated the effect of not feeling manipulate and the effect of not intending to manipulate but often we throw out this word that that is exactly what the intention was was to manipulate so I want you to just rethink the idea of it and the other thing is this and Marsha and then Hannah has talked about it if they're so good at manipulation and why they end up in hospital all the time well they end up in treatment all the time very good if there are manipulators that terrible manipulators historically BPD was a condition that clinicians refused to treat and we had I mean we get referrals from clinician say or while you're referring the patient is the patient suicidal so why don't treat suicide which is really sad to hear in mental health when it's one of the most tragic outcomes of many psychiatric conditions so a lot of people not interested that much in BPD per se at least in the clinical aspects of BPD have done research on this in any case and they what they do is they they do questionnaires and community samples and so what we find is somewhere between 1 to 3% of community dwelling teenagers have BPD and on inpatient units that it rises up to about 50 percent of adolescents and 42% in young adults so now and we saw earlier data on 20% so it's it's a big number of inpatients that have comorbid BPD and it has implications for our mental health care dollars given how much is there so if you're only treating the mood disorder but leaving out the BPD and you get a lot of recidivism a lot of people coming back in we're missing something really important now I'm going to just talk about the criteria as we see it in adolescents now you need 7 now you need five out of nine criteria according to the current DSM and Ken will talk about the dsm-5 and stuff like that but up until 2013 you still need five out of nine criteria all right so frantic efforts to avoid real or imagined abandonment so what we see on our unit is that people who come in come in often after a break up with a friend a break up with a roommate fight with a parent somewhere where they feel that they're going to be left abandoned there's a profound sense that that person won't come back so what happens is in in some of these cases this is where I can feel manipulative so what happens is I I feel I'm afraid you're going to that you're gonna leave I'm feeling really suicidal and I'm I'm gonna make a suicide attempt or I make a suicide attempt I'm in the emergency room I can't believe you were gonna leave me the person on the other end feels terrible oh my god you know I didn't know that you felt so bad and then gets reconnected with the person and so what happens is that the person with BPD under that circumstance learns that oh if I express suicidality then I get a certain response again learnt behavior just classically learn behavior and so so the problem is that the well-intentioned caregiving of that sort of thing can can actually increase suicidality and we have protocols on our unit where if one of our patients gets hospitalized on the residential unit we tell a parents they cannot visit their kid in hospital now very killing me I've been visiting my kid in hospital a hundred times well how's that working for you you know so the point is is that hospital isn't a place where people are going to come and visit you and that we actually start to reinforce behavior that we we want and once we do that it happens once or twice they don't get hospitalized again from our unit unstable relationships just characterized by over idealization and devaluation so that there's this idea that you know at one minute you're the best parent in the world the most wonderful human being that ever existed just give it 10 minutes and it's often a reflection of all-or-nothing black-and-white thinking there's this idea and BPD of this idea of granularity so that for many people who don't have BPD is that they can begin to see the granularity the the detail the finer detail of think of a painting you know that you see all the subtle shades that for BPD it's it's very black and white switches very rapidly in a hospital units hospital staff divided into good staff and bad staff it's great when you're on the good side switches or now and I see what happens and often on units where this isn't paid attention to this idea of splitting and again that's another word that we don't use on our on our unit we don't talk about splitting and and you know so you're on the good and you're on the bad when I'm in the bad and I know what you mean and all this sort of stuff and you can get so much more infighting in the meantime the patient's suffering in the background and that these designations are often mood dependent so if I'm feeling good then you're a good person and if I'm feeling bad that you're not so good this unstable sense of self now the problem with adolescence is that adolescents is an unstable sense of self you know you're trying to define who you are so so if you start thinking about needing to meet five out of nine criteria using the unstable sense of self criterion and adolescence of very difficult thing so now you're down to eight criteria you have to meet five out of eight right here because adolescence is a time of changing ideas of changing your gender identity changing your your sexuality changing how you see the world your values and your morals and all of these sort of things so it's it it's a time of fluidity but what they describe more than anything else is this sort of sense of porousness it's a sense of very rapidly taking on the identity of other people other people's emotions very rapidly belonging to whatever the culture is much more so than than other kids you know that they seem to switch groups from one to another parents will say you know I don't know God she was goth last week and this week she's wearing pom-poms I mean you know I don't know something like this I recognize that other people have a better sense but they're still trying to struggle with it again it's not a criteria that's very easy to define an adolescence dangerous impulsivity now now the the DSM criteria talks about driving fast sex drugs and all of that stuff but when you're talking about 12 13 14 year old adolescents they don't have access to cars they don't have access to you know if they're doing drugs it's not hard cord some weed here and there not of not many of them are necessarily sexually active although we definitely see a lot of sexual activity even in the younger ones so the dangerous impulsivity if you're just saying okay well no it doesn't drive fast you know again you can lose