The present study investigated structural and metabolic changes in the two brain regions of the limbic system, right hippocampus and anterior cingulate cortex (ACC), implicated in the pathophysiology of major depressive disorder (MDD). Three-dimensional-T1-weighted magnetic resonance imaging (MRI) and single-voxel in vivo magnetic resonance spectroscopy (MRS) were performed on a 3.0 T MRI in patients with MDD (n = 64) and healthy controls (HC, n = 47). The severity of depression was assessed using clinical scales (Hamilton Depression Rating Score [HDRS] and Montgomery-Åsberg Depression Rating Score [MDRS]). The automated volumetric segmentation of the T1-weighted MR images was performed using Freesurfer 7.2.0. The tissue-corrected concentration of neurochemicals was quantified using Osprey software. The relationship between hippocampal and ACC metabolite levels was examined with their volumes. Additionally, the levels of neurochemicals and volumes were correlated with the severity of depression. After adjusting for multiple comparisons using the false discovery rate (FDR), the concentration of total NAA (t-NAA, N-acetyl aspartate+ N-acetyl-aspartyl-glutamate [NAAG]), myoinositol (mI), total choline (tCho) and total creatine (tCr) were significantly reduced (pFDR < 0.05) in the hippocampus of the MDD patients. The ACC in MDD patients showed significantly higher levels of tNAA and tCr (pFDR < 0.05). Further, the volume of ACC was significantly increased in patients with MDD. Although hippocampal volume was not different between the two groups, a weak positive correlation was observed between the tCho levels and the volumes of the hippocampus and mid-ACC. Hippocampal glutamate + glutamine (Glx) levels showed a weak negative correlation with the MDRS score, whereas ACC tCho showed a negative correlation with the HDRS score. Our observations suggested that the pathophysiology of MDD is not only associated with hippocampal neurodegeneration but may also involve glial proliferation, leading to increased ACC volume. These changes might alter neurotransmission in the limbic system, contributing to the pathophysiology of depression.

Major Depressive Disorder (MDD) is a psychiatric disorder associated with altered neuro-metabolism. This study investigated the effect of antidepressant therapy on the metabolism of the right hippocampus and anterior cingulate cortex (ACC) in patients with MDD, using in vivo proton magnetic resonance spectroscopy (MRS) at 3.0 T. MRS was performed in 42 patients with MDD (at baseline and after 8 weeks of antidepressant therapy) and 35 healthy controls (HCs). Metabolite concentrations were quantified using Osprey software with partial-volume corrections. The Hamilton Depression Rating Scale (HDRS) was used to assess response to antidepressant therapy. Patients with MDD who had a > 50% reduction in HDRS scores were classified as remitted, and those with a < 50% reduction were grouped as non-remitted after therapy. Compared with HCs, baseline levels of hippocampal total N-acetylaspartate (tNAA), total creatine (tCr), total choline (tCho), and myo-inositol (mI) were reduced. Baseline levels of ACC tNAA and tCr were higher in patients with MDD than in HCs. After antidepressant therapy, a significant increase in tNAA and tCr levels was observed in the hippocampus of patients with remitted MDD, indicating a positive impact of therapy on energy metabolism and neurodegenerative processes, thereby supporting remission. Hippocampal metabolite levels remained unaltered after therapy in the non-remitted subgroup. ACC metabolites remained unaltered after therapy in both remitted and non-remitted subgroups. Thus, findings highlighted the importance of hippocampal metabolism in MDD and the possibility that metabolite levels may serve as biomarkers of antidepressant therapy response.

Aims 1.To study the neural correlates of OCD using functional MRI. 2.To compare the neural correlates of the pure washer dimension of OCD with other dimensions of OCD and healthy controls. Methods It was a cross-sectional, case-control study conducted from 2018 to 2021. OCD patients were recruited with purposive sampling from outpatient attendance at All India Institute of Medical Sciences, New Delhi following the inclusion and exclusion criteria. The patients were divided into two groups i.e. washing sub-type and non-washing/other sub-type based on dimensional YBOCS score. The healthy control group consisted of age and sex-matched healthy individuals. Each group had 10 individuals. The participants underwent functional MRI with resting fMRI and activation task-based MRI. Activation tasks included a cognitive task i.e. Stroop test and an affective task which included trigger words for OCD tailored according to the patient's triggers for OCD. The results were studied for significance within a group and also compared among the three groups and between OCD patients and healthy controls as well. Results In OCD-specific task using trigger words, the right frontal gyrus, right medial frontal gyrus, and left cingulate gyrus showed hyperactivation in the washer OCD subtype group. After correction for family-wise error, p-FWE (<0.05) corrected < 0.05, there was so significant result. The non-washing subtype had no significant areas of activity on the OCD specific task. But the combined OCD patient group (compared with controls), had hypoactivation of the right inferior frontal gyrus and fusiform gyrus at p-unc (<0.001) in the OCD task. In the Incongruent part of the Stroop task, the non-washer subtype had hypoactivation of the right caudate body compared with healthy controls at p-FWE (<0.05). In the congruent Stroop task, washer OCD subtype, the right insula was found to be hyperactive at p-FWE (<0.05). Conclusion Previous studies comparing activation on cognitive tasks in OCD patients and healthy controls have revealed differences in CSTC circuits as well as cerebellum and parietal areas. The washing symptom dimension is associated with insular hyperactivity in both emotional and cognitive tasks. It is associated with stimuli related to disgust. The role of the insula is being researched in functions like attention and response inhibition. Our study, with all its limitations, could replicate the insular findings in washing-subtype of OCD. With a better sample size, we may be able to explore further the findings that have not attained levels of significance in our study.

A 26-year-old female was hospitalized with complaints of repeated vomiting and weight loss (18 kg in 8 months); and incessant belching and nausea/regurgitation for 30 days subsequent to her COVID-19 treatment. After all the normal medical radiological reports, appropriate psychological and psychiatric evaluations were done. Incessant belching warranted a simple and flexible cognitive psychotherapy for histrionic personality with a therapeutic assessment technique. A total of 6 h of psychotherapy was delivered in three sessions. The belching and vomiting came down by 75% after the first extensive session, and almost 100% after the second session. However, mild belching reappeared, and after the termination-cum-booster session belching subsided till discharge and the first follow-up after 2 weeks.

Present study investigated volumetric changes in the brain of Indian patients suffering from Major Depressive Disorder (MDD) using Magnetic Resonance Imaging (MRI). These patients were seen to have significantly reduced brain and cerebellar volumes. Volume of caudate, putamen and globus pallidus were seen to be reduced but no significant changes were seen in hippocampus and amygdala. Volume of cerebellum and lobule VI of cerebellum was also reduced. Our results suggest that cerebellum as well as VI lobule of cerebellum may be associated with MDD.

