Black & white relations: Intimate relationships of patients with borderline personality disorder.

BACKGROUND: Individuals with borderline personality disorder (BPD) suffer from an excessive fear of abandonment, leading to tense moments in their intimate relationships. These struggles translate into lower marital satisfaction perceived by both intimate partners. However, this connection is bidirectional, since conflicts with a romantic partner are the most common precipitating factors of decompensation in BPD patients. METHOD: This narrative review was performed using PubMed, Web of Science, and Scopus databases with keywords "borderline personality disorder", "partnership", marital problems", and "marital conflicts". Articles, books, and book chapters published within January 1980 - December 2020 were extracted and analysed. Additional sources were found while reviewing references of relevant articles. The total of 131 papers met the inclusion criteria. RESULTS: Patients with BPD struggle with reaching marital satisfaction. They often find themselves in disharmonic and unfulfilling relationships. The association between the relationship issues and BPD may partly come from misunderstanding one or both partners' behaviour. Individuals with BPD tend to misinterpret their partner's behaviour, struggle with communication, and sometimes be verbally and physically aggressive. They often do not recognize that their intrapersonal processes influence their interpersonal struggles. Understanding the role of the maladaptive personality traits in the relationship and their management could be beneficial for both partners. CONCLUSION: Individuals with BPD often report dysfunctional romantic relationships characterized by insecure attachment, maladaptive communication, and lower relationship satisfaction. Future studies should focus on finding effective strategies of couples´ therapy working with this population.

Obstruction sleep apnoea and panic disorder.

OBJECTIVE: Both panic disorder (PD) and obstructive sleep apnea (OSA) are frequent conditions that can be comorbid. This article reviews the current state of knowledge about the comorbidity of PD and OSA and the effectiveness of therapy in patients with this comorbidity. METHOD: Articles obtained via PubMed and Web of Science search were selected; the publishing date was between January 1990 and December 2022. The applied search terms were: obstructive sleep apnea; panic disorder; CPAP; antidepressants; anxiolytics; antipsychotics. Eighty-one articles were chosen by primary search via keywords. After a complete assessment of the full texts, 60 papers were chosen. Secondary papers from the references of the primary documents were investigated, evaluated for suitability, and included in the list of documents (n = 18). Thus, seventy-eight papers were incorporated into the review article. RESULTS: Studies describe a greater prevalence of panic disorder in OSA patients. So far, there is no data on the prevalence of OSA in PD patients. Limited evidence is found regarding the influence of CPAP treatment on PD, and this evidence suggests that CPAP can partially alleviate PD symptoms. Medication used in PD treatment can significantly impact comorbid OSA, as explored in several studies. CONCLUSIONS: The relationship between the two conditions seems bidirectional, and it is necessary to assess OSA patients for comorbid panic disorder and vice versa. Both disorders can worsen the other and must be treated with a complex approach to ensure improvement in patients' physical health and psychological well-being.

Sleep Disturbance and Immunological Consequences of COVID-19.

The overarching importance of sleep was further emphasized during the pandemic of COVID-19. The subjects infected by COVID-19 frequently experience sleep disturbances; some are long-lasting problems and decrease the quality of life. Insomnia is the most studied sleep disorder associated with COVID-19. Insomnia affects patients who have experienced an infection and the general population. Good sleep is important in maintaining mental and physical health, including immune system functions. The interconnections between insomnia, the immune system, and COVID-19 are complex. Insomnia triggers numerous immune system dysregulations and makes individuals more vulnerable to respiratory infections. This narrative review overviews the influence of the COVID-19 pandemic on the immune system through sleep disorders.

Unmet emotional, interpersonal, and treatment needs in patients with borderline personality disorder.

