Severe Personality Disorders

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This book is about understanding and managing patients with severe personality disorders. It covers biological, psychoanalytic and cognitive-behavioural approaches and provides a pragmatic guide to best practice, based on the published evidence, where this is available. As well as discussing issues of severity, treatability and the range of appropriate management options, the content explores the common elements of effective interventions and covers early prediction, countertransference, disruptions of the therapeutic alliance, suicidal crises and what to do when dealing with dangerous, refractory and stalking patients. The chapters are authored by an international cast of distinguished investigators and innovators from the field. This is a holistic, practical guide to the treatment of patients with the range of these disorders and it should be read by all the members of the mental health team dealing with this challenging clinical group.

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Editorial Reviews

From the Publisher
Review of the hardback: 'This book covers important aspects of personality disorders management. It starts with treatability, methods of treatment, issues in children and adolescence, managing suicidal crisis, management of severe and dangerous cases and discussion of common elements of effective treatment. … a detailed, thoughtful and comprehensive survey of the available literature on treatment of personality disorders with meticulous attention to conceptual details. The reader explores the essential ingredients of an effective therapeutic approach for these conditions.' Saudi Medical Journal

Review of the hardback: 'By presenting the opinions of renowned experts on a broad range of issues integral to the understanding and treatment of severe personality disorders, the book is certainly a treasure box that contains an interesting mixture of stimulating ideas and useful practical guidelines. … Severe Personality Disorders can be recommended highly to anyone who want to enhance his or her knowledge of these challenging conditions.' Journal of Psychosomatic Research

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Product Details

  • ISBN-13: 9780521856515
  • Publisher: Cambridge University Press
  • Publication date: 10/31/2007
  • Pages: 264
  • Product dimensions: 6.85 (w) x 9.72 (h) x 0.67 (d)

Meet the Author

Bert van Luyn is Clinical Psychologist and Clinical Head of Ambulatory Services for Longterm Psychiatric Disorders, Symfora Group, The Netherlands.

Salman Akhtar is Professor of Psychiatry at Jefferson Medical College and Supervising and Training Analyst at the Psychoanalytic Center of Philadelphia, USA.

John Livesley is Professor Emeritus in the Department of Psychiatry, University of British Columbia, Canada.

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Table of Contents

1. Treatability in severe personality disorders: how far do the science and art of psychotherapy carry us? Michael Stone; 2. The treatment of choice: what method fits whom? John Clarkin; 3. Countertransference: recent developments and technical implications for the treatment of patients with severe personality disorders Otto Kernberg; 4. Beyond management to cure: enhancing the positive dimensions of personality Robert Cloninger; 5. Personality disorders from the perspective of child and adolescent psychiatry Arnold Allertz and Guus van Voorst; 6. Disruptions in the course of psychotherapy and psychoanalysis Salman Akhtar; 7. Managing suicidal crises in patients with severe personality disorders Joel Paris; 8. Borderline personality disorder, day hospitals, and mentalization Anthony Bateman and Peter Fonagy; 9. Pharmacotherapy of severe personality disorders: a critical review Thomas Rinne and Theo Ingenhoven; 10. Severe cases: management of the refractory borderline patient Bert van Luyn; 11. Dangerous cases: when treatment is not an option Reid Meloy and James Reavis; 12. Stalking of therapists Paul Mullen and Rosemary Purcell; 13. Common elements of effective treatments John Livesley.

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First Chapter

Cambridge University Press
9780521856515 - Severe Personality Disorders Edited - by Bert van Luyn, Salman Akhtar, W. John Livesley

Treatability in severe personality
disorders: how far do the science
and art of psychotherapy carry us?

