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Abstracts: Personality Disorders
FOCUS 2013;11:218-224. doi:10.1176/appi.focus.11.2.218
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S.F. McMain, T. Guimond, D.L. Streiner, R.J. Cardish, P.S Links. .Am J Psychiatry2012; 169:650–661

Objective: The authors conducted a 2-year prospective naturalistic follow-up study to evaluate posttreatment clinical outcomes in outpatients who were randomly selected to receive 1 year of either dialectical behavior therapy or general psychiatric management for borderline personality disorder. Method: Patients were assessed by blind raters 6, 12, 18, and 24 months after treatment. The clinical effectiveness of treatment was assessed on measures of suicidal and nonsuicidal self-injurious behaviors, health care utilization, general symptom distress, depression, anger, quality of life, social adjustment, borderline psychopathology, and diagnostic status. The authors conducted between-group comparisons using generalized estimating equation, mixed-effects models, or chi-square statistics, depending on the distribution and nature of the data. Results: Both treatment groups showed similar and statistically significant improvements on the majority of outcomes 2 years after discharge. The original effects of treatment did not diminish for any outcome domain, including suicidal and nonsuicidal self-injurious behaviors. Further improvements were seen on measures of depression, interpersonal functioning, and anger. However, even though two-thirds of the participants achieved diagnostic remission and significant increases in quality of life, 53% were neither employed nor in school, and 39% were receiving psychiatric disability support after 36 months. Conclusions: One year of either dialectical behavior therapy or general psychiatric management was associated with long-lasting positive effects across a broad range of outcomes. Despite the benefits of these specific treatments, one important finding that replicates previous research is that participants continued to exhibit high levels of functional impairment. The effectiveness of adjunctive rehabilitation strategies to improve general functioning deserves additional study.

M.C. Zanarini, F.R. Frankenburg, D.B. Reich, G Fitzmaurice. .Am J Psychiatry2012; 169:476–483

Objective: The purposes of this study were to determine time to attainment of symptom remission and to recovery lasting 2, 4, 6, or 8 years among patients with borderline personality disorder and comparison subjects with other personality disorders and to determine the stability of these outcomes. Method: A total of 290 inpatients with borderline personality disorder and 72 comparison subjects with other axis II disorders were assessed during their index admission using a series of semistructured interviews, which were administered again at eight successive 2-year follow-up sessions. For inclusion in the study, patients with borderline personality disorder had to meet criteria for both the Revised Diagnostic Interview for Borderlines and DSM-III-R. Results: Borderline patients were significantly slower to achieve remission or recovery (which involved good social and vocational functioning as well as symptomatic remission) than axis II comparison subjects. However, by the time of the 16-year follow-up assessment, both groups had achieved similarly high rates of remission (range for borderline patients: 78%−99%; range for axis II comparison subjects: 97%−99%) but not recovery (40%−60% compared with 75%−85%). In contrast, symptomatic recurrence and loss of recovery occurred more rapidly and at substantially higher rates among borderline patients than axis II comparison subjects (recurrence: 10%−36% compared with 4%−7%; loss of recovery: 20%−44% compared with 9%−28%). Conclusions: Our results suggest that sustained symptomatic remission is substantially more common than sustained recovery from borderline personality disorder and that sustained remissions and recoveries are substantially more difficult for individuals with borderline personality disorder to attain and maintain than for individuals with other forms of personality disorder.

M.H. de Moor, P.T. Costa, A. Terracciano, R.F. Krueger, E.J. de Geus, T Toshiko, B.W. Penninx, T. Esko, P.A Madden, J. Derringer, N. Amin, G. Willemsen, J. Hottenga, M.A. Distel, M. Uda, S. Sanna, P. Spinhoven, C.A. Hartman, P. Sullivan, Allik J. Realo, A.C. Heath, M.L. Pergadia, A. Agrawal, P. Lin, R. Grucza, T. Nutile, M. Ciullo, D. Rujescu, I. Giegling, B. Konte, E. Widen, D.L. Cousminer, J.G. Eriksson, A. Palotie, L. Peltonen, M. Luciano, A Tenesa, G. Davies, L.M. Lopez, N.K. Hansell, S.E. Medland, L. Ferrucci, D. Schlessinger, G.W. Montgomery, M.J. Wright, Y.S. Aulchenko, A.C. Janssens, B.A. Oostra, A. Metspalu, G.R. Abecasis, I.J. Deary, K. Räikkönen, L.J. Bierut, N.G. Martin, C.M. van Duijn, D.I Boomsma. .Mol Psychiatry2012;17:337–349

