Borderline personality disorder (BPD) is very common, with an estimated community prevalence of 1-3%, rising to 25% in psychiatric inpatients. The aim of this talk is to address the challenges clinicians face when diagnosing borderline personality disorder. The new dimensional approach to the classification of personality disorders adopted by ICD-11 diverges from the classical categorical case definitions used in the ICD-10 and DSM-IV/DSM-5 diagnostic frameworks, thereby significantly altering the concept of personality disorders. While the DSM-5 checklist is a well-known and widely used diagnostic entity by now, with the introduction of Personality Inventory for DSM-5 (PID-5) a new assessment tool has emerged, providing the possibility of a more detailed description of personality functioning and traits. PID-5 is a 220-item self-rated personality trait assessment scale, assessing 25 personality trait facets and 5 main personality trait domains. This talk will focus on analyzing the difference between categorical and dimensional diagnostic work-up, using a case presentation to demonstrate the diagnostic processes and their outcomes.

Personality disorders have ever been a troublesome group. From the early 90’s ICD 10 tidied up the group. DSM-IV, IV-TR, aand then DSM 5, changed the style but not substance, leaving clinicians to grapple with thorny questions of multiple diagnoses, treatment and prognosis. International views on the utility of the diagnosis often depended upon the institution or the funding mechanism. Were fears of exclusion and stigma dominated or where there was no treatment, there was under-diagnosis, such as in the United Kingdom and the Republic of Ireland. Where a label was a ticket of entry to treatment and funding, diagnostic generosity prevailed, such as in Australia, New Zealand and the United States. Gender discrepancies disappeared with structured interviews, and interest grew in the category which seem to only include the most severe forms. For many years the DSM taskforce tried to shift the construct but shied away from the cliff edge; a bold new initiative did not materialise. It was left to the ICD-11 to generate a much more adventurous and positive view of how characterological traits shift under pressure, moving from something that may at first have helped patients to ‘survive’ to something that became maladaptive and harmful. With a court tested case Dr Wise will demonstrate the differences between ICD-10 and ICD-11 highlighting the more important differences: onset, course and severity descriptors. PD’s are no longer lifelong impairments. Prepare for ‘The shock of the new’!

Kleptomania is an impulse control disorder characterized by the irresistible urge to steal not for monetary gain. Since its conceptualization, this categorical diagnosis has been conflated with common beliefs regarding the social class and gender such as the idea that women are intrinsically fragile and that people in the middle class were unlikely to commit theft. Also, its use has been controversial in the medical and forensic fields. This presentation will provide a historical excursus through the definitions of the syndrome and summarize the available pharmacological and psychotherapeutic options for its treatment. Currently, there is a lack of systematic studies regarding the clinical characteristics of kleptomania and its treatment options for practical standardized approaches.

The de Clèrambault syndrome is a psychiatric condition characterized by the presence of a delusion in which the patient is convinced that another person has fallen in love with him or her. Patients usually believe that their lover is a person belonging to a higher social and economic class, or is already married, or even is imaginary or deceased person. In the majority of cases, the patients do not seek for psychiatric help, but usually is referred to the mental health care system due to behavioural consequences associated with the syndrome, including stalking behaviours (repetitive calling, unexpected visits or continuous attempts to send gifts or letters to the loved person). The name of the syndrome derives from the French psychiatrist Gaetan Gatian de Clerambault, who systematically described this syndrome in a series of patients. According to the modern classification systems, the syndrome is conceptualized as erotomanic subtype of the delusional disorder. However, the presence of delusions is not the only clinical feature of the syndrome. In fact, specific affective features are usually present, such as grandiosity, hypersexuality and promiscuity. Therefore, it has been argued that De Clèrambault syndrome should be considered as lying on the continuum of the spectrum of bipolar disorders. Those diagnostic uncertainties highlight the difficulties for clinicians to properly manage this syndrome and should represent a valid reason for rediscovering this almost neglected psychiatric syndrome.