Michael H. Stone

Personality disorders, severe and otherwise, constitute what one might call a fuzzy set, after the theory developed by Lotfi Zadeh (1987), and expanded by Bart Kosko (1993). An analogous concept is that of “warmth” as applied to the ambient temperature: there are numbers below which almost no one would consider the temperature “warm,” and other readings, say – above 122 °F/50 °C – that would almost universally be experienced as too warm. As the temperature approached 50 °C, gradually increasing percentages of people would conclude it was “too hot.” This gradual change, which would speed up as one got very near to 50 °C, is the fuzzy set. As Kosko points out, the term life is itself fuzzy (p. 242). When it begins (when the sperm meets the egg? at the blastula stage? later?) is a matter of shading; a matter of degree and debate. Questions concerning fuzzy sets are decided often by expert opinion, not precise scientific measurement. In the domain of medical diagnosis, models that use cluster analysis may begin with performing a clustering algorithm ona set of patients – “by examining (a) the similarity of the presence and (b) the severity of symptom patterns exhibited by each” (Klir and Folger, 1988, p. 252). The authors mention that the similarity measure is usually computed between the symptoms of the patient in question and the symptoms of a patient possessing (by experts’ agreement) the prototypical symptom pattern for each possible disease or condition. The most likely diagnostic candidates “. . . are those disease clusters in which the patient’s degree of membership is the greatest” (p. 252).

   This line of argument is relevant to the task at hand, inasmuch as personality disorders, to a much greater extent than is the case with more distinctive conditions (such as mania or anorexia), differ widely in severity and at the same time often contain elements that are shared by two or three or more “disorders” that bear different names when conceptualized as categories. At the low end of severity, for example, the personality disorders shade into the normal population, ceasing at some “fuzzy” band on the continuum even to be a disorder. Meantime, ego-centricity – as a personality trait – is shared by the categories of narcissistic personality disorder (NPD) and antisocial personality disorder (ASPD), and reaches its height, i.e., is most severe, in the category of psychopathy, as defined by either Hare et al. (1990) or by Cooke and Michie (2001).

   Much of the current dissatisfaction with the traditional category approach to diagnosis in the domain of personality disorders as exemplified by the Diagnostic and Statistical Manual of Mental Disorders (DSM, 1994) derives from considerations of this sort. Particularly in discussion of responsiveness to therapy, acknowledgement of the dimensional aspects of personality disorder becomes necessary. But this is simultaneously to acknowledge the fuzziness of the concepts inherent in this domain.

   It is clear to most investigators and clinicians working with personality disorders, for example, that a patient showing four of the items for borderline personality disorder (BPD) (one short of meeting DSM criteria) may lay better claim to a diagnosis of BPD if those four items happen to be the ones considered most common or most close to prototypical of the disorder, as compared with another candidate patient showing five of the weaker items, or even some other candidate patient with six items – all present, but with only meager intensity.

   By the same token, psychotherapists with broad experience in treating personality disorders are aware that the difficulties attendant upon working with the most ominous-sounding categories (e.g., paranoid, antisocial, passive-aggressive) may be surprisingly fewer than those associated with the most intense and severe of the supposedly more easily treatable disorders. Put another way, the most avoidant or most dependent persons, every sector of whose lives is permeated by those traits, will prove more challenging (or perhaps untreatable altogether), compared with another person who shows merely a “touch” of paranoid traits confined just to a few relationships in just one sphere of life. It is observations of this sort that bedevil the attempts of any investigator to “well-order” the different categories of personality disorders from the most easily treatable to the most difficult. I have attempted to do so elsewhere (Stone, 2006), but have added the same caveat as mentioned here; namely, that the personality disorders usually placed in the inhibited category (DSM’s Cluster “C”) – which were the main types treated by the psychoanalytic pioneers – can in certain cases prove quite daunting, whereas a narcissistic or schizotypal patient with good reflective function (Bateman and Fonagy, 2004a) and good motivation may prove more easy to treat and more rewarding to work with. That said, the categories of psychopathy and sadistic personality (neither of which even figures in DSM) remain at the low end of any scale of treatability, no matter how one may configure such a scale.

Factors that influence amenability to psychotherapy

There are numerous factors that affect the treatability of personality disorders by psychotherapeutic means. The factors are basically the same as relate to the amenability of any condition to psychotherapy – by any of the acceptable therapeutic approaches, granted that some of the factors will figure more importantly in one approach, less importantly in another.

   Table 1.1 offers both a list of these factors and a guideline for evaluating each one. The list may be viewed as a collection of fuzzy sets, since each attribute or factor can vary over a wide range. Most of these can vary from high to low as in the case of psychological mindedness, mentalization (as defined by Bateman and Fonagy, 2004a), intelligence, empathy, likeability, and the various spirituality qualities. Life circumstances and cultural factors will vary between favorable and unfavorable; object relations, from harmonious to impaired (and within this factor, attachment style may vary from secure to entangled or dismissive); and concomitant symptom disorders such as substance abuse and depression, from absent to serious.

