Bipolar Disorder and Comorbid Borderline Personality Disorder
Bipolar disorder and borderline personality disorder have crossover traits and so a person with bipolar disorder can often mistakenly be diagnosed with borderline personality disorder. In fact, some feel that diagnosis with both disorders is inappropriate unless the patient’s bipolar disorder is in remission.
But some people do meet the diagnostic criteria for bipolar disorder and borderline personality disorder. I would have put this number much lower than it actually is thought to be. From the research I’ve done, it appears that borderline personality disorder is comorbid to bipolar in around 40% of cases. This is particularly surprising as it was once thought that personality disorders were only comorbid to bipolar in 12% of cases or less.
But what is borderline personality disorder and what does it mean if you’re diagnosed with both bipolar and borderline personality disorder?
What is Borderline Personality Disorder?
Borderline personality disorder is so called because it was considered to be on the border between psychosis and neurosis. According to Medscape Reference, the Diagnostic and Statistical Manual of Mental Disorder (DSM-IV-TR) provides the following diagnostic criteria for borderline personality disorder:
Borderline personality disorder is marked by a pervasive pattern of instability of interpersonal relationships, self-image, and affects and marked impulsivity beginning by early adulthood and present in a variety of contexts as well as five of the following:
- Frantic efforts to avoid real or imagined abandonment (Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.)
- A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation
- Identity disturbance: Markedly and persistently unstable self-image or sense of self.
- Impulsivity in at least 2 areas that are potentially self-damaging (eg, spending, sex, substance abuse, reckless driving, binge eating) (Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.)
- Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior
- Affective instability due to a marked reactivity of mood (eg, intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days)
- Chronic feelings of emptiness
- Inappropriate, intense anger or difficulty controlling anger (eg, frequent displays of temper, constant anger, recurrent physical fights)
- Transient, stress-related paranoid ideation or severe dissociative symptoms
Impact of Borderline Personality Disorder on Bipolar
The trouble is when people are diagnosed both with bipolar disorder and borderline personality disorder their courses of illness tends to be worse. People with both diagnoses tend to have a history of substance abuse and have had childhood symptoms of attention-deficit/hyperactivity disorder. Moreover, this dual-diagnosis group is at a higher risk of suicide.
Treating Bipolar and Borderline Personality Disorder
Two medications have shown usefulness in treating this subgroup. Divalproate has shown usefulness in treating symptoms like irritability, anger, volatility and impulsive aggression. Lamotrigine has also shown usefulness.
Of course, I would be remiss if I did not mention dialectical behavior therapy. This therapy was specifically designed to treat borderline personality disorder and is currently being tested in bipolar populations. While I know of no research on a dual-diagnosis group specifically, it stands to reason this group would see benefits.
In all, it’s critical to take any comorbid condition seriously as it can complicate treatment of any other condition.
Tracy, N. (2013, July 31). Bipolar Disorder and Comorbid Borderline Personality Disorder, HealthyPlace. Retrieved on 2019, June 27 from https://www.healthyplace.com/blogs/breakingbipolar/2013/07/bipolar-disorder-comorbid-borderline-personality
Author: Natasha Tracy
I know this article is old and most people haven't commented in over a year however I'd like some insight from the POV of someone who suffers/diagnosed with BPD and BP2. I was dating someone for about 3 years. We were really close friends with benefits. We eventually became closer over the course of 2015. He told me in 2014 (while in a hypomanic state) that he had been diagnosed with both as a teen. He is living unmedicated because he says he hates the way it makes him feel. For as long as I've known him he has not been on medication or therapy that I am aware of. With that being said I didn't do my homework on both conditions. I thought I knew what Bp was. I had friends that were BP and he did not act like them. In any case of course I started to see red flags and was always confused as to why he alienated me from his friends, always wanted to stay in, wanted to spend my money, would disapear for days sometimes weeks and also triangulate with another female friend of his. We definitley loved each other and I understood that sometimes he needed space but he started becoming distant in Feb. right after Valentines Day.
