Resonant‐tunneling transistors.
\\n\\n
Released this past November, the list is based on data collected from the Web of Science and highlights some of the world’s most influential scientific minds by naming the researchers whose publications over the previous decade have included a high number of Highly Cited Papers placing them among the top 1% most-cited.
\\n\\nWe wish to congratulate all of the researchers named and especially our authors on this amazing accomplishment! We are happy and proud to share in their success!
Note: Edited in March 2021
\\n"}]',published:!0,mainMedia:null},components:[{type:"htmlEditorComponent",content:'IntechOpen is proud to announce that 191 of our authors have made the Clarivate™ Highly Cited Researchers List for 2020, ranking them among the top 1% most-cited.
\n\nThroughout the years, the list has named a total of 261 IntechOpen authors as Highly Cited. Of those researchers, 69 have been featured on the list multiple times.
\n\n\n\nReleased this past November, the list is based on data collected from the Web of Science and highlights some of the world’s most influential scientific minds by naming the researchers whose publications over the previous decade have included a high number of Highly Cited Papers placing them among the top 1% most-cited.
\n\nWe wish to congratulate all of the researchers named and especially our authors on this amazing accomplishment! We are happy and proud to share in their success!
Note: Edited in March 2021
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There are many publications on wound healing, but this book intends to give an overview of its current perspectives so as to be useful to practice care in wound healing and to improve the quality of life. It is considered that this book will be useful for clinicians who are interested in wound care.",isbn:"978-1-78985-538-8",printIsbn:"978-1-78985-537-1",pdfIsbn:"978-1-83880-645-3",doi:"10.5772/intechopen.73808",price:119,priceEur:129,priceUsd:155,slug:"wound-healing-current-perspectives",numberOfPages:260,isOpenForSubmission:!1,hash:"fa7b870ad29ce1dfcf6faeafdc060309",bookSignature:"Kamil Hakan Dogan",publishedDate:"May 10th 2019",coverURL:"https://cdn.intechopen.com/books/images_new/7046.jpg",keywords:null,numberOfDownloads:12662,numberOfWosCitations:6,numberOfCrossrefCitations:11,numberOfDimensionsCitations:28,numberOfTotalCitations:45,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"March 22nd 2018",dateEndSecondStepPublish:"May 16th 2018",dateEndThirdStepPublish:"July 15th 2018",dateEndFourthStepPublish:"October 3rd 2018",dateEndFifthStepPublish:"December 2nd 2018",remainingDaysToSecondStep:"3 years",secondStepPassed:!0,currentStepOfPublishingProcess:5,editedByType:"Edited by",kuFlag:!1,biosketch:null,coeditorOneBiosketch:null,coeditorTwoBiosketch:null,coeditorThreeBiosketch:null,coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"30612",title:"Prof.",name:"Kamil Hakan",middleName:null,surname:"Dogan",slug:"kamil-hakan-dogan",fullName:"Kamil Hakan Dogan",profilePictureURL:"https://mts.intechopen.com/storage/users/30612/images/system/30612.jpg",biography:"Kamil Hakan Dogan MD, PhD is a Full Professor and Chair in the Department of Forensic Medicine at Selcuk University, Faculty of Medicine in Turkey. Dr. Dogan received his MD from Gazi University, Faculty of Medicine in 2000. After his extensive research in the forensic medicine field, he received his PhD in Biochemistry in 2012. He gives lectures on Forensic Medicine and Medical Ethics to medical students as well as students of the dentistry and law faculties. He is a reviewer for several international journals and he has published over 200 articles in refereed journals, chapters in textbooks and abstracts in scientific meetings. 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A.",surname:"Barku",slug:"victor-y.-a.