OBJECTIVE: Needs of psychiatric patients may be to a various degree frustrated. A sole focus on treatment effectiveness can lead to the omission of other patient's needs. Patients with borderline personality disorder present high demands on health and social services that often remain unmet. The review aims to identify common unmet needs of patients with BPD, map the areas in which they appear, and identify ways to manage them. METHOD: The PubMed database was used by applying the following key terms: "borderline personality disorder" and "needs" supplemented by a combination of "borderline personality disorder" and "unmet needs"; "treatment"; "therapy"; "management", "quality of life", "pharmacotherapy", "psychotherapy". the Papers were selected from a period between Jan 1, 1990, and Nov 30 2020. Primary keyword search yielded a total of 502 articles, of which 225 articles met the inclusion criteria and were subjected to a complete inspection. Secondary contributions from reference lists of the primary sources were examined, evaluated for suitability, and added to the primary document list (n = 182). After an evaluation of the relevance, a total of 197 papers were included in the review process. RESULTS: Recognizing patients' unmet needs with borderline personality disorder emphasises the importance of a comprehensive patient assessment. The diagnosis of comorbidities is also essential, especially with bipolar disorder and posttraumatic stress disorder, as comorbid conditions may require different therapeutic approaches. Traditional treatments of BPD tend to be demanding both in time and funding. However, alternatives are being developed to overcome these shortcomings by introducing methods focused on specific goals. Furthermore, supporting the patient's responsibility in the treatment choice can lead to better improvements. CONCLUSIONS: There is a need for further studies that will focus on the needs of this patient group and the possibilities of their treatment in psychotherapy, using psychotropic drugs, or social interventions. The development of step-by-step treatment models, adjunctive treatments, and technology-based interventions can bring greater access to care and reduce costs, especially for newly diagnosed patients or patients waiting for comprehensive treatment.

Schema Therapy for Patients with Bipolar Disorder: Theoretical Framework and Application.

Bipolar disorder (BD) is a severe mood disorder characterized by episodes of depression and hypomania or mania. Despite its primarily biological roots, the onset and course of the disorder have also been related to psychosocial factors such as early adverse experiences and related maladaptive schemas. Several researchers proposed a schema therapeutic model to treat patients with BD. In this paper, we further develop the theoretical model and elaborate on seven elements that were found effective in the psychosocial interventions with individuals with BD: monitoring mood and early symptoms of relapse, recognizing and management of stressful situations and interpersonal conflicts, creating a relapse prevention plan, stabilizing the sleep/wake cycle and daily routine, encouraging the use of medication, and reducing self-stigma and substance use. Apart from that, we describe the elements of the schema work with patients who suffer from BD. Illustrative clinical cases accompany the theoretical framework. The research of the schema therapy with patients with severe mental illnesses has only recently started developing. The presented paper also aims to encourage further research in this area and highlight potentially beneficial research goals.

Early life experiences and adult attachment in obsessive-compulsive disorder. Part 1: Relationships between demographic, clinical, and psychological factors in pharmacoresistant OCD.

OBJECTIVES: Obsessive-compulsive disorder (OCD) has been connected to various psychosocial factors that might influence its onset and course. Developmental factors, such as parenting styles or early adverse experiences, and adult attachment have been listed as examples. However, the research on the interconnections of these factors brought mixed results. The study explores the relationship between demographic, clinical, and selected psychosocial factors and the severity of adult OCD. METHOD: Eighty-seven pharmacoresistant inpatients with OCD were admitted between October 2019 and August 2022 for a 6-week cognitive behavioural therapy inpatient program in the psychotherapeutic department. The participants completed the following scales at the start of the hospitalisation: the self-report Yale-Brown Obsessive-Compulsive Scale (Y-BOCS-SR), Beck Anxiety Inventory (BAI), Beck Depression Inventory (BDI-II), Dissociative Experiences Scale (DES), Childhood Trauma Questionnaire-Short Form (CTQ-SF), PBI (Parental Bonding Instrument), ECR-R (Experiences in Close Relationships - Revised), and a demographic questionnaire. A skilled psychologist administered Mini International Neuropsychiatric Interview (MINI) to confirm the OCD diagnosis and Hamilton Anxiety Rating Scale (HAMA). RESULTS: OCD patients with more severe adverse childhood experiences (ACEs) showed earlier onset of the disorder and more pronounced attachment anxiety, depressive symptoms, and dissociation and subjectively rated the severity of the disorder as more severe. Physical abuse and physical neglect were related to the severity of specific OCD symptoms. Maternal care negatively correlates with clinician-rated anxiety, patient-rated depressive symptoms, and dissociation. The maternal and paternal control positively correlated with patient-rated anxiety and depression. Attachment anxiety negatively correlated with the age of onset and positively with the severity of the clinician-rated anxiety and the patient-rated anxiety, depressive symptoms, and dissociation. CONCLUSIONS: Early adverse experiences, perceived parental styles, and adult attachment anxiety could play a significant role in the symptoms of anxiety, depression, and dissociation. The connection with the specific obsessive-compulsive symptoms is less apparent. Still, adverse childhood events and adult attachment anxiety seem to influence the age of OCD onset.