Drug and alcohol use in adolescence is a major global public health concern. Adolescence is the highest risk period for the initiation of drinking and substance use. Since the 90s, a growing body of evidence has indicated the influence of peers’ behaviours and attitudes in the development of youth tobacco, alcohol and drug use. Based on these studies, the social norms approach has been developed, mainly applying to the Western countries. The approach argues that how a student perceives his/her peers’ health-related behaviours and attitudes (such as substance/alcohol use) does have an influence on his/her own behaviour, and negative behaviours are generally overestimated among peers. Correcting these misperceptions may contribute to the prevention of youth substance/alcohol use. The applicability and discussions on the social norms approach will be presented in this talk, with two example studies. Both studies are conducted in Turkey, which is ranked lowest in terms of alcohol use and related problems among World Health Organization Europe zone countries, despite and increasing trend in use over the past decades. In both university and high-school samples, we found that students’ misperceptions about higher peer tobacco and alcohol use facilitated their own alcohol use. We conclude that targeting social norms may be part of a generalized preventive approach with regards to drug use and is of universal value. References: 1. SÖNMEZ, E. & AKVARDAR, Y. 2015. A Social Norms Approach to Substance Abuse Prevention in Youth “The more I think you drink, the more I drink”. Bağımlılık Dergisi-Journal of Dependence, 16, 86-94 (Turkish) 2. GÜNDÜZ, A., SAKARYA, S., SÖNMEZ, E., ÇELEBI, C., YÜCE, H. & AKVARDAR, Y. 2019. Social norms regarding alcohol use and associated factors among university students in Turkey. Archives of Clinical Psychiatry (São Paulo), 46, 44-49.

Prodromal symptoms may precede onset of the psychotic disorders by years, and while we have instruments for identification of clinical high-risk (CHR), existing predictive models yield low specificity and fail in successfuly predicting transition to psychosis. This, along with the fact that we see a notable decline in transition rates, and the ever-looming lack of resources, means CHR work is still often relegated to research settings. First-episode psychosis (FEP) unit of our institution offers both inpatient and outpatient programs, and while it is common having CHR services emerge from FEP frameworks, there is an inherent risk in drowning the diverse CHR population into very specific FEP interventions and settings, risking additional burden of stigma. Model our institution introduced includes: ⇒Non-dependence on research funding; ⇒Flexible integration in available resources (e.g., FEP interventions, anxiety disorders interventions, substance-use programs); ⇒Dimensional approach with interdisciplinary assessment of capacities/needs non-reliant on supposed diagnosis; ⇒Embedded coordinating clinician ensuring “coordination” of CHR population “dispersed” among different programs; ⇒Collaboration with child psychiatrists allowing smoother transfer of at-risk youth; ⇒Recruitment through sensitized general practitioners and counseling services. No model of care, especially in area lacking conclusive predictive models, can be generalized to different health care systems, as practices and resources vary significantly. Nevertheless, the model presented makes a contribution to the care of CHR population, utilizing/integrating available resources, focusing on dimensional formulation of needs, and avoiding possible stigmatization. Furthermore, widely available CHR services, congruent with any research initiatives, might help us reach the necessary critical mass of data and experience needed for the final push towards clearer prediction models and treatment algorithms.

The COVID-19 pandemic and its related containment measures, such as lockdown, is affecting mental health of the general population worldwide. This is an unprecedented event, which is influencing the health care, political, economic, and social welfare systems. Among Western countries, Italy has been one of the first severely hit by the pandemic in terms of number of cases and mortality rates. Therefore, on March 8, 2020, the Italian Prime Minister issued restrictive measures in order to limit the spread of the disease. During this period known as “Phase one” of the national health emergency, all not necessary activities have been closed, more than 29,000 people have died and almost 100,000 people have been home-isolated, with strict lockdown measures. The COvid Mental hEalth Trial (COMET) network, including ten university Italian sites and the National Institute of Health, has promoted a national online survey in order to evaluate the impact of lockdown measures on the mental health of the Italian general population. The COMET survey reports data from a large sample of more than 20.000 people from Italian general population, showing that lockdown has had a detrimental impact on mental health, in terms of worsening of anxiety, depressive and stress symptoms. Findings from this study can be useful to inform national and international associations, policy makers and stakeholders on the importance to provide adequate support to the mental health of the general population.