-barku",fullName:"Victor Y. A. Barku"}]},{id:"63387",title:"The Strategies of Natural Polysaccharide in Wound Healing",slug:"the-strategies-of-natural-polysaccharide-in-wound-healing",totalDownloads:804,totalCrossrefCites:2,authors:[{id:"252781",title:"Ph.D.",name:"Juin-Hong",surname:"Cherng",slug:"juin-hong-cherng",fullName:"Juin-Hong Cherng"}]},{id:"66286",title:"From Tissue Repair to Tissue Regeneration",slug:"from-tissue-repair-to-tissue-regeneration",totalDownloads:1101,totalCrossrefCites:3,authors:[{id:"247667",title:"Prof.",name:"Emanuele Salvatore",surname:"Aragona",slug:"emanuele-salvatore-aragona",fullName:"Emanuele Salvatore Aragona"}]},{id:"64089",title:"Growth Hormone (GH) and Wound Healing",slug:"growth-hormone-gh-and-wound-healing",totalDownloads:1651,totalCrossrefCites:0,authors:[{id:"221342",title:"Prof.",name:"Jesús",surname:"Devesa",slug:"jesus-devesa",fullName:"Jesús Devesa"},{id:"257224",title:"Dr.",name:"Diego",surname:"Caicedo Valdes",slug:"diego-caicedo-valdes",fullName:"Diego Caicedo Valdes"}]},{id:"63308",title:"Autologous Platelet-Rich Plasma and Mesenchymal Stem Cells for the Treatment of Chronic Wounds",slug:"autologous-platelet-rich-plasma-and-mesenchymal-stem-cells-for-the-treatment-of-chronic-wounds",totalDownloads:1207,totalCrossrefCites:1,authors:[{id:"256306",title:"Ph.D.",name:"Peter A.",surname:"Everts",slug:"peter-a.-everts",fullName:"Peter A. 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Venkateswarlu",coverURL:"https://cdn.intechopen.com/books/images_new/371.jpg",editedByType:"Edited by",editors:[{id:"58592",title:"Dr.",name:"Arun",surname:"Shanker",slug:"arun-shanker",fullName:"Arun Shanker"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}]},chapter:{item:{type:"chapter",id:"55540",title:"Resonant Tunneling and Two‐dimensional Gate Transistors",doi:"10.5772/intechopen.69069",slug:"resonant-tunneling-and-two-dimensional-gate-transistors",body:'\nSize‐shrinkage as a main trend of the electronics development has already brought not only cut‐off frequency but also energy consumption increase. In addition, a current leakage of the field‐effect transistor (FET) has also increased. The leakage current consists of a current from the drain to the source (
In this chapter, an application of the 2DSC in a FET gate is considered for further leakage reducing.
\nTunneling has been revealed by Esaki [3] and studied mainly in semiconductor diodes since 1958. Several years before, Shriffer had proposed size‐quantization of the carriers in semiconductor films [4] that was observed by Tsui in InAs tunneling diode [5]. Then Esaki [6] and Kazarinov and Suris [7] proposed carriers resonant tunneling (CRT) in semiconductor heterostructures. In 1974, this effect was observed [6]. On the base CRT, a resonant‐tunneling diode (RTD) [8] and resonant‐tunneling transistor (RTT) [9] are realized as highest‐frequency solid‐state devices up to date. Carriers tunneling is well‐known to play a negative role in modern c CMOS transistors made on the base technology of 45 nm or less. However, the instances of the RTD and RTT give us a hope that a proper application of the CRT can improve the situation in the FET. To clarify this, let us consider the CRT in detail.
\nUsually, the CRT is observed in a double‐barrier heterostructure, the conduction band profile of which is shown in Figure 1. In a thin layer of a narrow band gap semiconductors, the localized states are forming and called subband states or levels. The ground subband state has energy
Energy profile of the conduction band bottom of the two barrier heterostructure.
To calculate current‐voltage characteristics, one can consider model of sequential tunneling [10]. In this model, tunneling of the electron can be described as sequential quantum transition perturbed by tunnel Hamiltonian
where
Then the matrix element of
where
where
where
Momentum space of the emitter and states available for resonant tunneling.
where
Let us suppose the emitter grounded, i. e., μfe = const, then the voltage dependence of
where α is a leverage factor, i.e., α =
Eq. (8) is justified when μfe >
As a result, the I‐V curve of the RTD is shown in Figure 3 as solid line. It is worth noting that Eq. (8) describes only resonant part of the current. Nonresonant current usually is monotonic function of the voltage and includes scattering tunneling and tunneling across all barriers. This provides nonzero current at any nonzero voltage. Thus, one can see that two‐dimensional state in the QW produces the resonant tunneling in a finite resonant voltage range from
Current‐voltage characteristics of RTD with a single quantum well between barriers (solid line) and a double quantum wells (dashed line).
Energy profile of the conduction band bottom of the heterostructure with two quantum wells.
Thus, the application of 2DSCs could significantly decrease the carriers tunneling in a wide range of the applied voltage. This means there is a new way to decrease carriers tunneling between a gate and a channel that is application 2DSCs in them. Semiconductor heterostructures with two 2DSCs separated by a tunnel barrier have been studied and demonstrated their properties [11].
