Personality Disorder Diagnosis and Treatment: DSM vs ICD, borderline, and other considerations with Dr. Ueli Kramer

Dr. Ueli Kramer joins Dan in this latest episode focusing on personality disorder diagnoses, treatment and more. 

Dr. Kramer discusses his journey through self-doubt in clinical practice, the evolution of personality disorder classifications, and the transition from categorical to dimensional approaches in diagnosis. Then, Dr. Kramer breaks down the ICD-11 personality disorder system, highlighting its strengths and weaknesses. They also talk about Borderline Personality Disorder in DSM and ICD. The episode concludes with the importance of understanding the severity of personality disorders and the impact of diagnostic language on stigma and treatment.

Guest: Dr. Ueli Kramer

Additional Resources

Case Formulation for Personality Disorders: Tailoring Psychotherapy to the Individual Client

Understanding Mechanisms of Change in Psychotherapies for Personality Disorders

Psychotherapy Skills and Methods that Work

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Chapters

• 0:00 Introduction and Episode Overview
• 2:00 Early Career Experiences
• 6:30 First Clinical Experiences and Initial Career Insights
• 12:00 The Evolution of Personality Disorder Classification
• 19:00 Comparing DSM-5 and ICD-11 Approaches
• 27:30 Personalizing Psychotherapy: A Case-Based Approach
• 35:00 Borderline Personality Disorder
• 41:00 The Future of Personality Disorder Treatment