Background:Obsessive-compulsive disorder (OCD) is a common psychiatric disorder whose underlying pathophysiology is insufficiently understood. The pathophysiology of OCD may be related to abnormalities in the biochemistry of neurotransmitters. Aim:The aim of the present study was to measure the absolute concentration of various metabolites in the right dorsolateral prefrontal cortex (DLPFC) and caudate nucleus (CN) in treatment-naive patients with OCD and compare it with healthy controls (HCs). Methods:The present study investigated the metabolic profile of two brain regions, namely right DLPFC and CN, by using single voxel in-vivo proton magnetic resonance spectroscopy (1H MRS) in drug-naive patients with OCD (n = 17, mean age = 30.71 ± 10.104 years) and compared it with healthy controls (n = 13, mean age = 30.77 ± 5.449 years). The patients with OCD were recruited after appropriate psychometric assessments. The 1H-MRS experiments were performed using the 3 Tesla (3T) human MR scanner, and absolute concentrations of metabolites were estimated using the LC model. Results:Significantly lower concentration of tNAA in the right DLPFC was observed in the patients with OCD compared to the controls, which may be indicative of neurodegeneration in this region. However, no significant differences were observed in the concentrations of the metabolites between the patients and controls in the CN region. The level of tNAA in DLPFC significantly correlated with the disability level (WHO-DAS) of the patients. Conclusions:The present study demonstrates abnormalities in the metabolic profile of an important region, DLPFC of the CSTC circuit, which is suggestive of neurodegeneration in the region in OCD patients.

INTRODUCTION Delimitation of the topic and target group This guideline uses the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) diagnosis of “borderline personality disorder”.[1] The guideline is intended to be applied to specialised psychiatric and general/primary healthcare settings. Personality disorders in the current classificatory systems Research on personality disorders (PDs) has progressed significantly. Classificatory descriptions of PD have been changing from categorical to more acceptable dimensional ones. However, for this guideline, we have followed DSM-5, as most of the existing good quality evidence is based on DSM-5 or DSM-IV-TR criteria. Present-day scientific research primarily emphasizes the BPD categorical diagnosis and so does this guideline. International Classification of Diseases 10 (ICD-10) emotionally unstable PD: borderline type is similar to the DSM-5 borderline PD diagnosis [Table 1].[1,2] ICD-11 and DSM-5 describe personality disorders differently; in ICD-11, the equivalent to ‘borderline personality disorder’ would be the diagnosis of personality disorder (usually moderate or severe) with a specifier ‘borderline pattern.’Table 1: Diagnostic criteria/guidelines for borderline personality disorderBASIC CONCEPTS Personality and temperament The term “Personality” encompasses a dynamic set of functions and traits. Personality can be described on four levels: Personality traits (e.g., temperament, Panel 1). Characteristic means of adaptation and individual goals. Narrative self (e.g., identity). Dynamics of interaction relationships. Panel 1: The five-factor model of the personality disorders“Temperament” refers to individual, biologically based skills in regulating emotions that can be recognized already in infancy. DSM-5 defines personality traits as persistent ways of perceiving, relating to others, and understanding oneself and the environment.[1] Among the personality traits, (i) emotional stability, (ii) conscientiousness, and (iii) social dominance continue to increase until the age of 30–40 years.[3,4] Traits of healthy and disturbed personalities seem to form a continuum. Personality disorder Borderline personality disorder (BPD) is associated with a limited, rigid, or unstable experience of the established self and self-concept and difficulties in interpersonal relationships. Accentuated negative emotionality is a hallmark of borderline personality but the condition is also associated with acute symptoms.[1,5] When managing BPD, it is important to remember that the diagnostic criteria for borderline personality describe a heterogeneous group of patients.[6] And also that the disease burden of PD patients is comparable to severe physical diseases.[7] EPIDEMIOLOGY Global prevalence PD have been found at varying rates all over the world. The prevalence of PD (as per DSM-5) in the general population is about 6%. Cluster-B PD, which includes borderline, antisocial, histrionic, and narcissistic PD, have an overall global prevalence of 1.5%.[8] PD is clearly more common in young adulthood than later.[9,10] In high-quality European population studies, the prevalence of borderline personality was reported to be 0.7%.[11] As per estimates, BPDs occur in 6% of primary care patients but the proportion of identified cases is probably much lower.[12,13] Western studies suggest that almost 60% of people with BPD may be in contact with primary healthcare services during the year, usually due to somatic symptoms and illnesses. The prevalence is relatively higher among young adults, women, and people with little education and low income.[14] There is no research evidence of an increase in the prevalence of BPD. Indian prevalence Systemic studies from India and other developing countries assessing the prevalence of PD are lacking. Early studies (from the late 1980s) reported the prevalence of PD in the general population ranging from 0% to 2.8%, with a weighted mean prevalence of 0.6%. Male gender was significantly associated with PD.[15] Most epidemiological studies conducted in India have systematically under-reported the prevalence because of sampling bias and other methodological flaws. The prevalence of PD among treatment-seeking Indian populations (0.3%-1.6%) is lower than that of western data (25%-50%). However, this difference is likely due to under-recognition.[15] A retrospective chart review (1996–2006) among North Indian patients seeking treatment in psychiatric outpatient settings reported a prevalence of 1.07% for ICD-10 PDs. The most common PD documented in the study were anxious-avoidant and borderline.[16] The reported rates are higher in special populations such as individuals in conflict with the law (7.3%-33.3%), individuals with substance use disorder(s) (20%-55%), and those who had ever attempted suicide (47.8%-62.2%).[15] A recent study on patients (N = 100) visiting the emergency department of a private hospital in eastern India using translated scales to screen for ICD-10 diagnosis of PDs found 24% of participants met the cut-off criterion.[17] RISK FACTORS Childhood antecedents BPD is thought to arise either from the interaction of predisposing factors or from the worsening of a childhood or adolescent psychiatric disorder. As per the so-called exposure model, BPD results from an interaction between predisposing factors. As per the so-called complication model, it is primarily the result of another psychiatric disorder. Support for both models has been found in longitudinal research because the age of onset and gender seem to lead to different developmental curves.[10] In girls, internalising symptoms in early adolescence, such as anxiety and depression, may predict BPD in late adolescence (complication model), while externalising symptoms, such as defiance and conduct symptoms in adolescence, may predict BPD in adulthood (exposure model).[18,19] Predisposing factors Factors that increase the risk of BPD are also associated with other psychiatric disorders and physical illnesses. The accumulation of several factors suggests a higher probability of a disorder. Hereditary factors are known to be associated with personality traits and BPD.[20] In some patients, the emergence of the disorder may be related to organic and neurocognitive factors, such as encephalitis (inflammation), epilepsy, learning disorders, and childhood attention deficit hyperactivity disorder. Risk factors during pregnancy, such as maternal smoking, medical complications, and complications during childbirth, seem to increase the risk of BPD.[21] Those suffering from BPD report more difficult, traumatic childhood experiences than healthy controls.[22] Anxiety sensitivity and aggressiveness or hostility related to the temperament trait of negative emotionality and severe emotional abuse are independently associated with the risk and severity of BPD. Heightened rejection sensitivity may be related to emotional neglect.[23,24] Sexual abuse as a single factor apparently increases the risk of BPD little or not at all.[25] There is conflicting evidence about the association between dissociation symptoms and traumatic anamnesis in BPD. Dissociation can manifest as forgetfulness, a feeling that the self (depersonalisation) or the world (derealisation) has become alien, or as short-term hallucinations. BPD is significantly but weakly related to accumulating parenting problems. The parent’s mental disorder and lower socioeconomic status may be background factors for abuse and emotional neglect. Prolonged separations from parents in the preschool years are linked to symptoms of BPD in adulthood.