Hikikomori is a form of severe social withdrawal, initially described in Japan and recently reported in other countries around the world. Individuals with hikikomori shut themselves in their homes with minimal interaction with society and little participation in school or the workforce. The nature of hikikomori makes the individuals suffering it a hard-to-reach population. While hikikomori was described in Japan much before the ‘digital revolution’ of the 2000s, the internet, social media, and online gaming have radically changed the way people interact. This may be particularly true among hikikomori who spend much time online for entertainment or social interaction. Given this, the online world has been proposed as an accessible gateway to reach and support individuals with hikikomori. This talk will present and discuss the results of the Twitter-hikikomori international studies, conducted between 2018-2020 and led by Dr. Pereira-Sanchez, which employed social media mixed quantitative-method analyses to characterize the public conversations related to hikikomori on the social media platform Twitter in several Western languages and Japanese. As for the results, Twitter data provided evidence that hikikomori extends well beyond Japan examining, and showed that tweets in Japanese are more often are related to personal anecdotes, whereas tweets in Western languages are more often related to hikikomori as a medical issue. Apart from the results of the content analyses studies have been a proof of concept on the use of social media contents to investigate a phenomenon affecting a hard-to-reach population, which may inspire future online-based efforts to better support these populations.

Most elderly patients with mental disorders are treated with polypharmacy (e.g., five or more medications), and they are receiving medications that are potentially inappropriate for elderly patients (e.g., PIMs). These aspects are often excluded in the clinical guidelines, meta-analyses, and randomized controlled trials but are very important for prudent prescribing in daily practice. The most robust approach to reducing irrational polypharmacy, PIMs, and other medications-related problems in this population is a careful deprescribing process. It is the process of tapering, withdrawing, discontinuing, or stopping medications. There are some tools available to help in the deprescribing process in clinical practice, including different medication lists (e.g., Beers criteria, STOPP/START, and guidelines) and collaborative care, including clinical pharmacist or pharmacologist. Medication lists have been used in clinical trials and guidelines, where Beers criteria are used predominantly in the U.S. and Priscus list in Europe. A collaborative care approach, including a clinical pharmacist, has been established only in some countries (e.g., USA, UK & Slovenia). The results are positive with a decrease of PIMs, polypharmacy, and an increase in the patients’ quality of life. The participants will learn the general deprescribing processes supported by the evidence-based data and real clinical pharmacological tools useful for daily practice.

Although depression in the elderly is often underdiagnosed and undertreated, some data show that next to this potential underuse, antidepressant prescriptions may also be overused and prescribed inappropriately. These potentially overused and inappropriate prescriptions of antidepressants are often related to polypharmacy, comorbidity and increased mortality. Deprescribing is the planned and supervised process of reducing or stopping medications that may no longer be of benefit or may be causing harm. Clinically relevant aspects and considerations of this deprescribing process in elderly patients with affective disorders will be discussed. Woodford HJ, Fisher J. New horizons in deprescribing for older people. Age and Ageing 2019;48:768-775. Hiance-Delahaye A, et al. Potentially inappropriate prescription of antidepressants in old people: characteristics, associated factors, and impact on mortality. Int Psychogeriatr 2018 May;30(5):715-726. Bobo WV, et al. Frequency and predictors of the potential overprescribing of antidepressants in elderly residents of a geographically defined U.S. population. Pharmacol Res Perspect 2019;e00461.

Polypharmacy is rather a rule than an exemption in the elderly. This applies also to the demented population, whether they live in private homes or in nursing homes. The application of multiple drugs increases the risk to develop delirium, to promote falling and to hasten cognitive decline, What can be done to reduce these risks? First of all, drugs should be given on the basis of an appropriate assessment. Pain e.g. may be misunderstood as challenging bevhaviour. Side affects might be misunderstood as newly occuring symptoms. Drugs should be prescribed with a written protocol, what the drug is expected to do. If this does not occur, the drug should be deprescribed. In addition, antidepressants should be deprescribed. Many demented patients receive more than two of them, mostly for years. Depresciption follows the evidence, that antidepressants are not much helpful in dementia. They may induce hyponatriamia, too. The deprescription of benzodiazepines requires patience and a long tapering-out. And overall, what about the antipsychotics? They shall be given at a minimum dosage and duration. That means, that drug pauses should be established regularly. And finally, what about the antibiotics, antihypertensive drugs and more? Having in mind, that severe dementia is mostly a state, where the priniciples of palliative medicine should be applied, also many of these drugs can be deprescribed.