   Experience with many configurations of personality makes it clear that a good prognosis for psychotherapy does not require optimal levels of all the variables in Table 1.1. Persons with mild antisocial traits, for example, often score poorly on measures of mentalization or “reflective function,” as well as on empathy. I am using the term empathy here to signify both the capacity to read correctly the emotions signaled in another person’s face and compassion. Empathy in this larger sense distinguishes the ordinary person from the psychopath, who, as Baron-Cohen emphasizes (2003), is often adept at “mind-reading” but lacks compassion. The mildly antisocial person may respond reasonably well to a cognitive-behavioral therapeutic approach of the sort recommended by Beck and Freeman (1990), even though the response to a psychodynamic therapy might be meager.

   The variables listed in Table 1.1 do not all carry equal weight vis-à-vis their impact on amenability to psychotherapy. The mildly antisocial person with limited reflective function but good motivation may become “the tortoise that outruns the hare” endowed with excellent reflective function but no motivation. One sees the latter situation in certain schizoid patients. Worse still, the psychopath (meeting the criteria established by Hare et al., 1990) has neither attribute, because, as Hare said elsewhere (1993), “. . . psychopaths are perfectly happy with themselves, and they see no need for treatment, at least in the traditional sense of the term” (p. 203). Motivation thus emerges as a sine qua non of amenability to therapy, since in its absence there is no patient.

   Two other weak links in the chain that binds patient to therapist during the long work of treatment are candor and character. The opposites of candor are

Table 1.1   Guideline for evaluating treatability factors

Treatability factors Evaluation: high, low, etc. A-1 Ability to think about oneself & others, and about one’s feelings Introspectiveness high . . .  . . .  . . .  . . .  . . . low Psychological mindedness high . . .  . . .  . . .  . . .  . . . low Mentalization high . . .  . . .  . . .  . . .  .  . . low Empathy high . . .  . . .  . . .  . . .  . . . low A-2 Intelligence above avg. . . . avg. . . .  . . . . . . . . below avg B Character Uprightness high . . .  . . .  . . .  . . .  . . . low Likeability high . . .  . . .  . . .  . . .  . . . low C Spirituality Hopefulness vs despair high . . .  . . .  . . .  . . .  . . . low Forebearance vs impatience high . . .  . . .  . . .  . . .  . . . low Humility vs false pride high . . .  . . .  . . .  . . .  . . . low Other- vs self-oriented high . . .  . . .  . . .  . . .  . . . low Faith in self vs disillusion high . . .  . . .  . . .  . . .  . . . low Self-acceptance vs self-pity high . . .  . . .  . . .  . . .  . . . low Resignation vs bitterness high . . .  . . .  . . .  . . .  . . . low Serenity vs tormentedness high . . .  . . .  . . .  . . .  . . . low Forgiveness vs grudge-holding high . . .  . . .  . . .  . . .  . . . low Compassion vs hardheartedness high . . .  . . .  . . .  . . .  . . . low Uncomplainingness vs querulousness high . . .  . . .  . . .  . . .  . . . low Self-transcendence vs giving up easily high . . .  . . .  . . .  . . .  . . . low Common decency vs meanspiritedness high . . .  . . .  . . .  . . .  . . . low Dignity vs lacking in dignity high . . .  . . .  . . .  . . .  . . .  . . .  . . .  . . . low Morality vs moral shabbiness high  . . .  . . .  . . .  . . .  . . . low D Candor high  . . .  . . .  . . .  . . .  . . . low E Motivation high . . .  . . .  . . .  . . .  . . . low F Perseverance high . . .  . . .  . . .  . . .  . . . low G Life circumstances favorable. . . .  . . . unfavorable H Object relations harmonious. . . .  . . .  . . .  . . . . . . impaired I Cultural factors favorable. . . .  . . .  . . .  . . .  . . . . unfavorable J Symptom disorders serious moderate mild absent