[24] Abnormalities of brain function have been observed in neurophysiological studies (EEG and arousal response studies).[26] BPD is associated with disruption of the functioning of the serotonin system in the fronto-limbic areas of the brain.[27] Brain changes that occur in patients with BPD, such as a decrease in the volume of the hippocampus and amygdala, are possibly related to childhood maltreatment, the severity of the disorder, and comorbidity.[28] PRIMARY PREVENTION There has been no research on the primary prevention of BPD. A BPD exposes children to problems in parenting; so, good treatment of the disorder is likely to be promoted by good parenting. Parental guidance has a positive effect on the parenting patterns of at-risk families and children’s behaviour problems. A wide-ranging program including nutrition, education, and exercise implemented in kindergartens may reduce disruptive behaviour and psychotic symptoms in young adulthood. Parental guidance reduces behavioural disorders in children and may reduce the costs caused by the continuation of behavioural disorders later.[29] CLINICAL FEATURES Core features of BPD The core features of BPD are marked affective dysregulation, marked disturbances in self-image, unpredictable interpersonal relationships, and marked impulsivity. A model by Sanislow et al., 2022[30] summarised the features of BPD into the following three dimensions: Impaired relatedness–Chronic emptiness, unstable relationships with others, and identity disturbance. Affective dysregulation–Affective lability, excessive anger, and violent efforts to avoid abandonment. Behaviour dysregulation–Impulsivity, suicidality, and self-injurious behaviour. Affective instability was shown to be the most sensitive and specific single manifestation of BPD in a sizeable psychiatric OPD sample evaluated using a semi-structured interview.[31] All symptoms of BPD are associated with psychosocial impairment and poor quality of life. Chronic feeling of emptiness was found to be associated with the highest morbidity, including suicidality. Other important presenting features of BPD Suicidality Suicidal threats, gestures, and attempts are common manifestations of BPD. Data on rates of suicidal ideas, attempts, and suicide deaths have varied markedly. In retrospective studies, the rate of death by suicide is between 8% and 12% among individuals with BPD.[32] Years of suicide threats and self-injurious behaviour may precede a completed suicide and therefore predicting a suicide outcome may be difficult. All reported suicide ideations or attempts should be taken seriously in patients with BPD. Suicide risk assessment is described later. Chronic feelings of emptiness, impulsivity, negative affectivity, and poor psychosocial function are commonly replicated chronic risk factors of suicide. More acute risk factors for suicide attempts in BPD include recent depressive episode, substance intoxication, adverse life event, and recent loss.[33] Interpersonal difficulties Patients with BPD usually have volatile relationships, especially with persons in close association.[34] A phenomenon called “splitting” often characterises the stormy relationship patterns where a support person (friend or romantic partner) is viewed as “all good”, loving and ideal when the patient’s needs are met, and at other times the same support person may be viewed as “all bad”, mean, or cruel. A feeling of abandonment drives the behaviour of anger, clingy demands, depressed mood, hopelessness, and suicidal thoughts and acts when the support person leaves (or is unable to meet the patient’s needs), even if for a short period. This alternating pattern of view may shift very rapidly, often with episodes of crisis in between. Patients with BPD often interpret neutral events, words, or faces as “negative”. Thus, the patient is prone to misinterpret relatively minor disagreements or adverse events as a sign that the caretaker or the therapist wants to terminate the relationship. This inclination to “split” can impact the relationship with the therapist and the treatment outcome. Affective instability Rapid and distressing intense changes in the affective state is a common presenting complaint in BPD. Changes in the emotional states can vary between happiness, intense anger, anxiety, panic attacks, dysphoria, sadness, and crying spells with interposing periods of euthymia. These mood shifts can happen within the span of a few hours and are frequently cued by environmental stress (e.g., fear of abandonment). However, affective dysregulation in BPD can also happen without any identifiable external factor. All efforts should be made not to miss a comorbid cyclothymia or more severe mood disorder. Impulsivity Impulsive and potentially self-damaging behaviour are common in BPD, with minimal regard for possible negative consequences. Impulsivity can manifest in many forms: substance abuse, binge eating, engaging in unsafe sex, spending money irresponsibly, involvement in physical fights, and reckless driving. The loss of control in sudden decisions or acts may manifest in damaging ways, for example, suddenly quitting a job that the person needs or ending a relationship that has the potential to last, thereby sabotaging their own success. Impulsivity can also manifest with immature and regressive behaviour and often takes the form of sexually acting out. Although the patient may regret their behaviour afterwards and may even appreciate its potential dangerousness, they may find it difficult, if not impossible, to resist the urge to repeat the behaviour. From a management perspective, impulsivity should be manifested in at least two areas of life to be clinically significant. Deficits in the cognitive functioning Neuropsychologic functioning in patients with BPD is impaired in many domains. BPD patients perform significantly worse on tests of attention, cognitive flexibility, learning and memory, planning, processing speed, and visuospatial ability.[35] Nonsuicidal self-injury (NSSI) Patients with BPD may hurt themselves. Patients may typically recognise the activity as a compulsive act to calm down “inner tension.” It helps them to relieve stress and avoid suicidal thoughts or behaviours. NSSI is often associated with acute substance intoxication and recent rejections and may lead to frequent emergency visits. Although NSSI is often not driven by a wish to die, it is crucial to assess for suicidal ideas or intent. Presentation of BPD in different age groups Adolescence Although features of personality disorder in adolescence usually ameliorate with age, severe PD symptoms in adolescence seem to predict adult PD. Features of PD can be observed in some cases as early as six years of age when they can remain stable for several years. BPD can be reliably diagnosed in adolescence. Clinically significant features of BPD occur in 10% of young people. Diverse mood symptoms often accompany the condition. By the age of 16 years, 1.3% of young people can be diagnosed as suffering from a BPD. The variation in the comorbidity of the disorders is similar to that in adult patients except for suicide attempts, which are more common in BPD in youth. For some patients, the criteria for diagnosis are only met in young adulthood. It is recommended that BPD should be diagnosed correctly in adolescence, as it enables the timely mobilisation of the necessary social and clinical support measures. The use of mental health services is as common in adolescents with BPD as in adults in western countries. Understandably systematic data from India are limited. Old age The prevalence of BPD in public healthcare patients aged more than 80 years has been estimated at 0.3%. The clinical assessment of personality disorders is complicated by changes in personality and cognitive functions with age: chronic depression, cognitive changes related to ageing, and behavioural changes related to organic brain and systemic diseases. Symptoms of frontal and temporal lobe degenerative disease may resemble symptoms of BPD. Presentations of BPD in different clinical settings Emergency department (ED) An individual with BPD may present to the emergency department (ED) with deliberate self-harm (DSH), nonsuicidal self-injury (NSSI), panic attack, stress-induced dissociative/psychotic episode, or physical aggression leading to conflict with the law (thus brought to the hospital by police). While in the busy ED, it is challenging to ascertain a BPD diagnosis for several reasons (including heightened emotional response, poor rapport, biased answering, lack of reliable informant, need for more emergent physical healthcare, and legal proceedings). However, the liaising psychiatry team should provide the option of further psychiatric services utilisation for in-depth assessment and care, especially because these individuals need more structured mental healthcare. A reliable informant, if available, may help in informed decision-making and shared responsibility in the continuation