Sandbox:Irfan: Difference between revisions
Jump to navigation
Jump to search
Irfan Dotani (talk | contribs) |
Irfan Dotani (talk | contribs) |
||
| Line 130: | Line 130: | ||
*** Dialectical behavior therapy is derived from cognitive-behavioral techniques (and can be seen as a form of CBT) but emphasizes an exchange and negotiation between therapist and client, between the rational and the emotional, and between acceptance and change (hence dialectic). Treatment targets are agreed upon, with self-harm issues taking priority. | *** Dialectical behavior therapy is derived from cognitive-behavioral techniques (and can be seen as a form of CBT) but emphasizes an exchange and negotiation between therapist and client, between the rational and the emotional, and between acceptance and change (hence dialectic). Treatment targets are agreed upon, with self-harm issues taking priority. | ||
*** The learning of new skills is a core component - including mindfulness, interpersonal effectiveness (e.g. assertiveness and social skills), coping adaptively with distress and crises; and identifying and regulating emotional reactions. | *** The learning of new skills is a core component - including mindfulness, interpersonal effectiveness (e.g. assertiveness and social skills), coping adaptively with distress and crises; and identifying and regulating emotional reactions. | ||
*** DBT can be based on a biosocial theory of personality functioning in which BPD is seen as a biological disorder of emotional regulation in a social environment experienced as invalidating by the borderline patient.<ref name=promising>Murphy, E. T. PhD; J. Gunderson MD (January 1999). "[http://web.archive.org/web/19991014032825/http://www.mcleanhospital.org/psychupdate/psyupI-3.htm A Promising TreatmentBorderline Personality Disorder]". ''McLean Hospital | *** DBT can be based on a biosocial theory of personality functioning in which BPD is seen as a biological disorder of emotional regulation in a social environment experienced as invalidating by the borderline patient.<ref name=promising>Murphy, E. T. PhD; J. Gunderson MD (January 1999). "[http://web.archive.org/web/19991014032825/http://www.mcleanhospital.org/psychupdate/psyupI-3.htm A Promising TreatmentBorderline Personality Disorder]". ''McLean Hospital Psychiatric Update''. Retrieved on 2007-09-23.</ref> | ||
*** Dialectical behavioral therapy has been found to significantly reduce self-injury and suicidal behavior in individuals with BPD, beyond the effect of usual or expert treatment, and to be better accepted by clients.<ref>Verheul, R.; L.M. Van Den Bosch, M.W. Koeter, et al. (February 2003). "[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=12562741&query_hl=3&itool=pubmed_docsum Dialectical | *** Dialectical behavioral therapy has been found to significantly reduce self-injury and suicidal behavior in individuals with BPD, beyond the effect of usual or expert treatment, and to be better accepted by clients.<ref>Verheul, R.; L.M. Van Den Bosch, M.W. Koeter, et al. (February 2003). "[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=12562741&query_hl=3&itool=pubmed_docsum Dialectical behavioral therapy for women with borderline personality disorder: 12-month, randomized clinical trial in The Netherlands]". ''British Journal of Psychiatry'' (182): 135-40. Retrieved on 2007-09-23.</ref><ref>Linehan, M.M.; K.A. Comtois, A.M. Murray, et al. (July 2006). "[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?itool=abstractplus&db=pubmed&cmd=Retrieve&dopt=abstractplus&list_uids=16818865 Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder]". ''Archives of General Psychiatry'' '''63''' (7): 757-66. Retrieved on 2007-09-23.</ref> although whether it has additional efficacy in the overall treatment of BPD appears less clear.<ref name="Cochranepsychotherapy"/> Training nurses in the use of DBT has been found to replace a therapeutic pessimism with a more optimistic understanding and outlook.<ref>Hazelton, M.; R. Rossiter, J. Milner (February - March 2006). "[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16594889 Managing the 'unmanageable': training staff in the use of dialectical behavior therapy for borderline personality disorder]". ''Contemporary Nurse'' '''21''' (1): 120-30. Retrieved on 2007-09-23.