He began pushing me away. He took a trip to Las Vegas after he had been borrowing money from me left and right. I was shocked when he told me he was going. When I asked why he said he "Just needed it" and "it was time". I was confused and felt like there was something wrong so I didn't get mad at him I just told him ok and to call me when he got there. He did and he told me that he had a dream that his dead bestfriend told him he was going to win. I was then pretty worried but knew there was nothing I could do. He also was honest with me in the past about hookers etc when he goes to Vegas so I started to also wonder what was coming back with him. In any case he sent me a photo at 2 am, he was alone. He also tired to call but I was asleep. He called the next day and said he won and was going to leave early. He never called me when he came back until I reached out 4 days later asking what's going on. He was kind of strange so took him to dinner to tell him I cared and I was hoping the fight we had on Valentines day didn't drive him to run away like that. He told me it wasn't and we both said I love you's. He was fine for about 2 weeks however he was borrowing more money from me. Then he told me he needed $200 to go see his bestfriend. I told him no and gave him $50 and asked him to leave. He never takes work off yet he took 2 days off and went no where because no one would give him money. In my gut I felt like he was borrowing money to go out with another girl but I thought there is no way...
I see him a couple more times and he's getting more and more distant. We woke up and he said something mean to me in a joking way. For whatever reason with all the constant stresses I was really hurt. Plus what he said was awful. I called him out on it and he said sorry. He felt really bad etc. He didn't want to talk about it. After that night he left and blew me off for 2 days. When I spoke with him he sounded different on the phone. Like the call was staged or being had for someone else in the room. Really weird. That really made me mad because I felt like he was cheating. Usually I'm right. We went to dinner and had a great time and he paid me back the cash he owed me. Then he just ghosted me. Told me he was going to start buying furniture for his room etc. Told me he was going to buy a coffee maker and he doesn't even drink coffee. I was really over it and thought he was just using me and obviously cheating.
Finally on St. Patricks day I felt like he was blowing me off for the 2 time in a row even though he said he'd meet up with me. He told me he was going to go running (at 8pm) and call me after. I knew where this was going so I drank. I emotionally drank and ended up flipping out. I got really angry and felt used. I texted him a bunch of mean and horrible things telling him he was using me and a loser and he should F*** off and stay that way.
I didn't talk to him for about week. Sent an apology email. He told me he'd call me. Never did. Texted me we'd talk about it. Then not respond to me. I eventually started to freak out and went out again drinking with friends. I texted him I was in pain and to please talk to me blah blah. He continued to ignore me. I called and he blocked me. I was frusterated and went to his apt to speak with him in person. Long story short I was obnoxious knocking on the door till his roommate answered. She told me he wasn't there. I didn't believe her. On the way out I told her he was a peice of sh** and that he does stuff like this because he's bipolar. (quick side fact---months before he told me that his roommate knew and had a friend with BP)
I was drunk and ended up coming back about 5 minutes after she told me he was not there and knocked again. I called an uber to come get me. Then the cops showed up. When that happened I knew he was inside hiding. My uber came just in time and I left.
Woke up next day and caught myself feeling like an idiot for being pushed to my limits like that. I'm usually more controlled when it comes to situations like that. Now, I know he knew exactly what he was doing and just playing me to react crazy. It's not like this is the first time he's done this.
So going on we didn't talk. He iced me out and we didn't really communicate. I'd try but he'd ignore me. Finally one night I sent him a text and he called me. He told me some BS story that he was being kicked out of his apt and it was all my fault. He said that his roommate told him he had to move a couple weeks after I came over and caused a disturbance. He said she told him it was because she got a promotion but he thinks it was because I told her that he was bipolar. I knew this was BS but he was also nuts on the phone, blaming me for everything. Telling me he was really angry with me and thought about hurting me he was so mad. Then he told me that loved me but he was too angry to be around and he "never ever ever wants to talk to me again." I asked him what happened and why was he pushing me away. I told him I thought there was someone else. He told me there wasn't and some BS line saying "don't believe all those things you think in your head" In my head I was like whatever dude, your cheating.
Then he told me maybe we could be friends in a couple months but he's not sure. He then told me "good luck" and said "I'll talk to you later". I was heartbroken and shocked. I tried reaching out a couple times after that via text and no response. I finally cut all contact and changed my number. I had to reach out to him last month due to emails from my landlord that I had to ask him about. I called and we spoke. He was indifferent and the call was short. He asked about my dog and just sounded angry. Told me he didn't want to talk because he was at work. After that I sent a text that I was done with reaching out to him and I was cutting my phone line off again. That was the last time we spoke.