of care. In case a patient visits ED repeatedly, the attending mental health professional may need to address the immediate psychosocial issue and establish rapport so that the patient follows up for more regular outpatient care. Outpatient department (OPD) Individuals with BPD may consider visiting OPD in acute crisis (suicidal ideas, acute stress reaction, dissociative episodes), marital/family relationship conflicts, comorbid psychiatric illness (depressive disorder, anxiety disorder, problematic substance use), or being asked by competent authority (school/college authority, employer, court of law). A thorough assessment of premorbid personality, preferably from different sources with careful evaluation of the pattern of emotional responses and behaviour, helps the clinician diagnose BPD. A structured assessment using a prevalidated tool may help the clinician to achieve a diagnosis of BPD with higher confidence. Inpatient department (IPD) A thorough personality assessment should be done in all the patients using psychiatric inpatient services considering the high burden of BPD (~20%) in this group of patients. This is even more relevant in patients with treatment resistance, poor adherence to pharmacological treatment, and multiple comorbidities. A comorbid diagnosis of BPD may help therapists make a more comprehensive management plan, including long-term therapeutic approaches, addressing the issues of future crisis management and improving the overall quality of life. ASSESSMENT Structured clinical assessment Usually, a single unstructured interview is inadequate to make a diagnosis of personality disorders. Hence, in clinical diagnostics, it is good to use a structured interview (e.g., International Personality Disorder Examination [IPDE]–Hindi translation is available) or assessment scales (IPDE Screen, Personality Disorder Questionnaire–Version 4 [PDQ-4]) and supplement the findings with comprehensive clinical observations. Various semi-structured interviews and self-assessment methods have been developed for the diagnosis of personality disorders, which are presented in Table 2. Internationally, the Semistructured Clinical Interview for DSM personality disorders (SCID-II/SCID-5-PD) is most commonly used in clinical practice and research settings to increase the diagnostic accuracy of personality disorders. The information received from a third party (e.g., informants) does not necessarily increase the reliability of the diagnostic assessment.Table 2: Structured methods for diagnosing personality disorders and borderline personalityThere are several confounders in the diagnosis of personality disorder. Issues related to culture, ethnic background, age of onset of the disorder, gender, developmental changes in personality, and current psychiatric symptoms may impact the presentation of personality traits. In diagnostics, attention should be paid to the duration of the symptoms because, in personality disorders, the symptoms should be recognisable at the end of adolescence or young adulthood and should describe the patient’s functioning in the long term. When making a diagnosis, it is necessary to ensure that the general criteria for a personality disorder are met. When evaluating the diagnosis, each symptom criterion must be evaluated in the light of whether the feature is clearly pathological, long-term, and manifested in different contexts. Implementing good diagnostics in general/primary healthcare is not simple. A proper assessment can be supported by a psychiatric consultation. Ways to deal with challenging patient behaviour are described in the “Clinical management” section and in Panel 2.Panel 2: Borderline personality disorder in general/primary healthcarePsychological assessment BPD is often accompanied by neuropsychological changes, especially related to executive functions. A lower ability to regulate information may evoke negative emotions related to emotional volatility. Disturbances in executive control may increase self-injurious behaviour. Tests used for personality assessment can provide additional information about the person’s ability to function and ways of processing information. A widely used method is the Rorschach inkblot test. Exner’s Comprehensive System helps in scoring and interpreting its results. The Rorschach inkblot test should not be used to diagnose BPD; it is mainly useful for assessing thinking, quality of object relationships, emotional instability, and suicidality. Assessment of comorbidities Other comorbid disorders occur in 70% of those suffering from BPD. BPD patients may have multiple psychiatric disorders at the same time. It is also associated with higher physical morbidity than the rest of the population, which further increases the risk of suicide attempts. Common psychiatric comorbidities with BPD and tools to assess these comorbidities have been described in Table 3.Table 3: Assessment of psychiatric comorbidities in BPDAssessment of medicolegal aspects Self-harm and physical or sexual abuse may lead to legal involvement in individuals with BPD. Comorbid dissocial traits and illicit substance use can also lead to conflicts with the law. Understanding the local and central legal standards on these aspects may be necessary while deciding the locus and modus of treatment. While underlying legal issues should not limit access to treatment, thorough record keeping and maintaining high standards of care is very important. All efforts should be made toward frequent monitoring and staff members should be well informed to avoid any abuse during patient care. Assessment of functional capacity Impaired functioning related to BPD is corrected more slowly than symptoms of BPD. The social functioning, physical health, and financial situation of a person suffering from BPD should be comprehensively evaluated when planning treatment and rehabilitation. Cognitive rehabilitation, psychoeducation, and dialectical behaviour therapy (DBT) may increase the functional capacity of a person suffering from BPD. Assessment of Quality of life Assessment of functioning and quality of life is important in planning the course of management. WHOQOL-BREF is a validated 26-item self-rated questionnaire to assess the quality of life objectively. The Hindi form of this scale is validated. While symptom remission and better emotional control are the initial focus of treatment, early social and occupational rehabilitation helps in recovery and improved quality of life. Assessment of the ability to work (disability assessment) Deterioration of functional ability is often accompanied by a decrease in ability to work. The ability to work may be most impaired in youth and early adulthood, when the transition to working life may be threatened. Vocational rehabilitation courses can improve working/life skills in adults, adults with disabilities, and young adults (aged 18-25 years). Such courses aim to increase life skills and support access to working life or education. For young people, the risk of being marginalised is high both when transitioning to working life and at the beginning of working life, when employment relationships are often temporary. To prevent the development of marginalisation, possible periods of sick leave should generally be limited to acute periods with severe symptoms of concurrent psychiatric disorders. Referral to enhanced vocational rehabilitation or its assessment and, if necessary, psychiatric rehabilitation is appropriate for the same reason. If the patient has previously been able to work despite their disorder, it can be considered that their work disability is not solely due to BPD. Medical reports related to the patient’s ability to work must describe carefully: Symptoms Life course Diagnosis Ability to work and function in real situations Treatment attempts and their results Educational and work history Vocational rehabilitation plan SPECIFIC ISSUES IN ASSESSMENT Risk assessment Assessment of the risk of harm to self/others is one of the most critical factors when formulating a management plan for BPD. A thorough history from the patient, relevant other informants and medical/legal records, followed by a detailed mental state examination, is crucial. When a patient’s thought is inaccessible and behaviour is unpredictable, appropriate precautions should be taken. Brief hospitalisation can be advised in such cases for further observations. Factors indicating high suicide risk: High lethality of attempt Suicide intent Active planning Depressive cognition History of suicide attempts Recent loss Poor psychosocial support Factors indicating a high risk for harm to others: Prior harm to or threatening behaviours toward dependent children Poor self-control on dangerous impulses Active homicidal thoughts Poor insight Considerations for the Indian context Presentation, interpretation, and treatment options for BPD may vary significantly depending on the culture. Although systematic data from India on the cultural effect on personality organisation and presentation are sparse, some points may be highlighted. Understanding and representation of self in the Indian context present as interdependent self with fluid and flexible interpersonal bonds.