</ref> | ||
** 1.30 '''Schema Therapy''' | ** 1.30 '''Schema Therapy''' | ||
*** | *** Schema Therapy (also called Schema-Focused Therapy) is an integrative approach based on cognitive-behavioral or skills-based techniques along with [[Object relations theory|object relations]] and [[Gestalt therapy|gestalt approaches]]. It directly targets deeper aspects of emotion, personality and [[Schema (psychology)|schemas]] (fundamental ways of categorizing and reacting to the world). The treatment also focuses on the [[Transference|relationship with the therapist]] (including a process of "limited re-parenting"), daily life outside of therapy, and traumatic childhood experiences. | ||
*** | *** It was developed by Jeffrey Young and became established in the 1990s. Limited recent research suggests that it is significantly more effective than Transference-Focused Psychotherapy, with half of the individuals with borderline personality disorder assessed as having achieved full recovery after 4 years, with two-thirds showing clinically significant improvement.<ref name="SFTvsTFT">Giesen-Bloo, J.; R. van Dyck, P. Spinhoven, et al. (June 2005). "[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16754838 Outpatient psychotherapy for borderline personality disorder: a randomized trial of schema-focused therapy vs transference-focused psychotherapy]". ''Archives of General Psychiatry'' '''63''' (6): 649-58. Retrieved on 2007-09-23.</ref><ref>Darden, M. (2006-10-10). "[http://www.eurekalert.org/pub_releases/2006-10/ppmr-nhf101006.php New hope for an 'untreatable' mental illness]". ''EurekAlert!'' Retrieved on 2007-09-23.</ref> Another very small trial has also suggested efficacy.<ref>Nordahl, H.M., T.E. Nysaeter (September 2005). "[http://cat.inist.fr/?aModele=afficheN&cpsidt=16983362 Schema therapy for patients with borderline personality disorder: a single case series]". ''J Behav Ther Exp Psychiatry'' '''36''' (3): 254-64. Retrieved on 2007-09-23.</ref> | ||
** 1.40 '''Cognitive Behavioral Therapy''' | ** 1.40 '''Cognitive Behavioral Therapy''' | ||
*** | *** Cognitive Behavioral Therapy (CBT) is the most widely used and established psychological treatment for mental disorders, but has appeared less successful in BPD, due partly to difficulties in developing a therapeutic relationship and treatment adherence. Approaches such as DBT and Schema-focused therapy developed partly as an attempt to expand and add to traditional CBT, which uses a limited number of sessions to target specific maladaptive patterns of thought, perception, and behavior. A recent study did find a number of sustained benefits of CBT, in addition to treatment as usual, after an average of 16 sessions over one year.<ref>Davidson, K.; J. Norrie, P. Tyrer, et al. (October 2006). "[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17032158 The effectiveness of cognitive behavior therapy for borderline personality disorder: results from the borderline personality disorder study of cognitive therapy (BOSCOT) trial]". ''Journal of Personality Disorders'' '''20''' (5): 450-65. Retrieved on 2007-09-23.</ref> | ||
*** | *** [[Eye Movement Desensitization and Reprocessing]] (EMDR) is a treatment for PTSD, a condition closely associated to BPD in many cases. It is similar to CBT and seen by some as a type of CBT, but also includes unique techniques intended to facilitate full emotional processing and coming to terms with traumatic memories. | ||
** 1.50 '''Marital or Family Therapy''' | ** 1.50 '''Marital or Family Therapy''' | ||
*** | *** Marital Therapy can be helpful in stabilizing the marital relationship and in reducing marital conflict and stress that can worsen BPD symptoms. Family Therapy or Family Psychoeducation can help educate family members regarding BPD, improve family communication and problem-solving, and provide support to family members in dealing with their loved one's illness. | ||
*** | *** Two patterns of family involvement can help clinicians plan family interventions: overinvolvement and neglect. Borderline patients who are from over-involved families are often actively struggling with a dependency issue by denial or by anger towards their parents. | ||
*** | *** Interest in the use of psychoeducation and skills training approaches for families with borderline members is growing.