Personality can be thought of as a set of characteristics that influence people's thoughts, feelings and behavior across a variety of settings. Variation in personality is predictive of many outcomes in life, including mental health. Here we report on a meta-analysis of genome-wide association (GWA) data for personality in 10 discovery samples (17,375 adults) and five in silico replication samples (3294 adults). All participants were of European ancestry. Personality scores for Neuroticism, Extraversion, Openness to Experience, Agreeableness and Conscientiousness were based on the NEO Five-Factor Inventory. Genotype data of ≈ 2.4M single-nucleotide polymorphisms (SNPs; directly typed and imputed using HapMap data) were available. In the discovery samples, classical association analyses were performed under an additive model followed by meta-analysis using the weighted inverse variance method. Results showed genome-wide significance for Openness to Experience near the RASA1 gene on 5q14.3 (rs1477268 and rs2032794, p=2.8×10(−8) and 3.1×10(−8)) and for Conscientiousness in the brain-expressed KATNAL2 gene on 18q21.1 (rs2576037, p=4.9×10(−8)). We further conducted a gene-based test that confirmed the association of KATNAL2 to Conscientiousness. In silico replication did not, however, show significant associations of the top SNPs with Openness and Conscientiousness, although the direction of effect of the KATNAL2 SNP on Conscientiousness was consistent in all replication samples. Larger scale GWA studies and alternative approaches are required for confirmation of KATNAL2 as a novel gene affecting Conscientiousness.

DS Bender, LC Morey, AE Skodol. .Journal of Personality Assessment2011; 9:332–346(Reprinted by permission of Taylor and Francis [http://tandfonline.com])

Personality disorders are associated with fundamental disturbances of self and interpersonal relations, problems that vary in severity within and across disorders. This review surveyed clinician-rated measures of personality psychopathology that focus on self-other dimensions to explore the feasibility and utility of constructing a scale of severity of impairment in personality functioning for DSM−5. Robust elements of the instruments were considered in creating a continuum of personality functioning based on aspects of identity, self-direction, empathy, and intimacy. Building on preliminary findings (Morey et al., 2011 /this issue), the proposed Levels of Personality Functioning will be subjected to extensive empirical testing in the DSM−5 field trials and elsewhere. The resulting version of this severity measure is expected to have clinical utility in identifying personality psychopathology, planning treatment, building the therapeutic alliance, and studying treatment course and outcome.

L.C. Morey, H. Berghuis, D.S. Bender, R. Verheul, R.F. Krueger, A.E Skodol. .Journal of Personality Assessment2011; 93:347–353(Reprinted by permission of Taylor and Francis [http://tandfonline.com])

The extensive comorbidity among Diagnostic and Statistical Manual of Mental Disorders (4th ed. [DSM-IV]; American Psychiatric Association, 1994) personality disorders might be compelling evidence of essential commonalities among these disorders reflective of a general level of personality functioning that in itself is highly relevant to clinical decision making. This study sought to identify key markers of such a level, thought to reflect a core dimension of personality pathology involving impairments in the capacities of self and interpersonal functioning, and to empirically articulate a continuum of severity of these problems for DSM−5. Using measures of hypothesized core dimensions of personality pathology, a description of a continuum of severity of personality pathology was developed. Potential markers at various levels of severity of personality pathology were identified using item response theory (IRT) in 2 samples of psychiatric patients. IRT-based estimates of participants' standings on a latent dimension of personality pathology were significantly related to the diagnosis of DSM-IV personality disorder, as well as to personality disorder comorbidity. Further analyses indicated that this continuum could be used to capture the distribution of pathology severity across the range of DSM-IV personality disorders. The identification of a continuum of personality pathology consisting of impairments in self and interpersonal functioning provides an empirical foundation for a “levels of personality functioning” rating proposed as part of a DSM−5 personality disorder diagnostic formulation.

E.B. Ansell, A. Pinto, M.O. Edelen, J.C. Markowitz, C.A. Sanislow, S. Yen, M. Zanarini, A.E. Skodol, M.T. Shea, L.C. Morey, J.G. Gunderson, T.H. McGlashan, C.M Grilo. .Psychol Med2011; 41:1019–1028

Background: This study prospectively examined the natural clinical course of six anxiety disorders over 7 years of follow-up in individuals with personality disorders (PDs) and/or major depressive disorder. Rates of remission, relapse, new episode onset and chronicity of anxiety disorders were examined for specific associations with PDs. Method: Participants were 499 patients with anxiety disorders in the Collaborative Longitudinal Personality Disorders Study, who were assessed with structured interviews for psychiatric disorders at yearly intervals throughout 7 years of follow-up. These data were used to determine probabilities of changes in disorder status for social phobia (SP), generalized anxiety disorder (GAD), obsessive-compulsive disorder (OCD), posttraumatic stress disorder (PTSD), panic disorder and panic disorder with agoraphobia. Results: Estimated remission rates for anxiety disorders in this study group ranged from 73% to 94%. For those patients who remitted from an anxiety disorder, relapse rates ranged from 34% to 67%. Rates for new episode onsets of anxiety disorders ranged from 3% to 17%. Specific PDs demonstrated associations with remission, relapse, new episode onsets and chronicity of anxiety disorders. Associations were identified between schizotypal PD with course of SP, PTSD and GAD; avoidant PD with course of SP and OCD; obsessive-compulsive PD with course of GAD, OCD, and agoraphobia; and borderline PD with course of OCD, GAD and panic with agoraphobia. Conclusions: Findings suggest that specific PD diagnoses have negative prognostic significance for the course of anxiety disorders underscoring the importance of assessing and considering PD diagnoses in patients with anxiety disorders.