that criterion but you see impulsivity in other areas you know they run away from home or they you know they will spend money that they don't have and and and and stuff like that and we also see in terms of a dangerous impulsivity that that we've had a whole spate of adolescents who have come in who are you know hooking up with with much older people recurrent suicidal behavior this is now I have to just say something I'm talking about you know obviously the unit that I work on is is people who've got who've made lots and lots of suicide attempts so this is not true of a broad group of patients with borderline personality disorder but nevertheless you know almost everybody comes on our unit self injures mostly through through cutting but you know we see punching breaking of bones and more lately we're seeing this phenomenon of what we call insertion so what happens is that they make these small little cuts in the skin and then put foreign objects under the skin and then self suture them up so it leaves the sort of festering wound is very very difficult to treat once they start doing these sorts of things it's a very specific form of self-injury most of the people have made suicide attempts and often by overdoses but we've had you know people who shot themselves people have made hanging attempts jumped in jumping in front of cars driving cars into polls and again that these behaviors can be reinforced by the loving attention of my god my poor child I'm so sorry I didn't realize that you were suffering and that that by not to say that we don't care but it's that that can be reinforcing okay so the affective instability they so sort of a hallmark is that they feel things quicker than others and with with apparently less provocation they feel things more intensely and there's longer to get to baseline now I tend to think of myself as someone like this to a certain extent you know so that I tend to feel things pretty deeply I consider myself quite sensitive and feel things more intensely the capacity that I have is to regulate that now if you if we can start moving away from constructs that call these behaviors manipulative and intentional and believe it as a skills deficit rather than a skill rather than a choice then we can start talking about something that that I've been thinking about it more of habilitation rather than rehabilitation so the idea in rehabilitation is that you have a skill you lose it you break a leg and then you rehabilitate so you learn how to walk again or whatever it is but habilitation is an ability that you don't have that then you acquire so if you don't have the ability to regulate learning that is going to be critical so that's the difference between those of us and many of us were in the mental health community are often quite sensitive and have the ability to a greater or lesser extent to regulate all right chronic feelings of emptiness in adolescence this can be expressed as boredom it's often temporary relieved with a lot of these risky behaviors and and hope Ken gets a chance to talk about some of the findings in in in in research that talk about the opiate system in the brain but but it seems like self-injury and and drug use and everything can trigger these feelings of well-being and and so some people think that the opiate systems involved with that often it's expressed as as loneliness and force for people who want to be so incredibly connected to others to feel lonely is absolutely intolerable and I can imagine how desperate that must be just to want to be connected and not being able to okay now the other another criterion is anger and they say you know so that regulation of angers is difficult for people with BPD and I think that that's true but I think it's true of all their emotional states so so that if you're going strictly by the criteria to say well does the person ever get angry and say well no not really but they experience intense sadness in experience intense shame intense guilt and other emotions that so I just think that that when we're looking at the criteria we should look at any intense emotion just yes controlling anger is a difficult problem and it's off it's difficult for parents that's difficult for clinicians but it's difficulty regulating any of these emotions paranoia and dissociation so we often find comorbidity with post-traumatic stress disorder and I think that as we start to look at the dsm-5 people are talking about this crisis this idea of complex post-traumatic stress disorder looking very very similar to what BPD looks like today but what's interesting and and Mary Santorini is now my embedded researcher she's hovers around our unit because we have so many BPD patients and it's very interesting to see how they evolve it turns out that only about a third of them using really broad criteria for trauma Mycroft's here have been abused so 1/3 the 2/3 haven't and that that the majority of them come from absolutely well-meaning well-intentioned loving compassionate families often there's a tremendous miss attunement a mismatch and kind of an emotional mismatch that happens with their kids a ways that kids don't feel understood in ways that parents don't feel understood and when you get that on a repeated an ongoing basis that you can see the evolution of BPD which is more the DBT Linehan theory however once there once they've been traumatized added to BPD it becomes really really difficult to treat because often what you can do is you can reduce the self-injury and suicide attempts but what happens is is that the PTSD symptoms are not treated and now and and in in traditional DBT you had to wait for a very long period of time before you started treating trauma we're working with new models where trauma is dealt with as soon as eight weeks after the last at the end of the target symptoms after people have stopped cutting in and stuff like that because often working with traumatic memories can reactivate a lot of BPD symptoms and so it's something that that we're looking at we're developing protocols for that right now okay now these are just other things that we see on our unit so these are not in the DSM but but I see it clinically a lot so often they talk about tremendous self-loathing feeling evil feeling contaminated feeling that being in relationship with other people will make them toxic and often it I had this one young woman who said you know that she was in a group with somebody and that one of the group members children had died and it was absolutely certain that it was because of her and she didn't want to be in therapy with me because