Any thoughts on this? Will he have any regret once he crashes? Do BP/BPD suffers regret when they have done breakups like this? Any advice on what I should do here?
I went threw something along the lines of what you were put threw but I allowed it to be repeated amd repeated and youre right, it makes you feel like an idiot and its true they do it to make you seem like youre the crazy one for losing control. It friggin hurts. Im 21 and my "friend with benifits/ partner" had bipolar and he was an addict which made things soso much crazier. The thing is that when they snap out of it that they will 8/10 will come back or make contact with you in some way and try "rekindle what you both had" becuase of some bs reason. But the BP will be works as their excuse or reason. Its honestly and i cant stress this enough, not worth accepting that reason and having them back with you again. Espesially if they arnt getting any treatment, because in a few months maybe even a year or more, it WILL happen again.. They will use you for money and leave. It will hurt just as much but you will feel even more stupid for letting yourself let it happen again.
Sure they regret the things they have done or said but they arnt sorry because it was the BP or it was the drugs or it was them feeling traped and too comfortable blah blah oh and that their wasnt anything to be commited too. Even after you lend them money or cook them breakfast (he even got me plucking his fucking eye brows and i hope you never had to do that lol).
But yeah if this helps just know youre always vunerable to letting his wedge back in to your life and youll think everythings back how it should have been before he went all fuck wit on you and it will feel like that for a time.. just if you do dont let yourself beleive you have the upper hand this time because you have your guard up or what ever, because you know how to "have your boundrys towards what he does" sure maybe you do but when he does it all over again and youre trying not to go crazy over it like last time, it means nothing.. It just hurts you the same all over again but you just feel completely out of control because you tryed to control it better this time and it didnt work for you or him. This might seem like a fuck men and BP but its not that, because he is still the person you love/loved but mental illness makes them someone else aswell that is damaging to their mindsets and lives untill they get legit help. Youve known him for 3 years but you have only known his BP for a short amount of time and It was cruel and crept its way to your head as it is for him. So im giving you insite to the likelyness of what could happen it you let it...
My X and I were living together for 2 years together on and off for 4 and its was a hell pit of anger hope naiveity, hate love hurt list goes on. He ended up getting a girl preganat when we lived together and went to jail 2 times, the amount of times i called the cops on him just to make it all stop and then be too scared to show them where he was hiding because i didnt want him to get mad at me is stupid. I help him when he was sad i laughed with him when he was happy and tolerated him when he was on drugs for so long and i trusted him when we opend our hearts in conversation and I loved him more then is healthy for a human being. And he left, came back when he was "better" then got bad and left agin and again and each time i put up more walls and rules for myself so i wouldnt get hurt becuase i expected he was going to leave i just hoped he wouldnt.. so only i get left with all these emothional and spiritual barries that only fucks me up when trying to make friends becuase he made me disconect from all my closest friends. Any way im rambeling.. sorry.. But if you get this i hope it helps, its also comforting to just have the insite even if you dont agree idk. Good luck with it all xxx
I wonder why my husband even stays with me. I am a disaster. He loves me but when is enough enough... My T said some BPD people are not nice underneath but I am, it was wonderful to hear... things I don't hear from my husband..
The other day when I got upset when once again we were arguing about money when I turned away and started crying he actually told me "oh don't do that, don't go down that rabbit hole because your upset" that hurt so much.... Doesn't he get it. I can't control it.
I am angry, frustrated, depressed and my anxiety is so bad.. I cycle and its the BP and I guess the BPD... I feel lost. To where I want to cut again, but I know he would just be frustrated with me and not strong...
His motto is to ignore me at times in stead of fighting with me when he knows he will never be right when Im Manic or Depressed... Again, why try...
Does anyone feel this way? I know he loves me deeply but is it enough?
I am currently separated (via a restraining order) from my estranged husband. I am positive he has some kind of undiagnosed mental illness (bipolar, BPD, etc) due to his erratic behaviour and denial of the same.