<ref name=AMN/> | ||
** 1.60 '''Psychoanalysis''' | ** 1.60 '''Psychoanalysis''' | ||
*** | *** Traditional [[psychoanalysis]] has become less commonly used than in the past, both in general and in regard to BPD. This intervention has been linked to an exacerbation of BPD symptoms<ref name=no_to_psychoanalysis>"[http://www.medical-library.org/journals2a/borderline.htm Borderline Personality Disorder]". Retrieved on 2007-09-23.</ref> although there is also evidence of the effectiveness of certain techniques in the context of partial hospitalization.<ref>Bateman, A.; P. Fonagy (January 2001). "[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=11136631 Treatment of borderline personality disorder with psychoanalytically oriented partial hospitalization: an 18-month follow-up]". ''American Journal of Psychiatry'' '''158''' (1): 36-42. Retrieved on 2007-09-23.</ref> | ||
** 1.70 '''Transference Focused Psychotherapy''' | ** 1.70 '''Transference Focused Psychotherapy''' | ||
*** | *** Transference-Focused Psychotherapy (TFP) is a form of psychoanalytic therapy dating to the 1960s, rooted in the conceptions of [[Otto Kernberg]] on BPD and its underlying structure (borderline personality organization). Unlike in the case of traditional psychoanalysis, the therapist plays a very active role in TFP. In the session, the therapist works on the relationship between the patient and the therapist. The therapist will try to explore and clarify aspects of this relationship so the underlying [[object relations]] dyads become clear. | ||
*** | *** Some limited research on TFP suggests it may reduce some symptoms of BPD by affecting certain underlying processes,<ref>Levy, K.N.; J.F. Clarkin, L.N. Scott, et al. (2006). "[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16470612 The mechanisms of change in the treatment of borderline personality disorder with transference focused psychotherapy]". ''Journal of Clinical Psychology'' (62): 481-501. Retrieved on 2007-09-23.</ref> and that TFP in comparison to [[Dialectical behavioral therapy|Dialectical Behavior Therapy]] and supportive therapy results in increased reflective functioning (the ability to realistically think about how others think) and a more secure [[Attachment theory|attachment style]].<ref>Levy, K.N.; K.B. Meehan, K.M. Kelly, et al. (2006). "Change in attachment patterns and reflective function in a randomized control trial of transference-focused psychotherapy for borderline personality disorder". ''Journal of Consulting and Clinical Psychology'' (74): 1027-1040.</ref> Furthermore, TFP has been shown to be as effective as DBT in the improvement of suicidal behavior, and has been more effective than DBT in alleviating anger and in reducing verbal or direct assaultive behavior.<ref>Clarkin, J.F. Ph.D.; K.N. Levy, Ph.D., M. F. Lenzenweger, Ph.D., et al. (June 2007). "[http://ajp.psychiatryonline.org/cgi/content/abstract/164/6/922 Evaluating Three Treatments for Borderline Personality Disorder: A Multiwave Study]". ''The American Journal of Psychiatry'' (164): 922-928. {{doi|10.1176/appi.ajp.164.6.922}}. Retrieved on 2007-09-23.</ref> Limited research suggests that TFP appears to be less effective than schema-focused therapy while being more effective than no treatment.<ref name="SFTvsTFT"/> | ||
** 1.80 '''Cognitive Analytic Therapy''' | ** 1.80 '''Cognitive Analytic Therapy''' | ||
*** | *** Cognitive Analytic Therapy (CAT) combines cognitive and psychoanalytic approaches and has been adapted for use by individuals with BPD with mixed results.<ref>Ryle, A. (February 2004). "[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=15061342&dopt=Abstract The contribution of cognitive analytic therapy to the treatment of borderline personality disorder]". ''J Personal Disord'' '''18''' (1): 3-35. Retrieved on 2007-09-23.</ref> | ||
* 2.0 '''Medication''' | * 2.0 '''Medication''' | ||
** 2.1 '''Antidepressants''' | ** 2.1 '''Antidepressants''' | ||
Revision as of 15:26, 31 July 2018
| Findings | Suggestive of | |||