\nAs can be seen from Figure 3, tunneling current strongly depends on the energy of quantum level in the QW, so if you create a third electrical contact to control this energy, it is possible to obtain a transistor with a large transconductance value, and even with a negative transconductance. Several types of such transistors have been investigated and are shown in Table 1. They differ by base contact making as it is shown in Figure 5.
\nTopology of resonant‐tunneling transistors. (a) RTT is shown where the base contact is connected directly to the QW and (b) RTT is shown where the base contact is connected to layer adjacent to the QW.
\n | Unipolar transistors | \nBipolar transistors |
---|---|---|
Base pin contacts to the QW | \nUnipolar RTT with contact to the QW | \nBipolar RTT with QW contact |
Base pin contacts layer close to the QW | \nUnipolar RTT on hot‐electrons effect | \nLight‐emitting RTT |
Resonant‐tunneling transistors.
In this case, double‐barrier heterostructure is located inside a vertical bipolar transistor in a thin layer being in connection with base contact [12]. One example implementation of such a heterostructure is shown in Figure 6(a) in the form of the band structure. QW layer is considerably doped with impurities of p‐type, which allows change in the potential of QW almost independently of the potentials of the source and drain. Resonant tunneling through the QW starts at finite drain‐source voltage (see Figure 6(b)). Figure 7(a) presents source‐drain characteristics of the transistor at different values of voltage on the base. As one can see from Figure 7(b), the resonant tunneling provides just weak features in the transconductance of the transistor, which appears to be associated with a strong broadening of the levels of dimensional quantization in the QW, due to its disorder induced by doping impurities. The usage of modulated doping could significantly improve the situation, but further research in this direction is not followed. Perhaps because in the transistor the doped layer is placed outside the quantum well and the contact to the layer outside the quantum well.
\nBand diagrams of the bipolar RTT with QW at zero drain‐source voltage (a) and at finite applied voltage (b).
Characteristics of the bipolar RTT with QW taken from Ref. [
In the case of a bipolar contact or p‐n junction, the flow of electric current accompanied by the light emission resulted from the electron‐hole recombination. Similar radiation was recorded in a bipolar RTD [13] and bipolar RTT [14]; in this sense, the third electrode can be considered as controlling not only current but also radiation. The presence of the region of negative differential conductance (NDC) allows to create not only an oscillator but also an optical pulsar with a clock frequency up to the THz range. One of the options for band structure of these transistors is shown in the insert in Figure 8. In this case, the base layer is doped by donors, but the contact is placed out from the side of the structure. This helped to maintain the quality of the QW between the tunneling barriers that has led to a significant effect of resonant tunneling. As a result, the region of the negative conductance and transconductance was present in all transistor characteristics (see Figure 8(a)).
\nElectrical and optical characteristics of the bipolar RTT with base contact separated from active region taken from Ref. [
It is possible to make a deep QW between the tunneling barriers. The QW will be filled by carriers from adjacent layers, if a ground subband has energy
Resonant‐tunneling transistor with deep QW. Topology of layers and contacts and conduction band bottom diagram of the active region of the RTT.
Electrical characteristics of the RTT with deep QW. (a) Source‐drain current‐voltage characteristics at different base voltage and (b) source‐drain current‐voltage characteristic at floating base potential.
The removal of the base layer outside the quantum well improves the work of RTT, as demonstrated in Refs. [9, 15]. The topology of the transistor and its diagram of the conduction and composition of the layers is shown in Figure 11. In this case, the heavily‐doped disordered base layer does not much influence the quality of the QW and bright NDC features are observed in all electrical characteristics. Figure 12 shows transistor characteristics obtained. The thickness of the base layer is 50 nm (a) and 25 nm (b). From Figure 12, one can see that the wide‐base layer degrades characteristics of NDC and increases the base current, decreasing the width of the layer characteristics improves characteristic and the gain current increases. It is worth noting that at low voltage, the current is very low because the ground subband has energy considerably higher the Fermi energy and only high energy electrons or hot electrons can tunnel.
\nResonant‐tunneling transistor on hot electrons. Topology of layers and contacts and conduction band bottom diagram of the active region of the RTT.
Electrical characteristics of the RTT on hot electrons. (a) Characteristics obtained on RTT with base layer of 50 nm thickness and (b) the same for 25 nm thickness.