Transcript

0:00

[Music] Broadcasting from the most beautiful city in the world, I'm your host, Dr. Dan Cox, a professor of counseling psychology at the University of British Columbia. Welcome to episode number 29 of Psychotherapy and Applied Psychology, where we dive deep with the world's leading applied psychology researchers to uncover practical insights, pull back the curtain, and hopefully have some fun along the way. If you find our show interesting, it'd be much appreciated if you shared it with someone you know who might enjoy it too. It's a great way to spread the word and keep the conversation going. My guest is a professor in the Department of Psychiatry at the University of Luzon, where he directs the University Institute of Psychotherapy. He's the president for the European Society of the Study of Personality Disorders, editor of the Journal of Psychotherapy Integration, and received multiple prestigious awards for a psychotherapy research. In the show description, I have links to a couple of his recent books, Case Formulation for Personality Disorders, and Understanding Mechanisms of Change in Psychotherapies for Personality Disorders. In part one of our conversation, we discuss several aspects of personality disorders, including categorical versus dimensional diagnostic systems, borderline classifications in different diagnostic systems, treating the illness versus treating the person, personalized psychotherapy, and much more. This episode starts with my guest responding to my question about a time early in his career when he experienced self-doubt. So without further ado, it's my pleasure to welcome my very special guest, Dr. Uli Kramer. Let me talk about this self-doubt. So I actually, when I finished my training, you know, master-level training at the time, it's already a couple years ago, I first wanted to be a researcher in anthropology. That's really what I want to, you know, really. I loved my class since anthropology, I had a minor in cultural anthropology, and I was really, you know, fascinated by the field. Although I had, you know, come from Switzerland, there's also constraints in terms of civil service which I've done, and at that time I worked with adolescents, both in, you know, violence prevention programs, and also with anorexia at the hospital. And I also had first clinical exposure at a practicum at a hospital working in a psychiatric ward. So basically, I was really exposed in the first year after I graduated to very diverse clinical populations, from, let's say, 10 to 65, all across the board, right? And then I, the first time I was like, I don't think I'm going to do at the researcher. I love this contact client so much, just being with a person to enable actually to help them and see the impact. I can have, when I, I short a very immediate impact, right? But I actually can have when I apply very, very easy at the time, beginner's tools, right? Just kind of listening tools and so forth, that were taught to us at the time. So I was really getting so much, I would say positive feedback, and I also worked a lot in these days, just to be a good clinician at this very beginning of my career. So, but then there's some time later, I still had, you know, this another self thought, that was actually, is that really what I only want to do to be a clinician? Maybe just, but because then, certainly there are these bigger questions coming up. So how is it that it works, right? How is it that psychotherapy works? And I have these questions from the get-go, and I don't think we have clear answers today, doesn't 24. So I was fascinated by these questions. I got a lot into readings, a lot and so forth. So I got back to, you know, then my PhD and so forth. So this is kind of the, you know, and there are other moments of doubt forms later as well. But I want to get to your moment to ask the question you asked about the moment of maybe how to say, like, I know what I want to do, is that what you meant as a serious second question. So it's also been, you know, I specialized in personalities or others, but I, you know, of course, it goes really hand in hand with what I just said before, right? It's basically discovering that being a psychotherapist would be something I really aimed to do, to be, which was really grounded in the first, let's say, long-term cases, you know, you see when you do a clinical training like this. And so I was exposed to a variety of clients working in the psychiatric environment. And I was fascinated by the variety and also the the severity of some of the clients, right? I thought that like some colleagues mentioned to me, so this is a very difficult client. He or she tried many different therapies or this person has trauma. It's extremely difficult. So that's kind of this severity in the room. And maybe also a question mark in the room in the sense of is this really can anything help, right? And I actually was convinced, I think, about two or three cases, like I can talk more. And actually one was published in 2009 in the Catholic case on his psychotherapy, which can be read is actually one of the first cases I treated as a psychotherapist. The case of Caroline, it first year or something, I can't remember, for a second year, of training, which really made me realize that with very good understanding, very detailed and systemic clinician can really make a change and help the client change profoundly. And this is particularly true for patients who present with a whole variety of symptoms, including interpersonal problems, identity problems, and very severe, you know, self-destructive behavior such as suicidal thinking, self-harm, mean behavior and things like that. So this is, this is just basically rooted in this clinical experience and really, the understanding, it is possible to help these people. But yet at the same time, we don't know much about how the change comes about, that I started to ask kind of these research questions that, so how can we study this? How can we base them, this clinical experience? How can we ask the right questions? And what kind of answers do we need to move to feel? You said something, or you said something like with understanding, you can really help these folks. What, did you mean the therapist understanding the client, help me understand what you meant by that? Well, I'm thinking about the therapist, you know, using some kind of formulation that helps the therapist first to understand what's going on, right? And of course, there's different ways to do this. But really, it comes down to really observe what's happening in the interaction and then put hypothesis on these observations in a systematic way. To really construct almost a new theory for a particular client that I see as a therapist. I'm always mindful of like how we structure these conversations so they're most useful for listening to them because I think that what you're flirting with here, we're