[36] Indian large and often joint families experience allow for frequent arguments/fights with minimal/no fear of abandonment, in stark difference to the western values of individualism and independence. Indian family constructs are tolerant of dependent or even manipulative acts (somatic complaints, provocative actions, misleading messages, and self-destructive acts), which are not considered particularly deviant unless they cause significant dysfunction in other areas of life or to the significant others. Cultural acceptance of psychosomatic expressions of distress also curtails the need for strong emotional responses during crises or interpersonal difficulties. DIFFERENTIAL DIAGNOSIS Disorders that are important for differential diagnosis of BPD are described in Table 4:Table 4: Differential diagnosis of the borderline personality disorderPROGNOSIS Remission is common in BPD and, once achieved, is usually stable.[37] More than half of the patients suffering from BPD no longer meet the diagnostic criteria for the disorder after five years. Likewise, depressive symptoms are alleviated and functional capacity recovers clinically significantly in a few years. Among the signs, the fastest to relieve are self-destructiveness and identity diffusion. Impulsivity and fluctuations in emotional life are relieved more gradually with increasing age. As personality instability eases, mood and anxiety disorders also decrease, but do so more slowly. Depression slows down recovery from BPD. Comorbid PDs have also been found to be alleviated in patients with BPD during a six-year follow-up.[38] The treatment results seem to be poor when people suffering from BPD have a lifestyle predisposing them to chronic diseases and high utilisation of health services. Even at the age of more than 50 years, the features of BPD may cause failures in relationships. Key prognostic factors are summarised in Table 5.Table 5: Factors predicting the outcome of the treatment of borderline personality during a 10-year follow-up periodMANAGEMENT Central to the treatment of someone suffering from BPD is psychotherapeutic methods. They can be combined with other forms of treatment. The therapeutic relationship and the effectiveness of the therapy may be jeopardised if shame is not recognised in the therapeutic relationship and in the patient’s most central emotional experiences. As per patients’ reports, recovery is facilitated when the care provider offers security, respect, trust, and understanding while guiding toward change by being appropriately active and using specific strategies. At the beginning of the treatment, the therapist should: Carry out a wide-ranging risk assessment, Define crisis management options, Work on the details of the treatment in coordination with the patient, and Avoid communication that increases stigma or negatively judges the patient. Treatment utilisation It may be helpful to understand the treatment of borderline personality as per the well-known phase model of substance use treatment: In the precontemplation phase, there is a lack of awareness of the need for change. In the contemplation phase, the advantages and disadvantages of the change seem equal. In the preparation phase, the person suffering from the disorder has understood the need for change and tells others about it. In the action phase, the person suffering from the disorder is committed to their treatment and works for change. Typical features in the treatment of those suffering from borderline personality are: Abundant and short-term use of different treatment services and forms (Emergency services, primary/general healthcare, specialist mental healthcare, complementary/alternative help). Difficulty adhering to treatment agreements can complicate the treatment of both mental and physical illnesses. Difficulty establishing a long-term psychotherapeutic treatment contact: the patient usually attends psychotherapy only for a short time and ends up using the service

Major depression and bipolar disorder are common conditions with substantial negative consequences for sufferers. Understanding the biological changes associated with these conditions is a major research priority, and a better understanding of their biological basis could lead to improved diagnosis and treatment. There is growing interest in the development of precision medicine algorithms with the aim of tailoring treatment strategies to individual patients according to unique biological signatures. This biomarker-based approach to precision prescribing has the potential to improve therapeutic response, minimize adverse reactions, and reduce time to symptomatic relief. However, few validated biological targets for treatment response prediction in depression have been identified to date. Biomarkers derived from neuroimaging data are potentially important contributors to the goal of guiding treatment selection using clinical and bio-typing data. Information on brain structure and function may be used to predict response versus non-response to various treatments. Ignited by the observation of a rapid antidepressant effect of the glutamate N-methyl-D-aspartate (NMDA) receptor antagonist ketamine, the glutamate system has emerged as a leading focus for novel drug discovery for depression and other mood disorders. Over the last two decades, neuroimaging has brought a deeper understanding of neurobiological alterations associated with these conditions, and researchers are moving towards developing these methods to diagnose and treat affective disorders. This research has been aided by developments in magnetic resonance spectroscopy (MRS), a method that allows non-invasive measurement of glutamate and glutamine levels in vivo. Glutamate and glutamine levels are typically found to be reduced in unipolar depression, most notably in prefrontal regions such as the anterior cingulate cortex, while studies in bipolar disorder suggests an increase in glutamate in this region.

The challenge of producing a classificatory system that is truly representative of different regions and cultural variations is difficult. This can be conceptualized as an ongoing process, achievable by constant commitment in this regard from various stakeholders over successive generations of the classificatory systems. The objective of this article is to conduct a qualitative review of the process and outcome of the efforts that resulted in the ICD-11 classification of mental, behavioural and neurodevelopmental disorders becoming a global classification. The ICD-11 represents an important, albeit iterative, advance in the classification of mental, behavioural and neurodevelopmental disorders. Significant changes have been incorporated in this regard, such as the introduction of new, culturally-relevant categories, modifications of the diagnostic guidelines, based on culturally informed data and the incorporation of culture-related features for specific disorders. Notwithstanding, there are still certain significant shortcomings and areas for further improvement and research. Some of the key limitations of ICD-11 relate to the paucity of research on the role of culture in the pathogenesis of illnesses. To ensure a classificatory system that is fair, reliable and culturally useful, there is a need to generate empirical evidence on diversity in the form of illnesses, as well as mechanisms that explain these in all the regions of the world. In this review, we try to delineate the various cultural challenges and their influences in the formulation of ICD-11, along with potential shortcomings and areas in need of more improvement and research in this regard.

An estimated 197.3 million people have mental disorders in India, and majority of the population have either no or limited access to mental health services. Thus, the country has a huge burden of mental disorders, and there is a significant treatment gap. Public mental health measures have become a developmental priority so that sustainable gains may be made in this regard. The National Mental Health Program (NMHP) was launched in 1982 as a major step forward for mental health services in India, but it has only been able to partially achieve the desired mental health outcomes. Despite efforts to energize and scale up the program from time to time, progress with development of community-based mental health services and achievement of the desired outcomes in India has been slow. Public health measures, along with integration of mental health services in primary healthcare systems, offer the most sustainable and effective model given the limited mental health resources. The main barriers to this integration include already overburdened primary health centres (PHCs), which face the following challenges: limited staff; multiple tasks; a high patient load; multiple, concurrent programs; lack of training, supervision, and referral services; and non-availability of psychotropic medications in the primary healthcare system. Thus, there is an urgent need for a fresh look at implementation of the NMHP, with a focus on achieving sustainable improvements in a timely manner.