For years now he has blamed our problems on me or his family or coworkers. He's always telling me I am 'crazy,' cannot self-regulate, emotionally stunted, looking up my 'illness' on websites, etc. But he utterly fails to see how charges of domestic abuse against him were his fault ("you overreacted"), or how child services investigated him for going after our son ("I just hit my head and reacted badly to that, that's why...it's an old head injury"). He has a spotty job record, serious anger and control issues, hoards, goes through periods of isolating or sleeping a lot, blames everyone and cannot see how his own behaviour brings his problems upon himself, can get very arrogant, is very smart, codependent (self-confessed), in recovery off/on for drug and alcohol abuse, twice tried to kill himself in his early-mid 20's (once when prescribed anti-depressants), and will go through periods of acting out sexually (dating sites, Craigslist, hookers, etc).
He can get verbally abusive and rages, is irritated easily, demands respect and nonresistance if you try to point out his behaviour (cannot take criticism), is hard to understand as he will talk fast and bounce from thought to thought (even a previous marriage counsellor asked him to stick to one subject!), and will go through phases where he's telling everyone he's going to write the next best selling novel,(then I'll regret being such a bitch all the time) while at the same time can't finish anything he starts, etc.
And now he is blaming me for there being a restraining order against him. Says he going to counseling but then sends me nasty, vindictive emails! What sane person would do that knowing there is already an order against him that could be used against him? It makes no logical sense to me.
Does this behaviour ring a bell for anyone (besides alarm bells)? I cannot help but think he's either really sick and mentally ill, or he's just a very abusive person living in denial of his actions.
Oh, and his family thinks he's bipolar but he just thinks its all us who are messed up!
Since then I have enrolled on a degree course and will be going into my final year in Sept (studying sociology). Studying has become an obsession, even though assignments take me 3 times as long to finish because everything I have read becomes jumbled up in my head with all my other thoughts.
I agree with you bipolar artist about feeling stigmatised. For me this comes from one particular member of staff
at the university. Each time I phone to explain I need an extension on assignments she advises me to suspend my studies. This hurts because I persevere against all odds, often increasing my anxiety levels to the point of being physically ill.
I don't expect a pat on the back or any sort of recognition from her for my determination. I've done this for myself and my very supportive partner, but mostly my children. My daughter was bullied for having a mental mum. I want them to see that no matter how tough things get I am more than the diagnosis. Bp and BPD are not only a part of who I am. Its really difficult to remember that though when you come across people who make yourself feel like you have a neon flashing arrow pointing at you.
That's my mini rant over.
Would just to add I'm glad I found this site. Its really helpful to read other people's experiences and reflect on my own.
I don't think for one minute that all dually diagnosed people will have the same experiences as me, but for me the differences stick out like a sore thumb.
I stumbled onto this blog researching my own dual diagnosis of Bipolar and Borderline. I am familiar with most of what all of you folks have posted regarding it's impact on one's quality of life and relationships . . . and I have a question. How many of you have experienced problems obtaining and/or maintaining gainful employment?
I am 44 and I have a degree majoring in Sociology. I was able to "keep it together" for some time until I had a major break that should have seen me hospitalized. However, that very night I met my husband . . . a pretty incredible guy who I am still with to this day. BUT . . . he is frustrated because I cannot seem to keep a job anymore. It only takes a few days before my suspiciousness and paranoia kick in and I am running for the door (literally). I have so many gaps in my work history and no references for anyone to call. I have tried several non-profit agencies for help buy I have yet to find anyone who can help someone with a personality like mine (ours, I guess!).
I am quite isolated as all of my friends and family have fallen away many years ago (although I argue that my family members are "touched" as well so it's probable for the best).
I spend most of my time alone. Trying to convince myself that I'm not really lonely . . . . .
Any thoughts on this would be most appreciated.
I took Celexa once and it made my anger episodes much worse. Stay away from SSRI's.
Anyway I wanted to reply to Megan. Whether you believe it or not, your family needs you. My parents were nowhere to be found when I was growing up. You need to be with them.
However, taking a day or two a week to yourself sounds to me like a great idea. You need more breaks than the average person, or you will be overwhelmed. You need lots of "me" time. You need a "safe room," for when you get overwhelmed, away from your family, for a few hours or a day. Is there any family members you can visit when this happens?
"I really do fear that once they leave they will see what it is like to have some type of structure around them and never want to come back to me."