Previously studied resonant‐tunneling transistors have considerable disadvantages such as the tunnel current is very low and high frequency application is possible only in the region of NDC. However, the resonant tunneling can be used in conventional FET to shrink gate‐voltage range where it takes place [16]. As already mentioned in Section 2, the situation can be significantly improved by using a structure with two quantum wells. In this case, the gate 2DCS has a carrier concentration different from the 2DCS concentration in the channel (see Figure 13(a)). To create such transistor, it requires an entire system of gates. The problem is that two conductive layers are in close proximity to each other, which significantly complicates the creation of separate ohmic contacts to each layer. In this case, ohmic contacts to the both layers are made, and then, additional gates (1, 2 in Figure 13(b)) deplete one of the layers. So, gate 1 can be used by applying a negative voltage to the depletion of the upper layer and double gate 2 is used for the depletion of the lower layer. Due to the difference of the energies the resonant tunneling between the layers will be suppressed and the leakage current from the gate to channel will be low. It should be noted that when using this transistor to completely eliminate the resonant tunneling which is impossible as to deplete the channel, one must pass through the resonance voltage
Field‐effect transistor with QWs. (a) Conduction band bottom diagram of the active region of the FET and (b) topology of the contacts of the FET.
Another possibility of a FET is proposed in Ref. [17] with a gate and a channel on the basis of 2DSC in different valleys. The key point of the device is that the 2DSCs are different. In particular, they are formed in different valleys of the carrier spectrum (see Figure 14(a)). Due to this difference, the carrier tunneling requires additional excitations with significant momentum and energy. This decreases the tunneling rate significantly. For example, the intervalley tunneling rate is less than intravalley that in 9 orders of magnitude in GaAs/AlAs heterostructures [18]. Application of 2DSCs in the gate and channel in different valleys can significantly decrease the tunnel leakage and allow further cut‐off frequency to increase. Moreover, in the case of low intervalley carriers scattering, the dielectric layer can be removed which increases the transconductance of the FET. Some realization of the conduction band bottom profile can be found in Figure 14(b). The heterostructure is modulation‐doped by Si donors. The AlAs is an indirect semiconductor where X‐valley has lower energy than Г‐one. Hence, in the layer 2, a quantum well (XQW) is formed in the X‐valley that is shown by long‐dashed line in the profile. The XQW can be used as a FET gate. A GaAs quantum well is formed in Г‐valley (ГQW) and can be used as a FET channel. A topology of the FET can be the same as in Figure 13. The source and drain are contacted to the ГQW and the gate is contacted to the XQW (see arrow 3 in Figure 13). The electric characteristics of the proposed FET are still under investigation. However, some discussion about their miniaturization is possible and follows in the next section.
\nElectrons spectra in active region of the FET with QW in different valleys. (a) Electron dispersion curves in the XQW (solid curve) and ГQW (dotted curve) and (b) conduction band bottom diagram of the proposed FET heterostructure.
As mentioned in Section 1, miniaturization of transistors is the main direction of development of microelectronics for more than 50 years and the reason is not only the attraction of investments or the usability of electronic devices. The main reason for miniaturization is to increase the cut‐off frequency of semiconductor devices. Let us consider how the size reduction leads to an increase in the operating speed of a FET. In Figure 15(a), one can see a typical topology of a FET with metal electrodes. The FET is plugged in the bias circuit through the contacts 1 (source) and 2 (drain). Offset
Topology and characteristics of the field effect transistor. (a) Topology of a field‐effect transistor and the plug‐in circuit. The dotted line shows the elements of the equivalent circuit of the transistor. (b) Source‐drain characteristics of FET for different gate voltages
Here,
where
where
Then taking into account Eq. (11), one can get the following expression for the cut‐off frequency:
\nThis shows that by increasing the value of
Thus, reducing the size of the active area of the transistors leads to an increase in the cut‐off frequency, which is the main physical reason for the miniaturization. However, as mentioned in Section 1, miniaturization of transistors has led to the increase in the leakage current, which significantly increases energy consumption and reduces the prospects for further development in this direction to zero. The use of resonant tunneling can significantly reduce leakage currents, but it is necessary to use a carrier system with reduced dimensions. These systems which appear in semiconductor nanoheterostructures, recently also actively studied the carbon nanomaterials. Here, there is a new problem with miniaturization. When reduction of
In summarizing, we can state that application of resonant tunneling can significantly increase the operating speed of the FET and reduce leakage currents. However, the application of 2DCS systems imposes new restrictions on the miniaturization, reducing her prospects to almost zero. However, even relatively large RTD already working on the frequencies exceeding the frequencies of the transistors. It is shown that devices based on resonant tunneling are able to replace the conventional FET. The main problem of widespread use of such devices today is a significant high cost of the technology of molecular‐beam epitaxy. Possible further development of technology toward a carbon nanomaterials. Carbon nanomaterials might allow high‐quality RTD, which is significantly cheaper than semiconductor materials. In this case, we should expect serious changes in the architecture of classical computers and the emergence of new solutions in the field of quantum computing.