OUTLINE Introduction Evolution of concept Principles of interpersonal psychotherapy (IPT) Assessment and Structure of IPT Steps in IPT IPT in Depression Interpersonal problem areas and relevant strategies Grief Role disputes Role transition Interpersonal (IP) deficits. Common IPT techniques Adaptations for depression in special populations Adaptations for other mood disorders Adaptations for non mood disorders INTRODUCTION Interpersonal psychotherapy (IPT) is a time-limited and diagnosis-targeted intervention It follows a strict time-limited format IPT has been successfully adapted for various other psychiatric disorders IPT follows a simple paradigm by assigning the patients a sick role by defining their problems as treatable medical conditions and linking their state of affective distress to their IP situations IPT focuses on the "here and now" of the illness by resolving issues related to IP problem areas[1] IPT has nonspecific and specific elements: Nonspecific elements include nonjudgmental approach, empathic listening, maintaining confidentiality, expressing warmth, and engaging the patient in the therapy Specific elements include providing patients a sick role, applying an IP inventory, and making a formulation that links the patients' IP problem areas with their psychiatric diagnosis. IPT follows a holistic approach, and it is recommended to use IPT in an integrated manner The underlying assumption is that IP relationships of a person either in the past or in the present, play a role in the origin and maintenance of psychopathology. Hence, IPT mainly focuses on IP context and related factors. The goal is to either help patients improve their IP relationships or change their expectations about them and focusing on improvements in their social support networks The specific elements of IPT constitute its basic core, but can be adapted in various ways. IPT can be planned as a short-term, time-limited therapy, maintenance therapy, or long-term, insight-oriented treatment IPT can be adapted for different age groups including adolescents and elderly, and can also be adapted depending on the target diagnosis There can be adaptations in the format of IPT for individuals or groups or couples IPT can be adapted for any psychiatric disorder where IP problems exist[2] Insight-oriented IPT, on the other hand, emphasizes that the therapist cannot be a neutral observer, but is rather a participant. The task for the therapist is to understand his own reactions toward the patients and reflect them therapeutically, by uncovering, resolving, and termination.[2] EVOLUTION OF CONCEPT The principles in the IPT are broadly based on the following models: Biopsychosocial model Some concepts of IPT are based on the Adolf Meyer's school of psychobiology, which sees psychiatric disorders as a consequence of an individual's attempts to adapt to psychosocial environment. The model further emphasizes that a person's current state of psychological functioning is a complex interplay of biological correlates, physiological factors, social relationships, and various psychological correlates such as one's temperament and attachment pattern[3] Thus, IPT is based on the biopsychosocial model of psychological functioning as it views the psychiatric symptoms in a broader aspect IPT emphasizes on the attachment bonds and effective communication as important predictors of good psychological functioning IPT builds on the principle that intimacy is protective against the development of depression, especially when facing stressful life events, which frequently precede depression The biopsychosocial model also stresses upon the patient actively taking the responsibility of making changes in IP relationships and his/her social environment rather than waiting for changes to happen on his/her own. Harry Stack Sullivan's theory of interpersonal relationship and parataxic distortion Harry Stack Sullivan's theory of IP relationship emphasizes on the role of social, cultural, and familial factors in the genesis of psychiatric illnesses[34] Sullivan stressed on that maladaptive behaviors emerge as a result of one's attempt to deal with the social environment He described parataxic distortion as a phenomenon in which the characteristics of previous relationships are imposed upon new ones, which results in distortions in the current relationships. John Bowlby's working model of relationships John Bowlby further built on the concept that the previous relationships an individual has had (whether healthy or otherwise), determine the ways in which he/she behaves in a new relationship.[4] PRINCIPLES OF INTERPERSONAL PSYCHOTHERAPY IPT focuses on identifying relationship between environmental triggers related to IP problem areas and clinical symptom onset or the phenotype of the disease The work of the therapist revolves around helping patients identify these stressors or IP problem areas and relate them to the symptoms or distress. The therapist also encourages patients to find out ways to ameliorate the situation. The interactions are depicted in Box 1. Box 1: Stress diathesis modelFor depression, IPT builds on the following two important principles: Depression does not occur due to an individual's fault and it can affect anyone. It is a medical illness which is treatable. Assigning a sick role to the patient helps in defining the problem and also excuses the patient from blaming himself/herself for the illness The second principle emphasizes that the affective distress and life situations are interrelated. The disturbing life events can either precipitate the symptoms of depression or other mood disorders or can follow the onset of symptoms.[5] Thus, a disturbance in the environment due to unavoidable stressors leads to changes in IP environment, which eventually leads to the symptoms of depression. When depression sets in, the IP functioning of the patient gets further compromised. It may seem very obvious to an observer that the symptoms have set in due to these triggers, but depressed individuals often tend to blame themselves for these events. The task of the therapist is to help the patient resolve these problems and develop his/her social support system.[6] Structure of interpersonal psychotherapy IPT is conducted over 12–20 sessions extending over a period of 4–5 months. In the acute phase, it includes three phases as shown in Box 2 After these three phases are over, a continuation/maintenance phase can be initiated for which a spate contract is made with the patient. An initial assessment for the suitability of IPT is carried out before the initial phase. Box 2: Three phases of interpersonal psychotherapyAssessment for the suitability of IPT The therapist must assess whether the patient is a suitable candidate for IPT prior to initiating the therapy. This phase is carried out for any psychological intervention that a therapist plans to initiate [Box 3]. Patients' ego strengths and motivation for change are assessed. Certain factors tend to increase the probability that a patient would benefit from the therapy. These include presence of good social support network, presence of an IP focus of distress, ability to relate a coherent narrative of IP network and specific IP interactions, and a secure attachment style. At the end of this phase, a contract is made with the patient regarding the number of sessions that will be carried out and that collectively the therapist will work along with the patient in one or more areas of IP distress.Box 3: Assessing suitability of interpersonal therapyInitial phase As the sessions begin, the therapist focuses on developing a good therapeutic alliance with the patient. The therapist carefully listens to the patient's complaints, carries out a detailed interview, obtains information about the history of presenting complaints, and identifies the diagnosis and the IP context in which the symptoms have occurred. The following steps are followed. Assessing the symptoms A formal diagnosis can be made using the International Classification of Diseases (ICD) 11 or Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5). The severity can be assessed using severity-measuring scales for depression, for example, Hamilton Depression Rating Scale (Ham-D). Patients are explained what the scores on these scales mean and that the scales would be repeated during the course of therapy. Making the diagnosis Once the diagnosis is made, its prevalence and presenting features can be discussed with the patient. The therapist also discusses about the expectations from the therapy. Once a diagnosis is assigned to the patient, it works in a dual manner. First, it instills hope that the patient has a medical condition which is identifiable and treatable. Second, it identifies the patient as a person who is in need of help. It is emphasized that the patients' full focus should be on recovery. Assigning a sick role Providing a diagnosis gives the patient a "sick role," which would simply mean that the disturbances in patient's functioning have occurred due to his/her current status and the illness has prevented him/her from performing adequately. It is stressed upon that the symptoms have not occurred due to the patient's own faults. The therapist also discusses with the patient that addressing the current problems in IP functioning will improve his/her psychiatric condition. Setting a time limit IPT is strictly a time-limited therapy. Following a strict time limit and initially deciding about a fixed end point helps in keeping the patient motivated to make changes. Prolonged sessions tend to shift the focus from the current IP issues to more intrapsychic conflict exploration, which is not the goal of IPT. Having a time limit and gradual tapering of sessions seems to be better than abrupt discontinuation at the end of 12–20 sessions. The therapist may predecide the number of times a week and number of weeks required for therapy. Reviewing the need for medications Evidence suggests that IPT alone can help patients recover from depression, but depending on the severity of symptoms, medications can be initiated. If required, the patient can be referred to the treating psychiatrist for initiating the treatment if the therapist is not a medical professional (clinical psychologist).