Maintenance treatment with antipsychotics remains the key principle in the long-term management of psychotic disorders. For some patients, it means life-long use of medication. Continuous drug administration helps to prevent relapses, maintain remission, and achieve functional recovery. Moreover, epidemiological data suggest that antipsychotic treatment significantly reduces mortality rates of schizophrenia patients. On the other hand, some authors argue that antipsychotic drugs may lose its efficacy over time, their long-term exposure results in more harm than benefit. Especially elderly patients are more sensitive to side effects. Several studies which followed-up patient cohorts over the span of several decades found that there are schizophrenia patients who can achieve good functional outcome and full recovery without antipsychotic treatment. Therefore, it is paramount to identify those individuals, particularly among elderly psychotic patients, who can thrive and benefit from timely antipsychotic discontinuation.

Blekinge Family Postvention is a grief facilitator-home-visiting postvention giving early support to families after a suicidal loss since 2015. It helps families overcome shock, pain, anger, guilt, suffering and other extreme emotions caused by suicide. Such situations should be treated not as a disorder. Medication should be used only as a last resort to treat individuals not responding to early family support, followed by individual sessions if needed. Everyone needs to express feelings and thoughts on all aspects of the suddenly interrupted relation. To achieve this, a person experienced in those issues must be leading all of the meetings. The conversations should start during the first days, frequently continuing for at least 3-5 weeks depending on the family needs. Helping the family bear each other and find coping strategies ease their pain, mourning and give them hope instead of prolonged grief. In this way, the family gradually finds new ways to overcome a never-ending negative looping that eventually can cause, e.g. post-traumatic stress disorder and depression. The support to the family after suicide loss should be a governmental matter. Today all work is done voluntarily. The close relatives need debriefing right after the district doctor has stated the death or the police informed the family about suicide. The military, the police, rescue services and healthcare professionals gets debriefing when a rescue operation has failed. This presentation discusses how to organise early family support and the Ellipse project’s interviews with survivors about their experiences of needed or received support if any.

Project ELLIPSE (E-LifeLong Learning in Prevention of Suicide in Europe) was developed in response to need for preventive suicide programs. It was noticed that it is important for academic teachers and students, especially those who teach and study in the fields of medicine, nursing, psychology, sociology or those related to the media. The goal is creating an e-learning platform for students and teachers on suicide prevention along with a textbook and a free self-help application. For this purpose the milestone was the conducting of the focus group interviews in Poland. Participants were recruited from the above mentioned groups (students and professionals). The objectives of this part of the project were among others: raising awareness of the problem of suicide and prevention, giving good examples on suicide prevention in working life, preparation of a program proposal for e-learning content. Students interest in the problems of suicidology was high and they comes optimistic to the idea of prevention, they want to know especially about how to help somebody, how to talk and not to harm people and something more in their future profession. Only theoretical approach will be not enough for them, the rules of how to NOT react, will not be interesting because they know something about it. They showed a knowledge of basic concepts, extensive and multi-context knowledge of causes and warning signals and great understanding for suicides of all ages. However, they themselves were uncertain how to help such a person, and showed poor recognition of institutional help.

There is a high demand for specific training on the understanding and management of suicidal behaviors. We will present a summary of a massive open online course that was launched in France in 2018 for the first time. The structure of the program was simple: 5 modules presented on a weekly basis, each module contained several short videos with direct training, interviews or discussion. The MOOC offered as well other ressources such as access to a forum during the course, an updated bibliography and vocabulary for each module and an evaluation at the end of the modules. In the first year, the number of registered candidates for the course was very high (>10000) and more than a quarter completed the course (>2500), with participants from 82 countries. The quality of exchanges with the students was very high. The results of this ongoing experience provides interesting insights on how to improve access and motivation to specific training in the field of suicidal behavior for participants from very different backgrounds.