   (For the Spirituality factors, rate as “high,” “average,” or “low” – the positive factors only: e.g., hopefulness, forebearance, humility, etc.)

deceitfulness and withholding (“guardedness”). The patient who lies is, in effect, creating a different persona, such that the therapist is reduced to treating merely a “look-alike” of the real patient, whose true nature remains hidden. Deceitfulness, if persistent, creates an insuperable barrier to therapy. The guarded patient (as one sees with many paranoid persons, or with avoidant patients who struggle under inordinate shame) presents difficult resistances that skillful therapy can often resolve eventually, though not always. I think in this regard of a markedly avoidant, depressed, and shame-ridden woman I undertook to treat years ago, whose main problem (as I was to learn by chance only many years later) was her shame about being homosexual. She was never able to reveal this either to me or to the two other therapists she subsequently saw. So in her, guardedness proved a stumbling block that could not be overcome.

   Regarding character, I am using the word here in its everyday meaning, denoting the set of values and standards by which a person lives, and by which each person becomes known over the course of a lifetime. This is the sense in which Freud was speaking of character when he commented a hundred years ago: “One should look beyond the patient’s illness and form an estimate of his whole personality; those patients who do not possess a reasonable degree of education and a fairly reliable character should be refused” (refused, that is, for psychoanalysis) (1904). Generally, there is a correlation between shabbiness of character and various degrees of narcissism. The spectrum of narcissism may be understood as stretching between “narcissistic personality” as in the DSM, at one pole, passing through malignant narcissism, and on to antisocial personality, and finally, to psychopathy. The malignant narcissist, as Kernberg describes this personality type (1992, p. 77), manifests ego-syntonic sadism, a measure of antisocial behavior, characterologically anchored aggression, and a paranoid orientation, while still retaining a capacity for loyalty and for feeling guilty. Even persons whose array of traits does not quite fill criteria for narcissistic PD, if they show shabby character, they will at least have some distinctly narcissistic qualities: they care more about themselves, after all, than about anyone else. Two brief examples will illustrate this point. One concerns a woman in her mid-20s who suffered a rejection in her first love-affair. Besides her emotional superficiality and depressive core, she was also remarkably immature and self-centered. She set about stalking her ex-boyfriend via hundreds of e-mails and telephone calls to his home and office, sometimes pretending to be someone else scolding him about how terribly he had treated his girlfriend. He finally complained to the police, and she was arrested and spent a night in jail. It was only on the threat of facing a long sentence were she to repeat her behavior that she finally stopped the harassment. Had she owned a gun, she would not have hesitated to kill him, after the manner of many a rejected lover with extreme jealousy and obsessive fixation on the former lover (Buss, 2005, Chapter 1). The other example concerns a narcissistic man nearing 40, married, father of a few-months-old daughter. He fancied himself a photographer, but his work was never accepted, and he was unemployed. His wife worked and supported the family, while he stayed home in the (for him) uncomfortable role of house-husband. What brought him to therapy was his anxiety about his receding hairline, making him afraid that he could no longer succeed in picking up young girls at the beach. One day his wife returned home unexpectedly – to fetch an umbrella: she overheard him talking on the phone to some young girl he had met at the beach the week before. Psychotherapy at this point consisted in admonishing him that he had to make a choice between (1) divorce or (2) giving up cheating on his wife (on whom he was economically dependent) and trying to deal in a mature fashion with his marriage and parenthood. Fortunately, he possessed enough character to commit himself to the second alternative. At follow-up 20 years later, he was still married, was working and had made a reasonably good adjustment to the responsibilities of adult life. But where character falls below some critical level, as in the thoroughly antisocial or psychopathic person, even the most carefully designed behavioral therapy, carried out by the most skillful therapist, would promise little improvement. Time and the maturation that comes with age will sometimes accomplish what therapy failed to do, as in some of the cases of chronic alcoholic and moderately antisocial persons described by Donald Black (1999).