[7] Exploring the interpersonal milieu Moving ahead in the initial phase, the therapist explores about the patient's close relationships and social functioning both in the present and in the past. Details of major life events in patient's life, associated changes in mood, changes in IP relations, and their relation to psychiatric symptoms are explored. All these information are obtained in a structured manner with the help of an IP inventory. The inventory helps in reviewing patient's significant relationships, nature of social relationships, and IP functioning. Identifying the focus IP problem areas are identified. Four IP problem areas have been mentioned as shown below. In IPT, one needs to identify the main problem area. Grief defined as loss of relationships or loss of healthy self IP role disputes with significant others such as friends, parents, and siblings IP role transitions including difficulties in adjusting to life changes, which is undesired, unexpected, or for which the patient is not psychologically and emotionally ready IP skill deficits such as maintaining relationships and communicating about feelings. Interpersonal formulation The therapist then prepares an IP formulation linking the target diagnosis to IP focus. It may be possible that more than one problem areas are identified. However, the focus should be on one area at a time or not more than two problem areas. If two problem areas are identified, the one which seems to be more responsive to treatment is dealt with initially. This helps in increasing the patient's competence, helping in recovery. Once the formulation has been prepared, the goals of the therapy and strategies to obtain those goals are discussed with the patient. This helps in formulating a treatment plan, and the strategies can always be referred to while one progresses in the therapy. The initial session usually extends for the first five sessions. Defining treatment goals The problem area that will be focused in the current therapy should be discussed with the patient. If there are more than one areas of focus, the one which seems to be more distressing for the patient is addressed initially. Treatment goals need to be decided and discussed with the patient. Practical issues about confidentiality or handling issues of missed appointments should also be discussed. The above steps can be summarized in a flowchart as shown in Box 4.Box 4: Steps in performing the initial phase of interpersonal therapyMiddle phase In the intermediate phase, sessions are focused upon addressing one or more of the four problem areas using IPT techniques. After the identification of specific problem areas in the initial phase, the therapist tries to obtain more information about these specific problem areas. The therapist and the patient then work together to develop solutions for these problems. Solutions may focus upon various domains of an individual's life such as modifying expectations of the patient, improving their communication skills, or developing social support. A suitable solution is selected, and the patient tries to apply it between the sessions. Throughout the sessions, the therapist keeps the patient focused on the specific problem area. Patients are psychoeducated about their illness and symptoms Every IP session is important in the therapy. The content and emotional tone, how did the patient feel, what did he/she say, and what was his/her tone, are important for the therapist If the patient performed well, the therapist congratulates him/her to reinforce the skills If things did not work well, factors responsible need to be explored Therapeutic alliance needs to be maintained throughout At the end of every session, the gains achieved and summary of sessions need to be highlighted After every session, severity rating scales need to be applied to monitor the progress The key IPT techniques targeting the four IP problem areas have been discussed later individually. Termination phase (credit or blame?) The last few sessions are focused on preparing the patient for termination of the therapy. If the problems have been addressed, the patient needs to be given credit for the success achieved. If the sessions did not turn out to be as successful as planned, blame the treatment. This helps by minimizing the self-blame by the patient. Alternative treatment options such as continuation to the maintenance phase and adding or changing medications are discussed with the patient. Conducting interpersonal therapy in depression The relationship between depression and IP problems can be bidirectional. The disorder can arise in the context of IP problems and depression may also interfere with one's IP functioning. Whatever is the cause and irrespective of what appeared first in the time line, IPT focuses on linking mood to the IP state. The therapist considers that depression has the following three aspects: The first are the symptoms which include low mood, anhedonia, easy fatigability, poor attention and concentration, eating and sleeping disturbances, and negative thinking The second aspect is the patient's social and IP context. IP problems can precede or follow depressive symptoms. In addition, the strong social support is protective and social stressors increase the vulnerability for depressive episode The third aspect is the personality characteristics of the patient. This can either predispose or maintain depression. An enduring pattern of avoiding confrontation, risks, expression, and being dependent may all lead to the occurrence of depressive episode. Irrespective of what contributes to depression, IPT focuses on dealing with the current IP issues and helps the patient to develop self-reliance to deal with these situations outside the therapy. For psychiatric disorders such as depression, the disturbances in these IP areas result in symptoms. The situations that lead to these IP dysfunctions are the areas of focus in IPT. These include: Grief IP role disputes IP role transitions IP deficits. The goals of IPT in depression include: Decreasing the depressive symptoms Helping the patient deal with the IP problems that led to depression in a better manner. The therapist begins by asking questions which can help in understanding about patient's symptoms, such as asking patients: What brings you here? How the symptoms started appearing? Are there any stressors? How the patient is currently dealing with the stressor? What happened before the onset of symptoms? Does the patient feel that something specific happened which triggered the symptoms such as death in the family? Detailed psychiatric assessment needs to be conducted to confirm the diagnosis. Once the diagnosis of depression is made, the task in the initial sessions is to assess the severity of symptoms using rating scales such as HAM-D or Beck Depression Inventory. Patients should be psychoeducated about depression. One example is as follows: "Depression is a common mental disorder and is treatable. We can understand your distress, but complaints of decreased confidence and poor attention concentration are the common symptoms of the illness and will resolve as you begin to recover from the illness. This can happen to anyone and with adequate treatment you will recover. The duration may however vary, as some patients respond early and some may take time to get relief from their symptoms." Once a sick role has been assigned to the patient, a time limit is decided. The need for starting medications is reviewed. An IP inventory is applied as described previously and the therapist tries to identify the IP problem areas. The therapist then prepares an IP formulation linking the target diagnosis to IP focus Key steps of IPT in depression are outlined in Box 5.Box 5: Key steps of performing interpersonal therapy in depressionMajor depressive disorder: Key steps are as follows: Establishing the diagnosis Identifying the focus areas (grief/IP role disputes, IP role transition, and IP deficits) Setting the goals (decreasing symptoms of depression and improving the coping skills) Assigning the sick role Defining the time limit Applying different types of IPT techniques targeting different focus areas Terminating therapy (consolidating gains and looking for options to deal with failure, such as continuation and addition of pharmacotherapy). In the subsequent section, we will discuss each of the four IP problem areas and ways to proceed in therapy including the IPT techniques. FOUR INTERPERSONAL PROBLEM AREAS AND WAYS TO PROCEED IN THERAPY INCLUDING THE IPT TECHNIQUES Interpersonal psychotherapy techniques Grief Grief is selected as a focus, when patients report depressive symptoms following the death of someone significant in their life. The presence of some depressive symptoms following the death is expected and the symptoms resolve as the person starts accepting the death. The low mood, decreased interest in activities, disturbed sleep, and appetite can be a part of normal mourning. However, in some people, the diagnostic threshold for depression is met as they begin to experience significant depressive symptoms leading to socio-occupational dysfunction. In these cases, IPT can be initiated. If the patient approaches due to his/her distress, but still does not meet the diagnostic threshold for depression, IPT can be initiated. Goals in dealing with grief The therapy begins with the initial sessions comprising of assigning a sick role to Mr. A as explained previously. The IP inventory would provide information about the IP context. It will provide information of the current relationships