Early life experiences and adult attachment in obsessive-compulsive disorder. Part 2: Therapeutic effectiveness of combined cognitive behavioural therapy and pharmacotherapy in treatment-resistant inpatients.

OBJECTIVES: Obsessive-compulsive disorder (OCD) is a chronic mental disorder that is often hard to treat with current treatment options. Therapeutic outcomes are predicted by many factors, ranging from biological to psychosocial. Early life experiences and adult attachment influence the effectiveness of the treatment. This study explores their predictive abilities in the combined treatment of adult inpatients with OCD. METHODS: Seventy-seven patients with OCD, diagnosed according to the ICD-10 criteria, were included in the study, out of which 66 patients completed the treatment. All patients were previously unsuccessfully treated with a minimum of two antidepressants for three months each. They were evaluated with rating scales and questionnaires at the start and the end of a six-week hospitalization in a psychotherapeutic department. The treatment approach presented a combination of group cognitive-behavioural therapy and medication. RESULTS: The average severity of OCD, anxiety and depressive symptoms significantly decreased during the inpatient treatment. The improvement in Y-BOCS negatively correlated with the age of onset. The history of emotional abuse and neglect and physical neglect predicted a lower change in anxiety evaluated by a psychologist and perceived maternal care positively correlated with a decrease in anxiety assessed with a rating scale. Adult attachment anxiety predicted a lower decrease in the anxiety measured by the clinician but not the OCD symptomatology. Dissociative symptoms did not significantly predict a change in any of the measures. Comorbid personality disorder did not have a significant impact on therapeutic change. CONCLUSIONS: The early onset of the disorder was the sole predictor of the treatment outcomes regarding specific OCD symptomatology. Selected early adverse experiences, maternal care, and adult attachment anxiety predicted a change in the anxiety symptoms. Future research should focus on mediation and moderation analyses that could help target specific treatment strategies to decrease the impact of these factors.

Attachment in patients with an obsessive compulsive disorder.

INTRODUCTION: This review aims to present the current state of knowledge about attachment and obsessive-compulsive disorder (OCD), the connection to the disorder's course, and the treatment effectiveness. METHOD: A literature search was performed using PubMed, Google Scholar, Web of Science, and ScienceDirect databases using the following search terms: obsessive compulsive disorder, attachment, therapy, treatment, and long-term outcome. The period of extraction was between January 1990 and October 2020. RESULTS: Insecure attachment leads to the formation of dysfunctional beliefs about the world and self, which influences the dynamics of OCD. It is associated with maladaptive cognitive processes such as an inflated sense of responsibility, perfectionism, and mind control. With worse emotional regulation and reduced self-esteem (which can also result from insecure attachment), it can lead to maladaptive behaviour such as perfectionistic and compulsive behaviour to secure and stabilize self-worth and safety. Of the two dimensions that define insecure adulthood attachment (anxiety and avoidance), attachment anxiety is more closely related to OCD. While anxious attachment can lead to a worse response in acute treatment, secure attachment is a protective factor that can improve remission. CONCLUSIONS: Anxious attachment is common in patients with OCD and interconnects with primary OCD symptomatology. From this perspective, strategies that promote feelings of safety, acceptance, and appreciation within a therapeutic relationship may be essential in treating OCD.

Self-stigma, severity of psychopatology, dissociation, parental style and comorbid personality disorder in patient with neurotic spectrum disorders Part 2: Therapeutic efficacy of intensive psychotherapeutic inpatients program.