COVID-19 pandemics has influenced many research and educational projects, and it influenced also ELLIPSE-project, aiming at the creation of a free online curriculum in suicide prevention for students in the higher education in Sweden, Austria, Hungary, Norway and Poland (September 2019-August 2022). The ELLIPSE (E-Lifelong Learning In Prevention of Suicide in Europe) (www.e-llipse.com) is the first international project in the area of education in suicide prevention in the higher education co-founded by the European Union Erasmus+ programme. We will reflect on some opportunities and challenges due to COVID-19 pandemics. Identified opportunities: 1) learning a new way of communicating, 2) reaching more participants (in case of Sweden we were able to get participants from more regions, 3) more frequent meetings heightening the quality of the project, 4) travelling less (online is the more eco-friendly solution). But there were also some challenges: 1) not be able to proceed according to the preliminary plan generated much more administrative work, 2) online meetings was a challenge for those partners who had problems adjusting to the online form of communication, 3) more negative attitudes to the canal of communication resulted in avoiding it, leading to less frequent interactions what resulted in diminished motivation to the project, and being unable to proceed with project tasks, 4) resignation of some patients from participation because of difficulties in accepting the online form of communication. We will discuss these issues in a more detailed way during the interactive workshop.

Mental disorders linked with the menstrual cycle, childbirth and the menopause are unique to women and have their specific requirements for identification, assessment, treatment and service provision as well as appropriately trained staff. Mental disorders that are linked to domestic violence, sexual abuse or victimisation and affect more women than men, also have their own specific requirements. This is increasingly being recognized by policy makers and health care planners. In the case of perinatal mental health some countries have set up specialised inpatient and community services. In the UK this was followed by the development of National competencies for different professional groups and National training programmes. This project and the current clinical training in perinatal mental health for psychiatric trainees will be described. Nationally recognized qualifications are currently being developed. Developments in other areas of women’s mental health appear less advanced. The presentation will discuss current guidelines and opportunities for training that are being offered in the UK and what we can learn from perinatal mental health for further development in these areas.

In the world of medical education, there is generally a lot of emphasis on following procedure and tradition, and a reluctance to challenge the norm. It takes insight and courage to question traditional approaches and paradigms: why are psychiatric training programs done the way that they are? Reverse engineering involves taking something apart and analysing its workings to figure out how it does what it does and how it can be improved. In education, reverse engineering implies one determines learning outcomes upfront and then works back from them. Applied to postgraduate psychiatric training, it requires us to determine the basic principles or core concepts resulting in the successful formation of a well-rounded psychiatrist. In times of crisis there usually is more leeway to challenge the status-quo – hence the saying “never waste a good crisis”. Indeed, if the COVID-19 crisis has taught us anything, it is that education should be meeting learners where their attention is at, and that any healthcare organisation can be transformed within weeks when given the right incentives. In this workshop, Dr. De Picker will reflect on how post-COVID European psychiatric training can reinvent itself to address long-standing concerns and unmet needs. Innovative approaches will be needed to start shaping the psychiatrists of the future.

There is still substantial variation in the amount, structure and quality of child and adolescent psychiatry (CAP) training across European countries, both in the training process of general adult psychiatry and CAP specialists. Inconsistency, scarcity and low quality of CAP exposure has been consistently identified by psychiatric trainees as one of major issues in organization of training. In the decades of independence, following the collapse of the Soviet Union, Latvia has witnessed a gradual decline in the number of CAP specialists in the country due to chronically low recruitment rates, that has subsequently led to a critical human resource deficit in the field, and rapid deterioration of availability and quality of CAP care. Only since the year 2018, when the normative regulation, structure and contents of CAP training in Latvia have been significantly reformed, there was a change in recruitment trends, that gives hope for resolution of the human resource crisis in the CAP field in the years to come. In this talk the author will share his experience of redesigning the CAP training program in Latvia, and discuss the motivations, challenges and successes one might face while trying to improve CAP training in a particular European country.