going to dive deep into. Before we do that, I wanted to talk, yeah, this is a little bit less fun maybe, but talk about personality disorder classification stuff because I know that, well, there's a couple of really useful perspectives that you bring. One is as a European. So the majority of the listeners, watchers of this are North American, although I still have a lot of international folks. And then, but along with being a European, you've also written about the ICD 11 and the current classification. So I'm wondering if you could maybe give a quick overview of how the ICD differs from the DSM in terms of personality disorder diagnoses and then we'll maybe dive more deeply into what that means in your experiences of that sort of thing. Okay, okay. I do think I need to give very very short, probably quite a subjective, historic background. That would be, I would actually, very short, I would actually really appreciate that. I see, but it is my own read, right? And I do think it's, you know, I would see three successive phases in a conceptualization of personality disorder. And even if I put them now in three phases, all three conceptions have been around all the time, not always by the same people. And even today, it's continuously ongoing, right? But there's kind of a shift from one to the second to third, right? So the first would be, and remember, what I'm going to talk about is always the same phenomenon, right? We're really going, actually taking different perspectives on the same client. This one person, let's, you know, I called it, I was mentioned, Karol I was a published client case, but it can be anybody else who has a certain number of features. So the first, but then depending on the, on the perspective, you, the clinical clinician may see certain aspects more clearly, right? And of course, into being a protein. So the first one is really to like in medicine, what we do in medicine is to kind of cut the phenomenon into categories, right? So have like a limited amount of categories, we have a phenomenon in nature, we try to categorize and say, well, this is a limit here, and this phenomenon is part of this particular disorder, and there's another phenomenon, part of another disorder, right? Okay? So that's, you know, and I'm not going into all the details, it can be read through, but it comes with a lot of disadvantages. If you cut nature in 10 different personalities orders, you end up with overlapping presentations when you have your next client, you have problems with changing, diagnosed, diagnostic categories over time, even if the client hasn't changed in reality, right? Because it's just kind of an artificial, copped, way to classify, and so forth, right? So still today, the DSM-5, the first, you know, classification from the American Psychiatric Association has the 10 or so categories of personalities orders that are narcissistic, borderline personalities, or two, but just the one that's mostly studied for a number of reasons we can talk about later, but, and, you know, dependent personality in these orders, that's awful. That's the first one, still around, and still helpful to some extent, but with a lot of limitations. The second would be, and I think, you know, you know, this is more dimensional constructs of personality and personal resource. It's also been around for a hundred and so years, right? The first more, but also similarly around for a hundred years. And, what's important there is to differentiate between two lines of research, which have not really been integrated. From the get-go, it has been really personality psychologists that have been thinking about how to, you know, how to conceptualize personality. And of course, there's lots of scales that have been validated and been used and reused and so forth across the globe. But the first, like, within this perspective, the first is what is personality? What is the further features of personality? What is the make-up? How does it look like? How can we describe personality? Right? And the second is what does personality? Right? This is outports differentiation. It's very old. It's like the functional impact of personality. What is the, what is kind of leaving? If I have an impact on you, what is this impact that leaves on you? Is it more, is it something that it's inviting or less inviting and so forth? Or what is the functional impact also on daylight? Right? If I have certain types of personality, what is the, how could I get along with other people? What is the impact on myself and so forth? So just to clarify, so what you're just distinguishing here is like the description of this is what a certain personality style or whatever. This is what this looks like versus the impact it has on the world and the self. And then we fast forward, of course, today we have the situation where the alternative model of personality is always in DSM5, that's 10 years ago, or maybe more, has now introduced these two aspects. Criterion A actually is kind of, you know, the translation of the functional impact. It's notion of severity of personality, so it's right? What does personality, what does personality do? The personality is sort of actually. What does it do? With three aspects, one is that it has an impact on relationships, severity of the impact on relationships, it has severity of impact in on the self. And it has a severity on the level of the management of emotions, combinations of behaviors. So these are the three components of a severity, which have been taken up in the ICT 11 two years ago when it's been published. But coming back to DSM5, there's the second piece to it that's the makeup or the description, descriptive part for personality is, or personality is order, which has five, you know, following up with the big five literature, with, you know, negative effectiveness, agreeableness, or with disinhibition, I'm not sure if I can put them all together, psychoticism actually is included in the DSM5 and I'm missing one. These have also been taken up by the ICT 11, this is really very fast forward 2022, right? And which is the non-clature, diagnostic classification of personalisors and mental disorders that is worldwide actually edited by the WHO, which has usually, you know, it has a very practical impact worldwide while the APA has maybe more limited, but it's a very useful classification for research and very transparent. So that's both has again, for long, this is a digital, but again for the ICT 11, because you're asking specifically, it has taken up this conceptualization, but to the fullest. So it has completely abolished the classification in terms of categories. So a clinician when he sees a potential client who has personalisors, he will first and foremost, assess severity of the three aspects I mentioned first, right? What's the impact of personality, personalisors, what's severity? And then if needed, he can describe, again, on five