\nEach person has a set of personality traits that are unique and make up one’s personality.
Temperamental characteristics show high stability and are developmentally associated with personality traits during adulthood including extraversion or high energetic level, agreeableness, conscientiousness, neuroticism (emotional stability), and openness [2]. An important personality trait is
Personality disorder (PD) is defined as an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, and leads to distress or impairment [4]. People with PD have disrupted behavior, cognition, and emotions when in contact with other people and society, while the individuals and the people around them suffer [1]. The ICD-10 classifies the following PD: paranoid, schizoid, dissocial, emotionally unstable (impulsive and borderline type), histrionic, anankastic, anxious (avoidant), dependent, and other (e.g., narcissistic) [5]. The DSM-5 divides PD into three clusters. Cluster A personality disorders are characterized by unusual and odd-eccentric behavior and introverted individuals including paranoid, schizoid, and schizotypal PD. Cluster B personality disorders are associated with dramatic, emotional, and erratic behavior: antisocial, borderline, histrionic, and narcissistic PD. Cluster C includes avoidant, dependent, and obsessive-compulsive PD associated with anxious and fearful disorders. The division into three groups is useful for educational and research purposes; however, it also has its limitations. Clinically, there is a lot of overlapping between various PDs. The frequency of individual PD varies from study to study, and even greater differences are present when looking at the frequency of individual PD in a given population. Borderline PD is present in 0.9–3% of the general adolescent population, in 11% of outpatient adolescents, and 49% of admitted adolescents [4].
People diagnosed with PD from one group may also meet the diagnostic criteria of PD from the other, which occurs in about 9% [4]. Individuals from group C and A most commonly have an associated PD (6.0 and 5.7%, respectively), while this occurs only in 1.5% of individuals in the group B [4]. Due to PD overlapping and for other reasons as well, the PD criteria in ICD-11, which will come into effect in January 2022, have been modified [6]. ICD-11 follows a dimensional understanding of PD and largely abandons the categorical view. The new division of PD follows the psychodynamic tradition, the scientific model of the core PD characteristics, and thus provides guidance for clinical treatment [7]. It provides an assessment of the severity of the disorder, and enables to diagnose three levels of PD and code subthreshold personality difficulty. ICD-11 specifies five domain qualifiers of personality, which include negative affectivity, detachment, dissociality, disinhibition, and anankastia. In addition to these five markers, a borderline pattern qualifier can also be specified. The latter may be applied if at least five out of nine borderline PD criteria according to DSM-5 are present. An example of a diagnosis of borderline PD following the new features in ICD-11 is for example a moderate PD with borderline pattern, negative affectivity, disinhibition, and dissociality [7].
Borderline PD is one of the most common PDs and these individuals are also more likely to seek medical help and suffer from significantly more associated mental disorders (depression, anxiety disorders, psychoactive substances abuse, and hyperkinetic disorder) compared to the general population [8]. Vulnerability for borderline PD can be clearly recognized during the development period. The concept of borderline personality has evolved throughout history. Morel and Kraepelin used this term to describe the states between neurotic and psychotic conditions primarily based on phenomenological clinical descriptions and by ignoring the developmental and dynamic aspects of pathology [9].
Kernberg linked the classical psychoanalysis, the object relations theories, the psychology of self (immature integrative self-functions) with the psychobiological and neurobiological theories, and defined the concept of borderline personality disorder as a pathological personality organization that is intermediate between psychotic disorders and neuroses—symptomatically, structurally, and genetically-dynamically [10, 11]. This concept was further enhanced by the Linehan’s biosocial model [12].
According to DSM-5, at least five of the following nine criteria must be present to code borderline personality disorder [4].
Frantic efforts to avoid real or imagined abandonment
Unstable and intense relationships
Identity disturbance, seen in an unstable self-image or sense of self
Impulsivity
Suicidal behavior
Affective instability (episodic dysphoria, irritability, anxiety: lasting a few hours to days)
Chronic feelings of emptiness
Displays of inappropriate anger (verbal/physical fights)
Micropsychotic episodes, transient stress-related paranoid ideation/dissociative symptoms
In addition, these patterns are enduring, inflexible, and clinically relevant to diminish social, educational, or professional functioning. The onset of this pattern is traced back at least to adolescence or early adulthood and it is not a manifestation of another mental disorder and is not due to the consumption of psychoactive substances [4].