|---|---|---|---|---|
| System | General Appearance | Deposition | Condensation | |
| Deposition | Condensation | |||
| Deposition | Condensation | |||
| Vital Signs | Deposition | Condensation | ||
| Deposition | Condensation | |||
| Deposition | Condensation | |||
| Skin | Deposition | Condensation | ||
| Deposition | Condensation | |||
| Deposition | Condensation | |||
| Head | Deposition | Condensation | ||
| Deposition | Condensation | |||
| Deposition | Condensation | |||
| Eyes | Deposition | Condensation | ||
| Deposition | Condensation | |||
| Deposition | Condensation | |||
| Ears | Deposition | Condensation | ||
| Deposition | Condensation | |||
| Deposition | Condensation | |||
| Nose | Deposition | Condensation | ||
| Deposition | Condensation | |||
| Deposition | Condensation | |||
| Throat | Deposition | Condensation | ||
| Deposition | Condensation | |||
| Deposition | Condensation | |||
| Neck | Deposition | Condensation | ||
| Deposition | Condensation | |||
| Deposition | Condensation | |||
| Lungs | Deposition | Condensation | ||
| Deposition | Condensation | |||
| Deposition | Condensation | |||
| Heart | Deposition | Condensation | ||
| Deposition | Condensation | |||
| Deposition | Condensation | |||
| Abdomen | Deposition | Condensation | ||
| Deposition | Condensation | |||
| Deposition | Condensation | |||
| Back | Deposition | Condensation | ||
| Deposition | Condensation | |||
| Deposition | Condensation | |||
| Genitourinary | Deposition | Condensation | ||
| Deposition | Condensation | |||
| Deposition | Condensation | |||
| Extremities | Deposition | Condensation | ||
| Deposition | Condensation | |||
| Deposition | Condensation | |||
| Neuromuscular | Deposition | Condensation | ||
| Deposition | Condensation | |||
| Deposition | Condensation | |||
Borderline Personality Disorder
- 1.00 Therapies
- 1.10 Psychotherapy
- Simple supportive therapy alone may enhance self-esteem and mobilize the existing strengths of individuals with BPD.[1] Specific psychotherapies may involve sessions over several months or, as is particularly common for personality disorders, several years.
- Psychotherapy can often be conducted either with individuals or with groups. Group therapy can aid the learning and practice of interpersonal skills and self-awareness by individuals with BPD[2] although drop-out rates may be problematic.[3]
- 1.20 Dialectical Behavioral Therapy
- Dialectical behavior therapy is derived from cognitive-behavioral techniques (and can be seen as a form of CBT) but emphasizes an exchange and negotiation between therapist and client, between the rational and the emotional, and between acceptance and change (hence dialectic). Treatment targets are agreed upon, with self-harm issues taking priority.
- The learning of new skills is a core component - including mindfulness, interpersonal effectiveness (e.g. assertiveness and social skills), coping adaptively with distress and crises; and identifying and regulating emotional reactions.
- DBT can be based on a biosocial theory of personality functioning in which BPD is seen as a biological disorder of emotional regulation in a social environment experienced as invalidating by the borderline patient.[4]
- Dialectical behavioral therapy has been found to significantly reduce self-injury and suicidal behavior in individuals with BPD, beyond the effect of usual or expert treatment, and to be better accepted by clients.[5][6] although whether it has additional efficacy in the overall treatment of BPD appears less clear.[7] Training nurses in the use of DBT has been found to replace a therapeutic pessimism with a more optimistic understanding and outlook.[8]
- 1.30 Schema Therapy
- Schema Therapy (also called Schema-Focused Therapy) is an integrative approach based on cognitive-behavioral or skills-based techniques along with object relations and gestalt approaches. It directly targets deeper aspects of emotion, personality and schemas (fundamental ways of categorizing and reacting to the world). The treatment also focuses on the relationship with the therapist (including a process of "limited re-parenting"), daily life outside of therapy, and traumatic childhood experiences.