traits, how it looks like, what's the makeup of this particular personality, this or whether it has negative activity, whether it has antagonistic features, whether it's this inhibition, inhibitive aspects. And the fifth is not the same, it's the only one that the only thing that's different between ICT 11 and DSM-5 that's the un-custick features, which are included in the ICT 11, but not in the DSM-5. This is because the psychoticism is included in a different scale of the ICT 11. So these are maybe a little technical details, but just want to highlight that there's a lot of overlap between it too. And I was also also going to mention that the borderline, because now we don't have any classification terms of categories anymore in the ICT 11, because the borderline feature, the specifier, that can also be added as a classification in the end. I did not finish my third, but maybe you have questions to these dimensional concepts, which is quite, people talk a lot about it, and there's frankly not too much research. There's some that's really good already, but I think more is needed to really own this dimensional conception of personal resource. Maybe, so just to clarify that because of course the DSM just has to make it even more complicated that what you're talking about is, so the DSM sort of has these two parts. So in like the major part of the DSM, the personality disorders have, are still this categories, a categorizational system where you put people in categories, but then they also have this alternative model of personal leaders' orders. And I had Bob Kruger actually on the podcast and talked to him. So I learned a lot about it, which was great, that that is, so that has this dimensional approach, which is, so the DSM kind of has both, but it really puts it the front, I would say, if I'm in training or if I'm a practitioner, you're kind of pushed to still use the categories, categories, so these are, I can't say the right system, that put people in categories, but it also includes the dimensional part kind of as a, hey, this also seems like it's promising, we're going to include as well, but I would say it doesn't push that as much, where the ICD has totally transferred over to this much more continuous kind of way of thinking about personal. Exactly, right. So just really from the ICD perspective, there's no other way now to categorize, then attribute them to that knows them to use the severity index, which is the only one among everything we talked about that's required. Everything else can be added if a clinician decides to do so. So it is, it is very subtle. Okay, you have kind of four levels of intensity. Right, so, so, so you're saying that, so for in the ICD, you have to, you have to rate the, the what does personality, you have to rate that, the impact of personality, you don't have to rate the what it is part of it. It looks like you don't have to. Okay, it can be interesting, it's, it's really offered as an additional, you know, piece to qualify, describe more in more detail the personal resource. So do you want to get to that finishing up that third piece because I want to ask you some other questions, but that way, yeah. Yeah, of course, yeah, of course, of course, well, of course, the third is the individualization. So, of course, the question is, shall we treat the illness, or shall we treat a person who has the illness, right? So nobody really knows who has says this the first, it's very old. So it's, it's an old wisdom. And I'm not sure any clinician would disagree with this. That's why also I'm saying that even a hundred years ago, even if maybe this hasn't been written that explicitly, but it has definitely come up again and time and again in the literature, not specifically on personalities or this, but it is most relevant in personalities or that I think. To really think about what does this particular client actually feature? And of course, then we use anything we have in terms of, you know, conceptualization and any any bits and pieces we know from both maybe categorical aspects and dimensional aspects of personal resilience. So that's why I get sometimes a little bit irritated when there's this debate between dimensional and categorical proponents of personalizers because actually when you think about it, it's really just the research just scratching the surface from a clinical perspective if we debate on this. Because what's really getting to the core of who the person is who has the illness is actually to understand the person using case formulation. It also goes a step further in that it doesn't only, of course, we need the classifications for diagnostic purposes. I'm not denying that so but it is already putting our radar on treatment. We're already thinking about theoretical implications. We're thinking about etiological implications. We're thinking about what do we know about processes of change? And so what's most promising in terms of treating for a particular client? So it's all coming together in a case formulation. So this is kind of the third piece which I think should, you know, has sometimes been missed but I think is actually on the rise with the notion of personalizing psychotherapy, which is of course a topic that is very, very, you know, on both I would say in psychotherapy for the last five to 10 years. Yeah, that's interesting. I'm sort of, someone follow up on the diagnostic stuff. But I also, sort of, what you're saying is very enticing as well. Because I think that in certain communities that I think that you're probably right in sort of the personalizing. But I think that, and I don't know, I come from a very North American perspective. And that I would say that superficially sure, but if you actually really dug into how most practitioners practice and are trained, I'm not, you know, that I think that, you know, I don't, I think it's invoked in a very small sliver of folks is what I would say. But I don't know, maybe it's different in Europe. I don't really know. I mean, it's definitely a reflection that's out there that's not new. I really have to say it's been out there since these wisdoms have been pronounced. And of course, it is currently a, you know, a central topic at, you know, conferences such as the ones from the Society of Psychotherapy, research, set B as well, and so forth. So there's a lot of new methods coming up in addition to case formulation, but lots of methods that help clinicians and researchers to actually conceive personalization. But because it's so, you know, maybe, you know, it's getting started now. It's maybe haven't reached some clinical communities yet. But I want to highlight that it's also kind of one of the potentials to rethink about some kind of patient-focused care, right? We're really not going beyond, let's say, you know, categories of treatment that we think, okay, either we're doing, let's say, behavioral therapy or we're doing humanistic