OBJECTIVES: The effect of short-term psychodynamic psychotherapy in patients with neurotic spectrum disorders may be related with predictive factors such as the severity of the disorder, diagnosis, self-stigma level, personality characteristics, comorbidity with depression and personality disorder, dissociation, and traumatic childhood experience. This study focuses on finding factors related to the effect of short-term psychodynamic psychotherapy in patients with neurotic spectrum disorders. METHOD: The study was conducted at the Psychotherapeutic ward of the Psychiatric Department in Regional Hospital Liberec from October 2015 to March 2019. The assessment method used at the beginning was the objective and subjective Clinical global impression (objCGI, subjCGI), Beck Anxiety Inventory (BAI), Beck Depression Inventory (BDI-II), Dissociative Experience Scale (DES), Liebowitz Social Anxiety Scale (LSAS), Internalized Stigma of Mental Illness (ISMI), Temperament and Character Inventory (TCI), Parental Bonding Style (PBI), Childhood Trauma Questionnaire (CTQ). The 6-week therapeutic program combines group dynamic psychotherapy (4 times a week for 1.5 hours), pharmacotherapy and other therapeutic activities. The primary criterium of therapeutic outcome was the change in objCGI severity, and the secondary criteria were changes in subjCGI, BAI and BDI-II. RESULTS: A total of 96 hospitalized patients with neurotic spectrum disorder diagnosed according to ICD-10, confirmed with the MINI (MINI-International Neuropsychiatric Interview) were included in the study and filled out the questionnaires' battery. There was a statistically significant decrease in the anxiety and depression symptoms and an overall decrease in the disorder's severity during the treatment. At the beginning of the treatment, a higher self-stigma rate was associated with a smaller decrease in anxiety symptoms (BAI) and depression (BDI-II). However, self-stigma is not a factor associated with the change in primary outcome criteria (objCGI change). Initial assessment of objective severity of the disorder (objCGI) and personality factor Novelty Seeking predict the change in objCGI severity. CONCLUSIONS: Self-stigma predicted the change in anxiety and depressive symptom but not the change of the disorder's global severity in short-term psychodynamic psychotherapy of patients with a neurotic spectrum disorder.

Self-stigma, severity of psychopatology, dissociation, parental style and comorbid personality disorder in patient with neurotic spectrum disorders Part 1: Relationships between self-stigma and clinical, psychosocial and demograph.

OBJECTIVES: Self-stigma represents a process of accepting negative social prejudices with a consequent negative impact on many areas of the patient's life (self-concept, social and work functioning, relationships, cooperation in treatment, quality of life, willingness to strive for something). The study was aimed to examine the level of self-stigma and other significant variables potentially related to self-stigma (personality characteristics, childhood traumatisation, anxiety, depression, personality disorder, dissociation, parental styles, attachment). METHOD: The study was conducted at the Psychotherapeutic section of the Psychiatric Department in Regional Hospital Liberec from October 2015 to March 2019. A total of 96 hospitalised patients with neurotic spectrum disorders diagnosed by an experienced psychiatrist according to ICD-10 (panic disorder and/or agoraphobia, social phobia, generalised anxiety disorder, mixed anxiety depressive disorder, somatoform disorder, obsessive-compulsive disorder, adjustment disorders) were included into the study and filled in the test battery. RESULTS: The main finding is that self-stigma is related to the severity of the disorder, anxiety and depression, social anxiety, the comorbid occurrence of other anxiety disorders or personality disorders, dissociation, personality temperamental traits Harm Avoidance, Reward Dependence and Self-Directedness. We have not established a connection between attachment in close relationships and self-stigma. The most important predictors of self-stigma are the disorder's duration, reduced Self-Directedness, a higher rate of depression and social anxiety, which together explain 58% of severity if self-stigma. CONCLUSIONS: Self-stigma is a contemporary topic in research and clinical practice. The results can be used as a basis for the development of targeted intervention strategies aimed at reducing self-stigma or for further research studies in the field of self-stigma.

Borderline personality disorder and recovery.

Recovery focuses on the broader concept of having a good life with mental health problems than remission. This review aims to deliver up-to-date information on the concept of recovery in borderline personality disorder. A computerized database search was conducted in PubMed and Web of Science sites, using various combinations of keywords for the period between January 1990 and April 2020. According to current findings, a full remission or complete disappearance of symptoms of a borderline personality disorder usually does not occur soon after the initiation of treatment, but recovery is an achievable goal. A precondition for recovery is the patient's responsibility for their health. Apart from psychotherapy and psychosocial rehabilitation, pharmacotherapy can help individuals with BPD improve their quality of life and can provide significant aid on their path to recovery.

Insomnia in Patients with Borderline Personality Disorder.