- It was developed by Jeffrey Young and became established in the 1990s. Limited recent research suggests that it is significantly more effective than Transference-Focused Psychotherapy, with half of the individuals with borderline personality disorder assessed as having achieved full recovery after 4 years, with two-thirds showing clinically significant improvement.[9][10] Another very small trial has also suggested efficacy.[11]
- 1.40 Cognitive Behavioral Therapy
- Cognitive Behavioral Therapy (CBT) is the most widely used and established psychological treatment for mental disorders, but has appeared less successful in BPD, due partly to difficulties in developing a therapeutic relationship and treatment adherence. Approaches such as DBT and Schema-focused therapy developed partly as an attempt to expand and add to traditional CBT, which uses a limited number of sessions to target specific maladaptive patterns of thought, perception, and behavior. A recent study did find a number of sustained benefits of CBT, in addition to treatment as usual, after an average of 16 sessions over one year.[12]
- Eye Movement Desensitization and Reprocessing (EMDR) is a treatment for PTSD, a condition closely associated to BPD in many cases. It is similar to CBT and seen by some as a type of CBT, but also includes unique techniques intended to facilitate full emotional processing and coming to terms with traumatic memories.
- 1.50 Marital or Family Therapy
- Marital Therapy can be helpful in stabilizing the marital relationship and in reducing marital conflict and stress that can worsen BPD symptoms. Family Therapy or Family Psychoeducation can help educate family members regarding BPD, improve family communication and problem-solving, and provide support to family members in dealing with their loved one's illness.
- Two patterns of family involvement can help clinicians plan family interventions: overinvolvement and neglect. Borderline patients who are from over-involved families are often actively struggling with a dependency issue by denial or by anger towards their parents.
- Interest in the use of psychoeducation and skills training approaches for families with borderline members is growing.[2]
- 1.60 Psychoanalysis
- Traditional psychoanalysis has become less commonly used than in the past, both in general and in regard to BPD. This intervention has been linked to an exacerbation of BPD symptoms[13] although there is also evidence of the effectiveness of certain techniques in the context of partial hospitalization.[14]
- 1.70 Transference Focused Psychotherapy
- Transference-Focused Psychotherapy (TFP) is a form of psychoanalytic therapy dating to the 1960s, rooted in the conceptions of Otto Kernberg on BPD and its underlying structure (borderline personality organization). Unlike in the case of traditional psychoanalysis, the therapist plays a very active role in TFP. In the session, the therapist works on the relationship between the patient and the therapist. The therapist will try to explore and clarify aspects of this relationship so the underlying object relations dyads become clear.
- Some limited research on TFP suggests it may reduce some symptoms of BPD by affecting certain underlying processes,[15] and that TFP in comparison to Dialectical Behavior Therapy and supportive therapy results in increased reflective functioning (the ability to realistically think about how others think) and a more secure attachment style.[16] Furthermore, TFP has been shown to be as effective as DBT in the improvement of suicidal behavior, and has been more effective than DBT in alleviating anger and in reducing verbal or direct assaultive behavior.[17] Limited research suggests that TFP appears to be less effective than schema-focused therapy while being more effective than no treatment.[9]
- 1.80 Cognitive Analytic Therapy
- Cognitive Analytic Therapy (CAT) combines cognitive and psychoanalytic approaches and has been adapted for use by individuals with BPD with mixed results.[18]
- 1.10 Psychotherapy
- 2.0 Medication
- 2.1 Antidepressants
- 2.2 Antipsychotics
- 2.1 Antidepressants
- 3.0 Mental Health Services and Recovery
- 3.1 Combining Pharmacotherapy and Psychotherapy
- 3.2 Difficulties in Therapy
- 3.3 Other Strategies
- 3.1 Combining Pharmacotherapy and Psychotherapy
- ↑ Aviram, R.B.; D.J. Hellerstein, J. Gerson, et al. (May 2004). "Adapting supportive psychotherapy for individuals with Borderline personality disorder who self-injure or attempt suicide". J Psychiatr Pract 10 (3): 145-55. Retrieved on 2007-09-23.