About the husband, it's impossible to be certain. Many women would like to think that their husbands are understanding and supportive, but many times these same husbands often appear ignorant and just want to run away from the marriage. That's biology. That's reality. He can't help it any more than you can help getting bpd. It all depends on the kind of man he is, and how disciplined he is.
Your husband is a fully-grown man. If he knows what's best, he'll be willing to go to therapy, alone or not.
The breaks I'm talking about will help your kids. They don't need their mommy all the time, but they DO need you! Also you need to start going to therapy, read bpd articles and selfhelp books. You need to do everything you possibly can do to help yourself. When you help yourself, you help your family.
I recently found out that I am Bi Polar 2, Borderline Personality, and PTSD. I am not on here to ask what I should do. I am asking for my family's sake.
I know that I have many problems and with my children being as young as they are (3yr and 9mnth), they don't need to see or be around this. I have family near me but they are "unable" to help. They have their own issues. I wonder if it is a good idea for my family to leave me until I am stable????
I really do fear that once they leave they will see what it is like to have some type of structure around them and never want to come back to me.
My husband has been with me since high school and he didn't know what he was getting into. When my symtoms got worse and nearly being placed in a hospital he realized that I had something wrong with me.
For the longest of times he thought that I was being lazy and not working. I have had 6 jobs and I have quit or it was a seasonal job. But still since 2006 I have had huge time gaps in between jobs. I have tried to get a job again and most places will not hire me because of something. I don't know.
His family is learning about all this with him. They have never heard or seen this before. And now that they understand and are learning what they can do to help.
Sorry went off topic.
Anyways, what can I do for my family??? Husband doesn't want to go to therapy alone and my kids are having nightmares. My eldest will say "time out, Mommy, time out."
What to do???????
Bipolar has several subcategories already (bipolar I, bipolar II, cyclothymia and rapid cycling etc.) and Borderline is starting to be considered another extreme form of the spectrum.
So don't get to hung up in the 'Borderline is a personality disorder and unchangeable' mind set. If research can progress to understanding how that cell signalling system can be re-set there is much hope for effective treatment. Even now with DBT, medication and better understandings of the physiological and psychological components of both bipolar and borderline many, many people are in recovery and doing well. But like so many contributors have said here they have to want to get well first. So keep working on it and keep your minds open to the possibilities.
I have recently bin diagnosed with emotionally unstable PD, I don't disagree with the diagnoses but from the relentless info searching and home work I have done, I believe I have a combination of personality disorder and bipolar. I remember feeling very different from a young age....5/6....and my childhood was accompanied by trauma violence control and sexual abuse, at 16 I was diagnosed with depression which was correct at the time, I was offered no therapy or help which means I have bottled my feeling and emotions up, there has bin a few things happening over the past year that I couldn't mentally deal with, these problems are what I believe have triggered a start to my illness, (doesn't seem to be uncommon for a bad situation to bring a persons illness out)I started smoking weed at a the age of 15 and it helped a bit, at 17 I tried heroin for the fist time and continued to use it, not often just 5/6 times a year, how ever I have found that since my illness started I have bin using heroin at least once a week, on my good days I don't give it a second thought, how ever I have more bad days then anything now and I find heroin is the only thing that makes me feel normal, I don't inject and I don't smoke it to the point of falling asleep, I smoke a little bit every few hours and it numbs the pain.....im desperate for help now though as I can see myself spiralling into a very dark place and more then anything I don't want to have the need to use heroin any more, I've seen how it devastates families as my mums sister had a fatal overdose on it, I have told my mum that I have dabbled with it but I cant ever tell her the full extent as she is very poorly and I don't think she would be able to cope knowing the true mess im in, (she also suffers from depression and had a major breakdown a few years ago)my dad although he tries is as pig headed as they come and doesn't seem to understand me....my nan (mums mum)was diagnosed as schizophrenic 30 years ago and committed suicide before I was bourn, my mum now says she disagrees with my nans diagnoses as me and my nan are the same in many ways, my eldest sister also has bipolar with phcychotic traits, she also has a very tough life (sexual abuse and violent boyfriend that regularly beat and raped her) but also started taking drugs to help take the edge off from the age of 13 onwards, I would say its clear that it has bin passed down threw out my family, but me and my sisters didn't have the greatest of childhoods and my mum had a devastatingly traumatic childhood as did my nan!......I start therapy soon at Francis Dixon lodge in Leicester and can honestly not wait, im hoping its as good as they say, this really is my last hope and option, if this doesn't work I don't hold much hope for my future because I think I will end things before they go further..........HOW EVER although I said my dad is pig headed about it I now realise that pushing people away is a strong train with these illnesses please don't walk away from your loved ones, they need you more then you can possibly imagine!!