Quite a few features of borderline PD (impulsivity, emotional instability, dysfunctional interpersonal relationships, impaired self-image, and identity diffusion) may also—to some extent—be characteristics of adolescent period. In order to diagnose a borderline PD in an individual during adolescence, the features must have been present for at least 1 year and cause severe dysfunction [4]. If the adolescent reacts highly destructive, has transient psychotic reactions and behavioral problems, uses psychoactive substances, has emotional disorders associated with the loss of a relationship with the important other or negative emotions, one can suspect a borderline PD [13].
In the clinical picture of borderline PD in adolescents, one often sees anger towards parents, depression without any existential despair, tension, loss of empathy, impulsive behavior, and brief psychotic episodes including a paranoid thoughts and depersonalization without thought disorder [14].
It is a legitimate question whether to diagnose or not to diagnose PD before the age of 18. That is during adolescence – the time of major developmental changes, when the personality is not yet fully formed. However, relevant classifications and guidelines, based on a number of studies, allow us to diagnose a PD before 18 years of age. According to ICD-10, a PD can be diagnosed regardless the age of person if the diagnostic criteria are met; however, this is exceptionally rare before the age 16 or 17 years [5]. This is even more clearly defined in ICD-11, where the diagnosis of PD is made whenever the diagnostic criteria are met [6].
The DSM-5 allows for a diagnosis of PD in children and adolescents, when personality traits are particularly maladapted, permanent, and not related to a specific developmental period, mental disorder, or cultural background with the exception of antisocial PD, which cannot be diagnosed before the age of 18. For a diagnosis to be made, the characteristics of PD should have been present persistently for at least 1 year [4]. One should keep in mind that the characteristics of PD identified in childhood will change and that some types of PD will become less obvious or even disappear in later developmental periods (borderline, antisocial PD). The NICE recommendations do not define a chronological age at which a PD can be diagnosed. Instead, they focus on the individual level of developmental maturity and an understandable therapeutic plan to be provided to the person diagnosed with PD [15]. However, PD should not be diagnosed in individuals under the age of 13 and is not applicable until an individual finishes puberty. Because PDs have long been considered as therapy resistant, this diagnosis is misused even today as an excuse to refuse a patient. When diagnosing a person with PD, especially if it is an adolescent, an appropriate treatment must be provided along with the diagnosis. Prevention, early detection, and timely treatment are essential [15].
The purpose of diagnosing PD is to provide the adolescent with the appropriate treatment. It is the adolescent period that has a corrective potential and by introducing a therapy in time, we can significantly influence the course of PD. Adolescents with PD should be treated by a team of highly qualified professionals with a clearly structured intervention model and therapeutic plan [8, 13, 15]. Primarily, the patient must be provided with continuity and consistency. Adolescents with PD, especially borderline patients, have a tendency to form intense relationships; therefore, it is necessary to set clear time and space framework for treatments with different therapists. It is essential to organize treatments adequately—not too much and too little. Team members often have different views on the adolescent’s problems and symptoms, which often lead to conflicts within the team; therefore, supervision is necessary. Often, many services (social services, school, general physician, previous therapist) are involved in the treatment; therefore, roles and tasks need to be clearly identified and coordinated. One of the main treatment goals of all team members is to support the adolescent in his separation and individualization and to actively involve him in the decision-making process. Many adolescents with borderline PD have experienced traumatic events; however, trauma processing is often not the primary intervention. Primarily, it is necessary to reduce suicidality and increase emotional stability [15, 16].
There are many different psychotherapeutic approaches to treat PD. Mentalization-based therapy (MBT), dialectical-behavioral therapy (DBT), and adolescent identity treatment (AIT) are among the most common. It is not so important which specific psychotherapeutic approach is used in the therapy but that certain changes outside the therapeutic relationship are triggered [13, 16]. According to Lambert, these changes are to be accountable for 40% of success in psychotherapy [17]. It is important to include the rest of the family in the therapy, to generate changes in the school, and that all significant others receive appropriate psychoeducation. Psychotherapeutic factors such as therapeutic posture, curiosity, optimism, consistency, empathy, and warmth contribute 30% to the success of a therapy. The adolescent’s expectations of how successful the therapy will be contributing a further 15%. In addition, 15% is contributed by the specific psychotherapeutic techniques [17].