OBJECTIVE: Both sleep disorders and BPD are prevalent in the population, and one is often a comorbidity of the other. This narrative review aims to assess contemporary literature and scientific databases to provide the current state of knowledge about sleep disorders in patients with borderline personality disorder (BPD) and clinical suggestions for managing sleep disorders in BPD patients and future research direction. METHODS: Articles were acquired via PubMed and Web of Science, and papers published between January 1980 and October 2020 were extracted. Authors made a series of literature searches using the keywords: Sleep problems, Insomnia, Nightmares, Obstructive sleep apnea, Borderline personality disorder. The inclusion criteria were: published in peer-reviewed journals; studies in humans; or reviews on the related topic; English language. The exclusion criteria were: abstracts from conferences; commentaries; subjects younger than 18 years. After an inspection of the full texts, 42 papers from 101 were selected. Secondary documents from the reference lists of the primary designated papers were searched, assessed for suitability, and included. In total, 71 papers were included in the review process. RESULTS: Sleep disturbance is common among patients with BPD. Nevertheless, the number of investigations is limited, and the prevalence differs between 5-45%. Studies assessing objective changes in sleep architecture in BPD show inconsistent results. Some of them identify REM sleep changes and a decrease in slow-wave sleep, while other studies found no objective sleep architecture changes. There is also a higher prevalence of nightmares in patients with BPD. Untreated insomnia can worsen BPD symptoms via interference with emotional regulation. BPD itself seems to influence the subjective quality of sleep significantly. Proper diagnosis and treatment of sleep disorders in patients with BPD could lead to better results in therapy. Psychotherapeutic approaches can improve both sleep disorders and BPD symptoms. CONCLUSION: Recognising and managing sleep disorders in patients with BPD may help alleviate the disorder's symptoms. Treatment of people with BPD may be more effective if the treatment plan explicitly addresses sleep problems. Further research is needed to reach reliable conclusions.

Sleep Disturbances in Patients with Nonepileptic Seizures.

OBJECTIVE: Up to 20% of patients treated for epileptic seizures experience psychogenic nonepileptic paroxysms (PNES). These patients present a significant burden for the health care systems because of poor treatment outcomes. The presented review aims to summarize the current state of knowledge on sleep disturbances in patients with nonepileptic seizures. METHODS: Articles were acquired via PubMed and Web of Science, and papers between January 1990 and March 2020 were extracted. Inclusion criteria were (1) published in a peer-reviewed journal: (2) studies in humans only; or (3) reviews on a related topic; (4) English language. The exclusion criteria were: (1) abstracts from conferences; (2) commentaries; (3) subjects younger than 18 years. From primary assessment, 122 articles were extracted; after obtaining full texts and secondary articles from reference lists, 45 papers were used in this review. RESULTS: Limited data are available regarding sleep disorders in PNES patients, over the last 30 years only nine original research papers addressed sleep problems in patients with PNES with only six studies assessing objectively measured changes in sleep. Current literature supports the subjective perception of the sleep disturbances with mixed results in objective pathophysiological findings. Conflicting results regarding the REM phase can be found, and studies reported both shortening and prolonging of the REM phase with methodological limitations. Poor sleep quality and shortened duration have been consistently described in most of the studies. CONCLUSION: Further research on a broader spectrum of patients with PNES is needed, primarily focusing on objective neurophysiological findings. Quality of life in patients suffering from PNES can be increased by good sleep habits and treatment of comorbid sleep disorders.

Self-Stigma and Treatment Effectiveness in Patients with SSRI Non-Responsive Obsessive-Compulsive Disorder.

PURPOSE: Obsessive compulsive disorder (OCD) is a debilitating mental disorder that often takes a chronic course. One of the factors influencing the treatment effectiveness in anxiety and depressive disorders is the self-stigma. This study focused on the relationship between the self-stigma, symptomatology, and therapeutic outcomes in patients with OCD. PATIENTS AND METHODS: Ninety-four inpatients with OCD, who did not sufficiently respond to at least one selective serotonin reuptake inhibitor trial, participated in the study. They attended a six-week therapeutic program consisting of exposure and response prevention, transdiagnostic group cognitive behavioral therapy, individual sessions, mental imagery, relaxation, sport, and ergotherapy. The participants completed several scales: the Internalized Stigma of Mental Illness Scale (ISMI), the self-report Yale-Brown Obsessive Compulsive Scale (Y-BOCS-SR), Beck Anxiety Scale (BAI), Beck Depression Scale-II (BDI-II), and Dissociative Experiences Scale (DES). A senior psychiatrist filled in the Clinical Global Impression (CGI-S). RESULTS: The average scales' scores considerably declined in all measurements except for DES. The self-stigma positively correlated with all psychopathology scales. It was also higher in patients with a comorbid personality disorder (PD). The higher self-stigma predicted a lower change in compulsion, anxiety, and depressive symptoms but not the change of obsessions or the overall psychopathology. CONCLUSION: The self-stigma presents an important factor connected to higher severity of OCD. It is also a minor predictor of a lower change in symptomatology after combined treatment.