therapy or doing psychedelic psychotherapy or we're conceptualizing our client according to any of these theoretical models, which is all fine, right? But ultimately, what client, what therapists tend to do, and you know, surveys have shown that many therapists think, you know, identify with actually some kind of mix and match of some of these theories when they work with clients, right? And of course, if that's the reality, I think psychotherapy research is, but also theoreticians, we should really think about whether we should continue, you know, doing our specific theory-based research and theory development, which may be interesting, or whether we would really go at the really core of change that is spanning through all psychotherapies. Of course, I'm a defender of the second, you know, integrative movement with all these problems that's there, but it is just to say that personalization brings us to this question, I think, to ask whether we actually adhere to one therapy school or whether we would accept that we're actually open to integrate to multiple models in our practice. Let's come back to that because I think, but I do want to just, you wrote a, or you were an author on a paper that came out in 2022, so I mean, you probably wrote it in 2021 or whatever, but it was on unanswered questions about the ICD-11. And so as I was reading that, I was thinking, well, it's been two, three years since you worked, you know, you and your co-authors worked on that. And part of you wondered like, one of the things that really stuck out in that article to me was it was something like, you know, with this ICD-11 system that you could have up to 93 different, was it 93? Is that right? 93 different labels, whatever you want to call it, that it was sort of a, oh wait, that's a lot. But so whether it's that specifically, or you know, I'm just curious, a couple years in now, what is your experience of the ICD-11 personality disorder system? Yeah, this is the buff of collaborators published in the Bolland Personalis Order and Emotion Disregulation. It's actually a paper that the ESSB-D-Ball European Society for the Study of Personalis Orders which I had to honor to preside in the last two years, wrote together as a group. So it's really an expert article, like the our opinion of all these different researchers put together in Europe. So to answer your question, I think I come back to what I said before a little bit, that's really highlighting and it's said in the articles, well, and really there may be new research coming up which I'm not aware of, but really what's important is that the severity index is the only one that's required, right? So everything you just mentioned with the 94 combinations possible, that's mathematically correct, but you can, especially for starters, right? It may be just good to get a grasp of how how severe is this personally? It personally, you know, severely disturbed, how severe is this personalis? I should say, right? So and there's a few rules of thumb which have been discussed in this paper as well, that is, if you have a severe suicidal thinking, self-harming behavior or impulses and impulsive behavior or aggressivity, then you probably are in the real severe person. If you don't have these aspects, but you have severe identity issues, or interpersonal issues as impact on others, then you're more into moderate range. I know mild range, if any of these problems come up fleetingly in a sense that is still clinically relevant, right? We don't want to miss these. And then personal, personal pathology that means a sub-frescial personality features. If this like you and me, we have a little bit of, you know, pronunciations, a little bit of that, a little bit of that, but without hopefully having a very negative impact on others and self-enagement. And so do you find that this new system, do you feel like it's an improvement? Like anecdotally, or are you feeling like, yeah, just sort of being required to focus on severity is a useful, it's useful. This is a good for practitioners. So there's a lot to say about this question. We could end the day with this, but we won't. I hope, I hope. But of course, of course, I can only say of course, but there's also problems. But let me say yes, let me say first yes, to have a severity index is so helpful. I think it's so helpful. Because you suddenly, if you really think about this, and this should be included in any other diagnostic categories, well, right? That we think about real severity and put specific behaviors attached to specific levels of severity. I think this is really revolutionary for diagnosis. Another piece that's more going the other way is really, there's an argument saying it's a huge improvement because it actually reduces stigma. Let me give a little bit of a balanced picture. I'm not sure this is helpful, but stigma is of course important. No one in this, in our field would say, it's good to stigmatize clients, and it is what we all are. Stigma, stigma of course, is related with language. What language means for all of us? So the idea here is the categorical system has been around for so long that you read in the newspapers, and I know in the US, and it's similar as in Europe, that you see the narcissistic come back and so forth. So you know, these kind of things. And of course, if you read this every year for 50 years, we know what the narcissistic amoeuid people, right? Everybody or first your psychology students, we know that this is a bad thing, right? And so there's stigma attached to these names, which you can debate whether that was the intent when people created these names. We, I don't know, I haven't been around that that time, so I don't completely speak to that, but I just want to highlight that it is a relative, it's very relative, and it is possible that in 10, 20 years, the notion of severity in personalize, or it's made similarly be seen or experienced by at least certain people as stigmatizing. I'm just highlighting this because it again speaks to some kind of interlizing, and just kind of being aware that what's really important and driving the change is what the client makes out of how we speak about their disorder. So that's why also certain, there's a disagreement, certain colleagues say, giving the diagnosis of borderline personalize over is helpful, right? It's also my experience for certain clients. You know, I have a, you know, active practice, even if I'm doing a lot of research and teaching, and so forth, but I know this is helpful, right? Because some clients can really relate to the features of this disorder, and then there's another group of people, researchers, acquaintances would say, by all means, never talk about borderline personalize or any more because it's so stigmatizing, right? So, but it may depend on the client. So that, so bring up the borderline thing. So in the ICD, there's also this borderline pattern