To achieve an optimal therapeutic process, regardless of the type of therapy, the therapist needs to be open, accepting, and optimistic and maintain a positive mental representation of the adolescent as well as curiosity and interest in getting to know the adolescent as a holistic personality, not only in the context of his or her disorder [16]. Since AIT is a younger and not so known therapy as MBT and DBT, it will be explained in more detail than the last two therapies below.
Adolescent identity treatment (AIT) is an integrative therapeutic approach based on the principles of Paulina Kernberg, which includes modified elements of transference- focused psychotherapy, psychoeducation, behavior-oriented home plans, therapeutic contract, and intensive family work with adolescents and parents (adapted from [16]). Identity diffusion and interpersonal misfunctioning are regarded as the core of the borderline PD in adolescents and, as such, forming a base for the essential principles of AIT. The AIT focuses on identity stabilizing and integration of the concepts of the self and significant others, which gradually affects interpersonal relationships and leads to resolving interpersonal conflicts. The AIT applies verbal and nonverbal communication as well as countertransference. The basic principle of the AIT is to work on the dominant affect. The therapist focuses on the dominant affect the adolescent is affected by—here and now. Clarification, confrontation, and interpretation are applied as therapeutic techniques.
I did not understand…
Did I get this right? You said…
What did you mean by saying…?
Please, could you explain that to me in detail?
Is it because you do not have words to describe it, or because you have not thought about it?
You are telling me about a rather excruciating pain, but you are laughing at the same time. This does not fit. Do you have any idea what could this mean?
You are saying that you are fine, but I see fresh cuts. How do these things fit?
You are telling me you are not disappointed, yet you are struggling with tears. Can you explain this?
This is how I see it, but correct me, if I am wrong.
On the one hand, you are telling me that you are fine, but I see many fresh wounds on your arm.
Then you tell me that no one would be sad if you killed yourself.
Could it be that all these contradictory images are within you and that you do not know exactly whether you are feeling well or maybe you are still sad?
Regardless of the psychotherapeutic approach, sincerity, empathy, and warmth are the key characteristics of a therapist. AIT, however, added playful flexibility to the list, with the therapist explaining his/her thoughts, offering possible explanations as a hypothesis (interpretation) and adjusting to the adolescent. The therapist maintains a sound and meaningful stance, knows right from wrong, and maintains his or her position. Optimism is a necessary condition for the therapist to develop an idea of the adolescent as a healthy and stable person, including therapist’s attitude that the adolescent is able to cooperate in sessions and that he or she can develop. The therapist maintains hope for change during therapy stagnation and when the risk of discontinuation of therapy occurs. The absolute presence of the therapist is crucial for the therapy. It can be manifested as curiosity and a genuine interest in the adolescent’s experiences. The therapist is absolutely present when his or her nonverbal/body language and tone of speech reflect the adolescent’s experience of the here and now. The therapist is a role model. For an adolescent, therapist may be the first person to ever really take a truly interest in him or her. By doing so, the therapist engages the adolescent to be curious, motivated, and interested in himself/herself.
Body language is an important factor in AIT. Therapists must be fully aware of their tone, facial expressions, thinking, and interest, paying attention to the adolescent in the treatment, and how all of this is being acknowledged by the adolescent. Nonverbal information is vital in therapy with PD adolescents, who are overly sensitive to possible rejection, split, and are not able to recognize contradictions in verbal and nonverbal communication or are prone to misjudging it. It does matter how the therapist dresses and whether he/she has a piercing or a tattoo. The latter, in particular, can be an important message of how a therapist treats his/her body or allows for various manipulations.
Intensive parental involvement in therapy is especially important in adolescents with PD and is therefore a crucial element of AIT. Working with parents can only be successful if there is no attribution of blame to the parents for the development of PD in their adolescent. If the parents are viewed as the “bad guys,” then the therapist may cause the adolescent to see him/her as a “better parent” and a “savior,” which brings many risks to the therapy. At the beginning of therapy, even very competent and functional parents can appear to be “pathological” due to psychological burden when living with an adolescent with PD.