   À propos, the personality and the skill of the therapist should be included as an important variable affecting the treatability of the severe personality disorders. In the severe cases, one cannot make a neat dividing line between the characteristics of the patient and those of the therapist, since many patients in this category will fail to improve with a fair number of therapists, yet may show remarkable improvement when working with a therapist of special skill and where the two personalities “click.” Judd and McGlashan (2003), in their outstanding book on borderline personality, mention, for example, that “Work with BPD patients is not for everyone. . . . Flexibility and creativity within an ethical and commonsense frame of reference not only are essential but make the work challenging and rewarding” (p. 173). They go on to caution that “Work with BPD patients requires a better than average ability to maintain consistent empathy” (p. 186), adding that “Treating BPD patients requires a therapist who can tolerate anger, neither personalizing it, nor becoming so anxious that he is intimidated  . . . into premature responses and actions” (p. 202).

   This need for the proper “click” between therapist and patient is particularly evident in the treatment of borderline patients, in contrast to the situation with neurotic-level, better integrated persons who enter psychoanalysis. As an example of the latter situation, it was the custom at the Columbia Pyschoanalytic Institute years ago that the match between the training analysts and the beginning candidates was made by having the training analysts pick the names of their prospective candidates out of a fishbowl. There were rarely any problems. It was assumed that the trainees could work out whatever problems they had either in their interpersonal lives or in the choice of which analyst they ended up with via analysis with any of the training analysts. The trainees usually showed no more than mild obsessive-compulsive or depressive-masochistic traits that were generally “subclinical” with respect to the criteria in DSM. If some of the candidates were initially unhappy with the choice of analyst assigned them, this disappointment was merely a problem to resolve in the beginning phases of the therapy: one that probably highlighted similar problems in the everyday lives of the trainees.

   Borderline patients behave quite differently. Many embark on what seems like an extended odyssey past half a dozen or more therapists, till the “right” one is at last discovered. Since this process depends on the subtle “chemistry” between the two participants, it is difficult at the outset to predict which therapist will be the “right” one for a given borderline patient. The following vignette is illustrative:

A woman of 20 was referred to a psychiatric hospital in New York that specialized in the long-term psychodynamic treatment of borderline disorders. She had been placed in special boarding schools for disturbed children when she was 15. At 18, because she had made a series of nearly lethal suicide attempts, she was sent to a hospital, where she remained for 2 years. Attractive, bright, but nearly mute, she was diagnosed as “schizophrenic” and treated with nearly 100 electro-shocks, which were completely without effect, except to induce a kind of retrograde amnesia, making it harder for her to recall details from her past. She was then sent to the hospital in New York as a “hopeless case.” During the first year-and-a-half of the three she spent on the new unit, she was assigned to two different therapists, but did not feel comfortable with either. She remained nearly mute, confining her thoughts to a diary where she recorded her feelings of despair, unworthiness, guilt, and suicidality. With the third therapist, however, she “clicked” from the very beginning. She began to open up, gradually became less preoccupied with suicide as her “only option,” and was well enough after a year-and-a-half to be discharged. Continuing to work with the same therapist for another 10 years, she first enrolled in college, where she graduated with high honors, and then went to graduate school, earning a PhD in psychology. Meantime she married and began raising two children. In 2005, 40 years after leaving the borderline unit, she is now a practicing psychologist, living in comfortable circumstances with her husband and two grown children, and writing a book about her extraordinary experiences as a recovered patient. She can now speak candidly about the sexual molestation she experienced at the hands of her father and grandfather – which she did not even recall till several years after leaving the second hospital.

      Two qualities among the many that contributed to her eventual recovery were: she was not schizophrenic by any acceptable criteria, and, in line with the favorable items in Table 1.1, she showed no bitterness. Bitterness, as I have argued elsewhere (Stone, 2006), appears to exert a rate-limiting effect upon the possibility of recovery in borderline patients, inasmuch as several other such patients, who suffered much less traumata in their early years than did the patient just described, remained embittered persons over the course of their lives, and have made much less substantial gains, especially in the spheres of friendship and intimacy.