Mr. A has irrespective of it being problematic or supportive. Subsequently, the IPT therapist prepares an IP formulation. Facilitating mourning and coming to terms with the loss One of the goals in IPT for the management of grief would be catharsis. The therapist encourages the patient to talk about the loss, what they miss the most about the person. Patients are encouraged to describe their relationships, about the sequence of events that occurred prior to the loss, during and after the loss. Patients also tell about all that they experienced since the loss of their loved one. The therapist helps the patient describe all their memories associated with their loved one whom they lost To connect with the existing relationships and re-establish the lost interests The other goal of IPT in grief management is to help the patient figure out relations which can act as a substitute for the lost person and lost relationship. One way is to encourage patient to involve others in the process of remembering their lost one. Strategies in dealing with grief The strategies includeassessing the psychopathology if any, and help patient relate his/her symptoms with the death of the significant person. The therapist educates the patient about grief and depression, helping the patient to express his/her feelings and helping in finding new pleasurable activities and relationships to substitute the loss. Catharsis The strategy that the therapist uses is to encourage patients to talk about their feelings. It is stressed that the expression of feelings does not make a person weak. Some people even fear that once they start expressing their feelings, they may become overwhelmed. Patients are encouraged to focus on the positive and negative aspects of the relationship with the loved one. Reestablishing the support networks Death of a loved one often leaves a void in the patient's life, and it is important that this gap is filled up. Once the therapist has explored about the support system of the patient, important relationships in their life can be reestablished. Patients can be encouraged to connect with important people in their life and share their feelings. The therapist must also encourage patients to engage in activities which they enjoyed before the death. This may be difficult for the patient, but still efforts must be made to engage in relationships. Sometimes, patients may completely withdraw themselves from their social life and so, they must be told that they can just go out with a friend to see how things work. Following this, it must be inquired about what the patient enjoyed, which parts he/she did not, and will he/she be interested in repeating the activity again. As the sessions proceed, the therapist shifts the discussion from being more about the deceased to more about the issues coming up in the new efforts patient is making in reestablishing his/her support system. The end of the therapy includes termination sessions, focusing on consolidating the gains that occurred in the therapy and preparing patient to work outside the therapy in real-life situations. Interpersonal role disputes For a healthy relationship, it is very important that both individuals have a sense of harmony, regard for each other's expectations, and have willingness to compromise for each other. Two people in a relationship may have different aspirations and perspectives, but when their expectations from each other become contrasting or different, it can result in strained relationship. If they do not understand the needs and expectations of each other, it is very likely that disputes will result. If the patient presents with such complaints, the focus of the IPT will be directed toward resolving the role disputes. Often, role transitions may lead to role disputes or the opposite situation. Like shifting to a new job or to a new place may change the expectations, two people in a relationship may have from each other. It can happen the other way around, where differing expectations can interfere with smooth transitions in the role changes one is expected to go through. In either of the circumstances, depression may result from these situations or depression may interfere with the successful handling of these transitions. It is important for the therapist to identify these situations and identify whether role transition or role dispute is the important contributing factor in the initiation or maintenance of depression, and that particular area should be selected as the focus of the therapy. Goals in the treatment of role disputes After going through a long-standing role dispute, the patient starts believing that there is no way out and there is no benefit of initiating any therapy. Often, patients find themselves as the main reason behind the dispute and place the partner at a superior position. Goals of the therapy include helping the patient find the dispute, identify it, and look for options to deal with it. The therapist helps to work out a plan of action. Even if the issues may not resolve completely, therapy will help the patient modify his/her expectations or in those cases where even this is not possible, therapy helps the patient in better communication with the partner about his/her expectations and feelings. Recognizing the dispute After going through the patient's history of presenting illness, the therapist needs to identify the area of dispute. Even though the patient reports that there is no possible solution, it needs to be reemphasized that no matter what the dispute is, some solution is always possible Finding options to decide an action plan After having an agreement with the patient about the dispute area that will be targeted during the therapy, the therapist needs to explore various ways in which the relationship can be renegotiated. If this process is successful, the patient learns to be more assertive and expresses his/her feelings in a more positive and less demeaning way. In cases when the renegotiation does not turn out to be successful, the patients at least learn to communicate their feelings more adequately Rectifying faulty expectations and facilitating better communication to resolve issues The cause of many disputes is the contradictory expectations which two people in a relationship have from each other. The goal of the therapy is to identify these faulty expectations and modify them in a better manner. It is better if the partner is also involved in the therapy, but it may not be possible in all cases when the therapist continues sessions with the patient. Strategies in dealing with role dispute The following steps are undertaken for dealing with role dispute in IPT: Assessing the depressive symptoms The key to initiating any session is detailed exploration of the symptoms with which the patient has presented to us. This will be done in the initial sessions of IPT as described previously. The IP inventory also provides information about the IP issues. Once the depressive symptoms have been assessed, the next step is to draw relations between these symptoms and evident or covert dispute. The IP formulation caters to this. Identifying the stage of the dispute Once the depressive symptoms have been assessed and their relation with the dispute has been drawn, the therapist tries to identify the stage at which the dispute currently is. RenegotiationOften, patients may be aware of the differences in expectations but lack skills to express themselves. They consider their expectations as less important than the other person with whom the dispute is present. The communication between the two people has not stopped. The therapist helps the patient learn that even their expectations are genuine and they need to express it to the other person.ImpasseIn this stage, the relations have reached a point when conversation between the two people has stopped. There are no more discussions and the patient feels that renegotiation is no more an option. Patients feel hopeless about any positive progress in the relationship. At such a stage, discussion can be brought forward clearly in the open.DissolutionThis stage is reached when either one or both the patient and partner are looking out ways and struggling to bring an end to the relation. This is usually not the first stage, but often, patients may report that they do not see a future ahead with their partner and are actively looking out ways to terminate the relationship. At this stage, dissolution is advisable. It must be kept in mind that dissolution may lead to interference in role transition. Strategies that are used in dealing with role dispute are as follows: Exploring the patients' feelings Validating these feelings Finding out options and deciding out a plan of action depending on the stage of the dispute Role play. Once the therapist is aware of the patient's feeling with the IP encounter he/she have, the therapist tries to validate these feelings by considering them genuine and reasonable. If the patient's dispute is at the stage of renegotiation, the patient is encouraged to express about the differences in expectations and communicate his/her objection to the demands made by the other person. The patient may speak about alternative steps, and the therapist must also help the patient understand the consequences of his/her actions. If the stage of impasse has been reached, the therapist encourages the patient to directly ask for the other person's expectations. The disharmony may initially increase, but this opens a conversation between them which had stopped, and it helps the therapist understand the contradictory expectations better. Sometimes, it is better to go for dissolution of the relationship. This is facilitated by the therapist when he/she realizes that the relationship has become strained and both the partners are aspiring to get out of it. This stage should be reserved for the point when all attempts to reestablish the relationship have been ex