- ↑ 2.0 2.1 Gunderson, J.G. MD (2006-04-10). ""Borderline Personality Disorder - Psychotherapies". American Medical Network. Retrieved on 2007-09-23.
- ↑ Hummelen, B.; T. Wilberg, S. Karterud (January 2007). "Interviews of female patients with borderline personality disorder who dropped out of group psychotherapy". Int J Group Psychother 57 (1): 67-91. Retrieved on 2007-09-23.
- ↑ Murphy, E. T. PhD; J. Gunderson MD (January 1999). "A Promising TreatmentBorderline Personality Disorder". McLean Hospital Psychiatric Update. Retrieved on 2007-09-23.
- ↑ Verheul, R.; L.M. Van Den Bosch, M.W. Koeter, et al. (February 2003). "Dialectical behavioral therapy for women with borderline personality disorder: 12-month, randomized clinical trial in The Netherlands". British Journal of Psychiatry (182): 135-40. Retrieved on 2007-09-23.
- ↑ Linehan, M.M.; K.A. Comtois, A.M. Murray, et al. (July 2006). "Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder". Archives of General Psychiatry 63 (7): 757-66. Retrieved on 2007-09-23.
- ↑
- ↑ Hazelton, M.; R. Rossiter, J. Milner (February - March 2006). "Managing the 'unmanageable': training staff in the use of dialectical behavior therapy for borderline personality disorder". Contemporary Nurse 21 (1): 120-30. Retrieved on 2007-09-23.
- ↑ 9.0 9.1 Giesen-Bloo, J.; R. van Dyck, P. Spinhoven, et al. (June 2005). "Outpatient psychotherapy for borderline personality disorder: a randomized trial of schema-focused therapy vs transference-focused psychotherapy". Archives of General Psychiatry 63 (6): 649-58. Retrieved on 2007-09-23.
- ↑ Darden, M. (2006-10-10). "New hope for an 'untreatable' mental illness". EurekAlert! Retrieved on 2007-09-23.
- ↑ Nordahl, H.M., T.E. Nysaeter (September 2005). "Schema therapy for patients with borderline personality disorder: a single case series". J Behav Ther Exp Psychiatry 36 (3): 254-64. Retrieved on 2007-09-23.
- ↑ Davidson, K.; J. Norrie, P. Tyrer, et al. (October 2006). "The effectiveness of cognitive behavior therapy for borderline personality disorder: results from the borderline personality disorder study of cognitive therapy (BOSCOT) trial". Journal of Personality Disorders 20 (5): 450-65. Retrieved on 2007-09-23.
- ↑ "Borderline Personality Disorder". Retrieved on 2007-09-23.
- ↑ Bateman, A.; P. Fonagy (January 2001). "Treatment of borderline personality disorder with psychoanalytically oriented partial hospitalization: an 18-month follow-up". American Journal of Psychiatry 158 (1): 36-42. Retrieved on 2007-09-23.
- ↑ Levy, K.N.; J.F. Clarkin, L.N. Scott, et al. (2006). "The mechanisms of change in the treatment of borderline personality disorder with transference focused psychotherapy". Journal of Clinical Psychology (62): 481-501. Retrieved on 2007-09-23.
- ↑ Levy, K.N.; K.B. Meehan, K.M. Kelly, et al. (2006). "Change in attachment patterns and reflective function in a randomized control trial of transference-focused psychotherapy for borderline personality disorder". Journal of Consulting and Clinical Psychology (74): 1027-1040.
- ↑ Clarkin, J.F. Ph.D.; K.N. Levy, Ph.D., M. F. Lenzenweger, Ph.D., et al. (June 2007). "Evaluating Three Treatments for Borderline Personality Disorder: A Multiwave Study". The American Journal of Psychiatry (164): 922-928. doi:10.1176/appi.ajp.164.6.922. Retrieved on 2007-09-23.
- ↑ Ryle, A. (February 2004). "The contribution of cognitive analytic therapy to the treatment of borderline personality disorder". J Personal Disord 18 (1): 3-35. Retrieved on 2007-09-23.