she thought that bad things would befall my life and and if anything bad happened but she could never always seen through that lens of that negativity because if good things happen in my life well that would be discounted this profound sense of hopelessness and self-hatred and a you know like what Ken was talking about that it's it's not depression but we don't have good words for this so it we call it depression and then you know people are treated with antidepressants often many of which don't work again the school performance this idea of also connecting emotionally rather than anatomically or physically so what happens is that often the connections especially romantic and sexual connections or people they feel connected to it's got nothing to do with gender and so even though they will often identify as as heterosexual parents often come in and say well I don't care if they're gay or homosexual it often doesn't have to do with sexuality per se and many of these kids will be in relationships with various genders but it's it's got less to do with the gender specificity rather than the way that they feel connected to emotionally this complaint of being universally misunderstood I think that one of the things that happens on our unit is the reason we haven't had security move in and all of that is that when you're in an environment where other people understand how it is that you're feeling connected with other young people who have similar problems that you feel more understood and you feel that there can be more hope again there's a tournament two nonverbal communication and very susceptible to others emotions okay so what's the difficulty well the difficulty in getting treatment is that even though we often begin to see symptoms early on we miss an opportunity to treat so here's these the eleven-year-old who's twisting her skin but she doesn't meet criteria for any psychiatric diagnosis so we're not going to treat her wait until things get worse the problem is that on the other hand if I'm treating her what am i treating her for well I'm treating her for twisting her skin that's what I'm treating her for well no you have to have a criterion otherwise we can't bill for we can't submit for for for insurance purposes so what do I say do I say she's depressed well then why aren't you treating her with an antidepressant dresses she's personality disordered well I don't think she's personality disorder so what do you what do you call this and so you know we don't want to jump on personality disorders because if I'm doing it with 11 year olds what about 8 year olds you know what about Kens person who was in the womb there how far back do we go treating yeah people aren't signing up for this because treating adolescent with borderline personality disorder it's like that one not me I'm not I'm not touching this this case you know somebody else somebody else do it cuz I'm not ready to deal with all the stuff that goes on the message is at two o'clock in the morning on your cell phone that said you know what you didn't answer your phone I'm done the-the-the leaving the session and just being totally devalued as they walk out looking like they're doing so well and then the next day falling apart whew feeling as a clinician this is where ego comes in that you personally have failed ego you know it's me I I'm such a good therapist see how well they're doing well now I'm terrible therapist see how you can't show me up this way start doing better so sorry anyway okay early intervention now sadly because 95% of the literature has been done in adults with BPD we're only just beginning to catch up so we are now doing the study with Mary's an Iranian we're enrolling a lot of patients with adolescent BPD to see this actually BPD I mean can we formally make this diagnosis going forward and I think we've enrolled 60 patients in our site and we're going to you know we saw the study with 392 patients so this will be the adolescent equivalent but because of that they really haven't been good studies and in terms of treatment and there's actually been only one randomized study of treatment early treatment of of BPD and it's called cognitive analytic therapy developed by well the person who did this study was a guy called Ian chain and in Andhra China in in Melbourne Australia and they did a cognitive analytic therapy it's too complicated to the details of it but everybody does cognitive analytic therapy who's doing cognitive energy therapy the other thing that maybe Brian hadn't hadn't mentioned is that with all of these treatments there everybody who's doing the treatment is doing the same thing so that's another commonality between between a lot of these treatments is that when we're all talking the same language and have common ideas about what we're doing we're going to get better outcomes so everybody who's doing this treatment is is doing cognitive therapy so anyway they looked at a 24-month group where they did treatment as usual versus cognitive analytic therapy and they found rates of improvement you can you can you can read that so there's all these other treatments for for BPD we happen to use dialectical behavioral therapy there is gonna be a lot of research coming out on DBT in adolescents but the thing is it's very difficult to randomize because here's the thing in order to randomize okay so when I was speaking to Marsha about this I said look people come into our unit and they after they leave their rates of hospitalization go down the rates of suicide attempts go down the rates of self-injury go to go down well I mean we can attribute it to our treatment but maybe something else the only way to do it is to truly randomize so what would you do is you would have a waitlist you would have okay these people go in and you tell somebody else listen I'm sorry that your kids trying to kill himself but can you just hang on for a bit in it's certainly antithetical to American practice to do that so but what they're doing in in in Germany Martin Bohm has in his group they're looking at LS and DBT studies where they have a DBT unit and then they get people on a waitlist and and they say look you if you participate in our study then you can move to the front of our waitlist I don't know that that that would be allowed here but it certainly allowed there and so now you're going to be able to compare DBT treatments to to treatment as usual or to waiting or not getting treatments but certainly in adults I mean it has a lot of compelling evidence and anecdotally and just the outcomes from our unit seem really good and a lot of