Marriage under control: Obsessive compulsive disorder and partnership.

BACKGROUND: People who have an obsessive-compulsive disorder (OCD) tend to manifest a need for excessive control over their partners and other relatives, which then constitutes a principal problem in their relationships. This behaviour probably relates to an unmet need for safety in their childhood. This review article aims to explore the interpersonal dimension of OCD. METHOD: Sources used in this review were acquired via PubMed from January 1990 to January 2020. The search terms included "obsessive compulsive disorder", "OCD", "marital problems", "marital conflicts", "marital attachment", and "partnership". Primary search with keywords in various combinations yielded 242 articles. After applying inclusion and exclusion criteria, 68 articles were found eligible for further research, and a secondary search was performed by screening their reference lists for relevant articles. In total, 124 papers were included in the review. RESULTS: OCD patients often have interpersonal problems that are related to symptomatology and the excessive need for control over the relationship. The patient is often addicted to his/her loved ones and transmits his excessive concerns to them. The studies describe increased marital distress, less satisfaction with their partner and couples experiencing less intimacy. The communication style of people suffering from OCD often shows a tendency to control others extensively, which is probably related to their exaggerated need for safety. Individuals with preoccupied or avoidant attachment styles are more likely to become jealous and to consider any rival as threatening than those people who have a safe attachment style. CONCLUSION: Participation of the partner in the therapy can have positive effects. Furthermore, family-based exposure and response prevention programs might be useful for reducing OCD symptoms.

"Don´t tell me that I am hysterical": Unmet needs of patients with panic disorder.

OBJECTIVES: In the new millennium, a growing focus on human rights and preserving individual autonomy urges the promotion of needs of the psychiatric patients. The topic of human needs takes its place also in patients with panic disorder. This review intended to explore current facts concerning the needs of the patients and present a broader understanding of patients' needs, due to the complexity of problems of patients with panic disorder. The text also focuses on psychosocial well-being and the quality of life of patients with panic disorder. METHODS: The PubMed was used to search for articles published between January 2000 and February 2020 using the following keywords: "panic disorder" or "agoraphobia" and "unmet needs" in combination with "pharmacotherapy" or "psychotherapy" or "cognitive behavioural therapy" or "family" or "quality of life." A total of 264 articles were selected by primary keyword picking in different combinations. Altogether 182 articles were reviewed. RESULTS: We identified the most important unmet needs of patients with panic disorder connected to symptoms, treatment and help-seeking, stigma and self-stigma, family and quality of life. To help the patients to improve the unmet needs connected with: (1) symptoms is to increase the awareness of treatment steps for patients and their families, good cooperation with therapists, and management of persistent symptoms, alleviation or elimination of anxiety symptoms, avoidance and safety behaviour. (2) treatment is the quick approach, effective one, not too difficult, without side effects and harmless, not requiring hospitalization and not disturbing the daily routine, increasing treatment compliance, improving patient self-confidence and an active social network, affordable health and social services and more suitable information for families; (3) stigma is to change of public opinion about people with mental health problems and to create effective antistigma programs; (4) family is to include the support for a functional and independent life, helping to manage everyday tasks and stop excessive protection, while reducing the stigmatization of the whole family. (5) the quality of life is to help to integrate into the community and improve the factors that affect the quality of life; like esteem, self-acceptance, social acceptance etc. CONCLUSIONS: This review aimed to explore the unmet needs in patients with panic disorder or agoraphobia. In selected articles we identified 5 basic unmet needs and described the basic strategies to cope with them. It is essential for every clinician to understand those needs as it can substantially help to alleviate patients' symptoms and improve their quality of life. The importance of this understanding further highlights that unmet needs described for panic disorder overlap with unmet needs of other psychiatric disorder and thus have broader utility.