Estimates of treatability

At this point there is little methodical, let alone rigorous, research devoted to estimating the amenability of the severe personality disorder to the various forms of psychotherapy. This is particularly true of the more ordinary disorders most psychotherapists confront in their practice. Forensic psychiatrists working with psychopathic persons in hospitals or prisons utilize a number of measures to estimate recidivism, such as the Violence Risk Appraisal Guide (VRAG), developed by Quinsey et al. (1998) or the Psychopathy Checklist-Revised (PCL-R) of Hare et al. (1990). With regard to the PCL-R, it has been documented that the higher the score on this measure, the higher the rate of recidivism, and, in general, the earlier the recidivism (for either violent or non-violent convictions) following release from an institution (Hemphill et al., 1998). But observations such as these are not so much measures of treatability as measures of untreatability. Comparable data are not available for assessing the responsiveness to therapy of dependent, or paranoid, or compulsive personalities as encountered in everyday clinical practice. There is instead, a kind of attitudinal consensus built up from the collective experience of seasoned psychotherapists, representing different approaches as to which kinds of personality-disordered patients are likely to do well, and which are not. These impressions can be summarized in a way that yields fuzzy sets – approximations, if you will – of the responsiveness to psychotherapy among the various personality disorders. As an example, Figure 1.1 shows the contrasting impressions concerning the amenability of two disorders – dependent and paranoid – to psychotherapy. Paranoid PD is generally considered less responsive than dependent PD, as reflected in the different curves: the curve for paranoid PD is slanted to the left, since there will be a surplus of cases responding at the levels “nil//poor//fair” compared with those responding at levels “good//excellent//optimal.” The curve for dependent PD is slanted in the other direction, since most cases are amenable to therapy, despite a few being so intractable as to show “nil” response. Image not available in HTML version

Figure 1.1 Contrasting levels of amenability to psychotherapy: dependent vs paranoid PD’s

   Clinicians, of course, take in a multitude of factors when making their estimations of treatability: not only the ones outlined in Table 1.1, but also such factors as age, work history, and the intensity of traits belonging to other categories of personality. A paranoid personality admixed with antisocial features would represent a more challenging picture therapeutically than a paranoid personality free of antisocial traits. An avoidant person with paranoid features would probably be more difficult to treat than an avoidant person with dependent features. The sheer multiplicity of combinations renders the task of accumulating statistically useful numbers of all these subtypes quite forbidding, leaving us back where we began, with more expert opinion than hard data.

   Follow-up data might offer a rough index of treatability, on the supposition that good outcomes in the severe personality disorders might be a reflection of good amenability to psychotherapy, and that, mutatis mutandis, those with poor outcomes owed their eventual fate to a poorer responsiveness to therapy at the outset. The index would be only rough – because we know from the long-term follow-up studies of the 1980s that about one patient in eight behaved counter-intuitively, in the sense that the functional level at long-term was either much better, or occasionally much worse, than the therapists (or treatment staff in hospitals) estimated in the beginning (Stone, 1990a). Furthermore, a proportion of borderline patients treated originally at the Menninger Clinic with expressive (psychoanalytically oriented) therapy were shown to have improved years later under the aegis of expressive therapy, while a proportion of other borderline patients showed similar (but unanticipated) levels of improvement once their therapy had eventually changed to a more supportive mode (Wallerstein, 1986). In the 10- to 25-year follow-up studies (which concentrated on borderline patients, but also included narcissistic and schizotypal patients) good reflective function and high motivation were not guarantors of success: some borderline patients with these characteristics nevertheless committed suicide (McGlashan, 1986a, 1986b; Plakun et al., 1985). Others who abused substances and had few of the favorable factors outlined in Table 1.1 nonetheless made impressive gains years later, little of which could be ascribed to individual psychotherapy (McGlashan, 1986a; Stone, 1990a). These caveats aside, Image not available in HTML version

Figure 1.2a Ten- to twenty-five-year outcome in borderline patients in the P.I.-500, by percentages in each level

Image not available in HTML version

Figure 1.2b Ten- to twenty-five-year outcome in borderline patients in the P.I.-500, by the numbers traced

   it is still possible to map out some correlations, based on long-term results, that relate to treatability. If, for example, one looks at the distribution of outcomes (ranging from suicide/incapacitated/marginal to fair/good/recovered) in the nearly 300 patients with borderline personality organization (Kernberg, 1967) from the P. I.-500 study, it emerges that male BPD patients had the highest suicide rate (14%) and the least likelihood to function at the good [corresponding to Global Assessment Score (GAS) of 61 to 70] or recovered (GAS > 70) level when traced (Figure 1.2 b).

© Cambridge University Press
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