people move to the Boston area after they've had treatment just to continue this work but we do need better outcome studies for a lot of these other therapies it's very difficult to do in adolescence so transference focus psychotherapy is a very psychoanalytically rich psychotherapy and movement seems quite slow mentalization is something that we use on our unit we are beginning to add that as a treatment module but we stick with with strict DBT medication so about a quarter of the kids who come to our unit to come I mean almost everybody comes in on polypharmacy can't spoke about them about a quarter leave on no medications and just feeling a lot better because I think that what happens and okay so kids had 12 hospitalizations they get admitted what happened they were depressed all right here's your antidepressant they get to the next hospitalization what were they doing well their moves are up and down and they were yelling at me okay here's your mood stabilizer what happened well they were dissociating all over the place and cutting all right here's your antipsychotic let go into the next one or they were very anxious so here's your anti-anxiety agents is this Adam med you know because you've seen someone in a slice and time and then you know people are getting you know so they come in and they're zombie why are you here oh can you talk oh you know it's a they're they're so shut down and you start removing the medication and now what happens now you can start to see the dysregulation well that I can do something about because now we've got you know we can start applying some of the the skills that we treat people who didn't have them in the first place and there's no evidence that medication is going to add capacity that you didn't have to start with all right so just to what there's the literature's beginning to come out on adolescent BPD and I actually had some other slides that there's a researcher in Florida marina born and lova and I always get her name wrong but what she has done is she had no interest in BPD but she was doing a Minnesota twin study there 2500 pairs and she just started looking at various symptoms and took some interest in BPD and found that in adolescents and in children BPD symptoms appear to occur in about you know three to four percent of the population and if you just followed these people over time between the ages of 17 and 24 with no clinical intervention there was a dramatic drop-off in symptoms so you know I mean it's great to do treatment during that time because then your patients are gonna look really great it could be just because their brains are maturing you know this is idea that that that brain it's a brain maturation problem I see it as a neurodevelopmental disorder not that much different in some ways than autism so you know we can talk about that that that you know if autism is hyper focused and very unaware of others emotions this is almost the opposite side of the same course but I said sort of a neurodevelopmental disorder that that with with genetics and environment or influencing each other you know create an adolescence thrown in but anyway from 17 to 24 it begins to try and by the way those of you who have adolescence it looks like adolescence ends at 33 now so get them out early think if there's a few take-home messages think of think about the way that we use our language or they're just acting out what the heck does that mean acting out we say this they're acting out acting out what I mean so try to be behaviorally descriptive try to understand this as a skills deficit problem rather than just misbehaving that it and you can have a lot more compassion for somebody who you know if somebody you know is doesn't have legs and they can't run you're not gonna blame them or that sort of thing with is if there's a deficit if there's a problem with that you can have a lot more compassion so if you see this as a skills deficit problem you know that that compassion can come from both parents and treaters so it skills deficit is this I mean so you know if I didn't know how to write with a pen I mean we take writing for granted but it's a skill that you develop over time and so so the idea is is that you know if you didn't have it you'd say my god everybody else can do it but I can't do it so I said okay I'm gonna I'm gonna teach it but I don't say we'll take out your your your handwriting skill and write a letter you just you know write a letter so so this idea that it just evolves over time so your capacity if I yell at you right now you might then feel flustered but then regulate and not going smash my car window in hope so now now your ability your and think about how did I do that you don't think about oh I you know so you've got a capacity to do that and it's a skill but you don't think about it as a skill but if you didn't have that skill then I'd have to go out there and make sure that you don't have a brick with the window because they because it's just not built into you it's not wired in it's not something that you've learned how to do there's a lot of theory about why that happens which we can talk about at some point so the skills deficits and incapacity something that you don't have that that lots of other people have it but because I'm a majority of us have it to some extent you think that somebody else should have it it's so obvious I mean you never think about a skill until you don't have it if you can walk you don't think of walking as a skill but you know break a couple legs and suddenly you're saying alright rethink manipulation again not to say it it's not manipulative but just take a second and be curious about the function of the behavior just think about it a little bit I mean it might maybe been manipulative but more often than not it's just learned behavior this idea of habilitation versus rehabilitation that dedicated treatments are emerging so that these aren't you know people that we're going to lock up for the rest of our lives and never take care and we got to continue to develop the treatment and then we must persist in ongoing efforts to increase public awareness and you know Perry was right there was I couldn't I'm so busy because we're opening up our 26th bed but she called and said can you come and do this yes you know because it's such an important mission critical mission and you know again people can join the NA BPD so that's it thank you very much and I'm sure we'll take questions [Applause]

Channel: NEA BPD

Views: 106,903

Keywords: BPD, NEA.BPD

Id: q4KjxxPp3Ls

Length: 41min 56sec (2516 seconds)

Published: Wed Nov 23 2011