It is important that the parents are not viewed as bad and invalidating by the therapist. If parents are not included in the therapy, the power of family dynamics and interactions significantly shaping the adolescent is being underestimated. It is essential to educate parents on the adolescent’s heightened sensitivity to emotional stressors, such as criticism, rejection, and separation, and how stressors can be avoided or reduced. Parents need an explanation that the therapy will not change the adolescent’s temperament; however, it will help him to control it more easily. Their job is to encourage the adolescent to go to therapy.
Therefore,
At the beginning of therapy, a
A home plan involves clearly agreed responsibilities of both the adolescent and parents. This includes clear measures for self-injurious behavior such as addressing the wound without any additional comments, threats, rewards, or conversation; the adolescent will discuss this with his/her therapist at the next regular session. If the wounds are deep, the adolescent should be taken to see a surgeon. Behaviors that violate the home plan resulting in the revocation of privileges are agreed upon and set out in the contract, including a reward system for behavior if the adolescent sticks to the home plan.
Mentalization-based therapy is a psychosocial therapy to treat borderline PD (adapted from [18]). It derives from psychoanalysis, attachment theory, and developmental psychopathology and is based on mentalization. It was first intended for the treatment of adults with borderline PD, later on a version for adolescents (MBT-A) was developed. Mentalization is the ability to understand our own mental states and the mental states of other people and represents the capacity that makes us human. We mentalize when we are aware of the mental states of others and ourselves. MBT is based on the assumption that instability in mentalization is a key problem of borderline PD. Similar to AIT, the therapist takes the position of a curious listener, who does not know what is going on and therefore encourages the adolescent to explain. The therapist observes the capacity for attachment and mentalization and applies various interventions to improve or at least maintain the adolescent’s capacity to mentalize.
Dialectical behavioral therapy was developed by the psychologist Marsha M. Linehan and colleagues in the late 1980s to treat borderline PD [19]. Later on, Rathus and Miller developed a version of DBT for adolescents (DBT-A) [20].
The DBT is based on cognitive-behavioral therapy, dialectical philosophy, and on the findings of M. Linehan that people with borderline PD are prone to more intense and dramatic responses when facing specific emotional situations (e.g., romantic, friendly, and family relationships) compared to people without PD. People with borderline PD have quick and strong emotional reactions in the situations described above, remain emotionally aroused, and require more time to calm down than people without borderline PD [19]. As a result, DBT does not focus on the core unconscious conflict, such as in MBT. Instead, it focuses on how to change problematic responses with a range of different behavioral strategies [21].
DBT-A is a 16-week treatment that includes individual adolescent therapy once a week, family therapy as required, and a skills training group for families of adolescents with borderline PD [22]. It is aimed at reducing life-threatening and undesirable behaviors in therapy and behaviors that impair the quality of life. It empowers the adolescents to regulate their emotions, to appropriately deal with interpersonal relationships and cope with stress, and encourages mindfulness [20].
The 2001 American Psychiatric Association recommendations [23], the 2009 NICE guidelines [15], which were reaffirmed in 2018 [24], and the Australian NHMRC guidelines for the treatment of borderline PD [25] do not recommend the use of pharmacotherapy as the first-line therapy. The World Federation of Societies of Biological Psychiatry recommendations mentions several studies reporting the efficacy of serotonin reuptake inhibitors (SSRIs), such as fluoxetine and fluvoxamine and second-generation antipsychotics in the treatment of PD [26].
The 2019 Timaus et al. study confirms clinical observations that most patients with PD are also treated pharmacotherapeutically [27]. Polypharmacy is high, which can also be attributed to the great comorbidity of PD with at least one additional mental disorder. For the most part, tricyclics, first-generation antipsychotics, and mood stabilizers are being omitted in the pharmacotherapy of PD. The mood stabilizer lamotrigine did not prove to be successful in the treatment of PD in a 2018 study [28]. The use of the atypical antipsychotic quetiapine and the opioid antagonist naltrexone has been increasing [27]. However, more studies are required to support the justification for using these medicines.
Prevention and early detection of PD are essential in order to prevent long-lasting effect of PD on adolescent’s overall functioning and interpersonal relationships. When diagnosing a PD in adolescence, we are obliged to provide an appropriate and a PD specialized treatment (AIT, DBT-A, MBT-A). By introducing a therapy in time and by a licensed therapist PD treatment is very effective especially in the adolescent period which has a strong corrective potential.
This work was part of a Slovenian Research Agency project J4-9434.
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\n\nMetadata for all publications is also automatically deposited in IntechOpen's OAI repository, making them available through the Open Access Infrastructure for Research in Europe's (OpenAIRE) search interface further establishing our compliance.
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