specifier that you can slap on to any personality disorder diagnosis. And it sort of struck me, and the way I sort of read it is that that specifier looked very similar to how I would think about the DSM-5 borderline personally just diagnosed. Same thing, right. Same thing. So it struck me as a little bit odd that you have that we have this sort of dimensional classification system. And then this specifier didn't have like a dimensional piece to it necessarily, and you know, it was still all this big list of things, and it's certainly possible that you might have, that you're going to have clients who, yes, some of these things are descriptive of their experience, but not all of them. So it was like, it was like, what, how could, it was almost like, why couldn't you just sort of make these as more specific specifiers that could be extraordinary? That could be useful, but it just sort of seemed like, well, just sort of kept this whole thing and allowed you just paste it onto, it struck me as a little bit a skew from the changes that have happened. But, again, I'm an outsider and I'm not sure, maybe I'm missing something. What are your thoughts about that? Well, a little bit of history, I'll make it very, very short. So the first proposal for the revision of the DSM, excuse me, the ICD-11 was put forward by the WHO in 2015-16 at that time, and it didn't have the borderline specifier. So then the societies and basically, really, all the body of research, in particular in the domain of psychotherapy, there's a lot of actually good evidence showing that for the cluster of symptoms that we call today, or we use to call, or still call, in the future borderline personality, we do have good treatments. So it would be really out to have, as I said before, like the clients don't change, they still have the same problem. So if these group, this group of people would suddenly, for insurance purposes or any other reasons, would not actually be able to benefit for treatment. That would be really sad, as a consequence. And a lot of other additional arguments were made by the International Society for the Study of Personality of the UPN Society for the Study of Personality of Personality of Personality of Personality of Personality of Personality and others, other actors in the field of the years, and they actually managed to communicate very clearly the need to add a specific borderline specifier that takes up the criteria, exact same criteria, from the DSM 5. So that was really the idea to make a copy paste, which is also the first time that the ICD and the DSM correlate on the borderline personality disorder. The diagnosis, because before DSM 4 and the ICD 10 didn't correlate at all, there were different categories proposed. So that was the idea, but I also have to say that this is not to last, is my sense at least, I hope I'm not overstating anything, but it's really, as you mentioned clearly, it looks a bit odd to have an additional specifier, but research will show it next 10 years. I hope that, and we do have good data already, that there's a little bit of borderline features, the severity, actually in the severity index, and also in all the other presentations of personal resource that are already described in criteria in D or the descriptive part of the five traits I mentioned. So it's actually already in there, it's just not named a spotal line. If you look at data looking at, you know, if you rate your roommates, you ask 100, 1000 undergrad to rate the roommates on category code, a diagnosis of personal resource. You've seen this maybe in the study 2003, quite a lot of study, but it actually shows that the traits of the nine categories other than borderline, they go together. So there's really the traits of the dependent personalities of there can be identified in your next door roommate. But all the nine criteria that we have for the borderline diagnosis, these are nine criteria that match up, but they don't go well together, actually. They're completely cautically distributed in the population of roommates you may have in the first year. So this has been replicated with soldiers who also know each other very well because they're very close, work close together. So it really indicates that there's a problem, let's say a psychometric problem, a validity problem in the constellation of symptoms, putting this together, and it may be, it's a good for the future for research and clinical practice to consider more most of these symptoms as moderate and severe personal resource. This is what I can say today, but I know I'm not sure. Research will tell, I think research should be done to clarify this question. So just to make clear that so for borderline that the symptoms that underline or make up borderline that they're not as, they don't co-vari, they don't correlate as well as we would want them to correlate to say that all of these symptoms are a manifestation of this same human experience, this borderline personality disorder, but they're kind of, it's a little, they're a little more thrown together. They don't hold together as tightly as some of the symptoms for some of the other disorders. Yeah, at least in some healthy populations, these are healthy populations, but tricky thing in very severe populations it will hold together. Interesting. So but that's that's what I was saying before and what's called a sharpest showing in impatient, almost a thousand patients, that the severity index of the DSM-5 goes together with the intensity of the borderline symptoms. Yeah, it's interesting, you know, in your explanation of why we have this borderline specifier, it does remind me of what sort of how Kruger was explaining it that, or how he was conceptualizing it kind of this, you're repairing the airplane while you're still in flight. You know that it's like, there's this desire, you know, the ICD, this desire to move to this more accurate, this more effective, effective, useful, clinically useful way of conceptualizing these things, but we still have to deal with the systems and the ways of thinking that were set up, have been set up for decades, and we basically don't want to screw a whole bunch of patients in the process of trying to improve this. Absolutely. So there's a whole lot of political influences, I think we should be aware, we should be aware of, and if it would be only scientific reasons, I think that would be also tool, you know, short viewed. I think it's really important to see that the ultimate beneficiary is the patient. So how about if we get into treatment? That's a wrap on the first part of our conversation about personality, disorder diagnosis, and treatment. Join us in our next episode when we dive much deeper into how practitioners can bring this into their practice. As I noted at the top, it'd be much appreciated if you could spread the word to anyone else who you think might enjoy the show. Until next time...[Music]