All of the above being said, I do feel sorry for those who do have bipolar and bpd at the same time. I am no doctor. But I am pretty sure I know such a person. She is offically diagnosed with bipolar but she is a major alcholic. Sadly, her mood swings go from euphoric to rages. She gets very combative and conflictive. She becomes a brick wall. She has an idea that she is always right. She has a sense of entitlement to everything. She lies all the time. She lives in her own fantasy world that does not make any sense. It seems as though her bpd actually stabilizes her bipolar I disorder and allows her to remain in a very negative pattern. She is a miserable person with no sense of self-esteem or true identity. She is a manipulator and you have to check her stories all the time. I have had to give up being around her. She wants to argue frenquently or create drama. She is caustic to my own bipolar. I just hope she can get help somewhere. I can't be her friend.
I have to limit my interactions with them, esp. my sister. I can't take the stress of the drama she's continually making. Luckily, both live over 400 miles away.
I have to take care of myself and my own illness. Part of that care is limiting as much stress in my life as possible. They are definitely that stress!
I did have an additional and unrelated question for Natasha, and there's no other way to contact you that I could find. My question is if you've ever written and/or done research on the presence of catatonic symptoms (whether they meet full diagnostic criteria or only partially) in bipolar mania, and how they present themselves. I'm also wondering about any first-hand accounts.
Furthermore, though, personality disorders exist in a much higher degree in patients with psychiatric (mental) illnesses. This makes sense, particularly if those mental illnesses have been untreated or undiagnosed in the past. In fact, I am of the opinion that any personality disorder cannot be really diagnosed (certainly not treated) until underlying psychiatric illnesses have been treated, and treated successfully for a substantial period of time. Then if those abnormalities still appear, though perhaps to a lesser degree, despite stability (let's say bipolar for now because that's what this blog is about), then those issues may not be a result of the bipolar disorder. They may be due to an additional disorder, be it another mental illness, or perhaps a personality disorder.
These are all things that a well-trained psychologist AND psychiatrist can pare out. Sometimes treatment is nearly impossible because of the additional personality disorders that a patient may have. Lastly, I don't know what they are, but it would be neat to find out the prevalence rates of personality disorders are in the population of those without mental illnesses.
The man I am with was diagnosed in 2005 as being bi-polar. He was given medications which he took but he never bothered to refill them. He claims he is not bi-polar. His mood swings are bizarre. He can be "normal" acting for a day or two then, he goes off on these tangents about anything and everything. I mean...he will go on...and on...and on...for days. Hollering, name calling, threatening, gets on the internet and gets into verbal fights, he uses alcohol when he feels tense, which is most of the time. Some days, it seems like his mind is just rushing because he goes from one topic to another and I can barley keep up with his line of thinking. His actions are just insane....and very embarrassing too. He has been in and out of jail multiple times for drinking issues. The ironic part of all this is, he is actually a very intelligent man. Seriously, he is. Probably one of the most intelligent people I have ever met but....his mood swings are off the charts. Is there anything that can be done if he will not admit he is bi-polar? Or will he have to crash himself before he gets help. I know if I stay it will not be mentally healthy for me. Any comments or advice will be welcomed.
I did received the diagnosis of Bipolar II at age 40. That was a turning point in my life because getting the right treatment and the right understanding of myself and my illness was crucial. It opened a door to recovery.
I recently was an in-patient and then out-patient for several weeks. In a psychoeducation session, I asked the psychiatrist what was the difference between borderline and bipolar -- and she said they were simply different points on a spectrum. She added that many experts maintained that BPD was just a subtype of bipolar and should be abolished as a separate diagnosis.
I have the sense that BPD is diagnosed mainly to signal to the treatment team that the person self-harms and is volatile, nothing more. It holds no separate implications for treatments or outcomes.