A.E. Skodol, C.M. Grilo, K.M. Keyes, T. Geier, B.F. Grant, D.S Hasin. .Am J Psychiatry2011; 168:257–264

Objective: The purpose of this study was to examine the effects of specific personality disorder comorbidity on the course of major depressive disorder in a nationally representative sample. Method: Data were drawn from 1,996 participants in a national survey. Participants who met criteria for major depressive disorder at baseline in face-to-face interviews (in 2001–2002) were reinterviewed 3 years later (in 2004–2005) to determine persistence and recurrence. Predictors included all DSM-IV personality disorders. Control variables included demographic characteristics, other axis I disorders, family and treatment histories, and previously established predictors of the course of major depressive disorder. Results: A total of 15.1% of participants had persistent major depressive disorder, and 7.3% of those who remitted had a recurrence. Univariate analyses indicated that avoidant, borderline, histrionic, paranoid, schizoid, and schizotypal personality disorders all elevated the risk for persistence. With axis I comorbidity controlled, all personality disorders except histrionic personality disorder remained significant. With all other personality disorders controlled, borderline and schizotypal disorders remained significant predictors. In final, multivariate analyses that controlled for age at onset of major depressive disorder, the number of previous episodes, duration of the current episode, family history, and treatment, borderline personality disorder remained a robust predictor of major depressive disorder persistence. Neither personality disorders nor other clinical variables predicted recurrence. Conclusions: In this nationally representative sample of adults with major depressive disorder, borderline personality disorder robustly predicted persistence, a finding that converges with recent clinical studies. Personality psychopathology, particularly borderline personality disorder, should be assessed in all patients with major depressive disorder, considered in prognosis, and addressed in treatment.

K. Lieb, B. Völlm, G. Rücker, A. Timmer, J.M Stoffers. .Br J Psychiatry2010; 196:4–12

Background: Many patients with borderline personality disorder receive pharmacological treatment, but there is uncertainty about the usefulness of such therapies. AIMS: To evaluate the evidence of effectiveness of pharmacotherapy in treating different facets of the psychopathology of borderline personality disorder. Method: A Cochrane Collaboration systematic review and meta-analysis of randomized comparisons of drug v. placebo, drug v. drug, or single drug v. combined drug treatment in adult patients with borderline personality disorder was conducted. Primary outcomes were overall disorder severity as well as specific core symptoms. Secondary outcomes comprised associated psychiatric pathology and drug tolerability. Results: Twenty-seven trials were included in which first- and second-generation antipsychotics, mood stabilizers, antidepressants and omega−3 fatty acids were tested. Most beneficial effects were found for the mood stabilizers topiramate, lamotrigine and valproate semisodium, and the second-generation antipsychotics aripiprazole and olanzapine. However, the robustness of findings is low, since they are based mostly on single, small studies. Selective serotonin reuptake inhibitors so far lack high-level evidence of effectiveness. Conclusions: The current evidence from randomized controlled trials suggests that drug treatment, especially with mood stabilizers and second-generation antipsychotics, may be effective for treating a number of core symptoms and associated psychopathology, but the evidence does not currently support effectiveness for overall severity of borderline personality disorder. Pharmacotherapy should therefore be targeted at specific symptoms.

A. Bateman, P Fonagy. .Am J Psychiatry2009; 166:1355–1364

Objective: This randomized controlled trial tested the effectiveness of an 18-month mentalization-based treatment (MBT) approach in an outpatient context against a structured clinical management (SCM) outpatient approach for treatment of borderline personality disorder. Method: Patients (N=134) consecutively referred to a specialist personality disorder treatment center and meeting selection criteria were randomly allocated to MBT or SCM. Eleven mental health professionals equal in years of experience and training served as therapists. Independent evaluators blind to treatment allocation conducted assessments every 6 months. The primary outcome was the occurrence of crisis events, a composite of suicidal and severe self-injurious behaviors and hospitalization. Secondary outcomes included social and interpersonal functioning and self-reported symptoms. Outcome measures, assessed at 6-month intervals, were analyzed using mixed effects logistic regressions for binary data, Poisson regression models for count data, and mixed effects linear growth curve models for self-report variables. Results: Substantial improvements were observed in both conditions across all outcome variables. Patients randomly assigned to MBT showed a steeper decline of both self-reported and clinically significant problems, including suicide attempts and hospitalization. Conclusions: Structured treatments improve outcomes for individuals with borderline personality disorder. A focus on specific psychological processes brings additional benefits to structured clinical support. Mentalization-based treatment is relatively undemanding in terms of training so it may be useful for implementation into general mental health services. Further evaluations by independent research groups are now required.

J.G. Gunderson, K Lyons-Ruth. .J Pers Disord2008; 22:22–41(Copyright © Guilford Press. Reprinted with permission of the Guilford Press)

This paper explores the development of BPD as it might emerge in the child's early interpersonal reactions and how such reactions might evolve into the interpersonal pattern that typifies BPD. It begins to bridge the relevant bodies of clinical literature on the borderline's prototypic interpersonal problems with the concurrently expanding relevant literature on early child development. We will start by considering how a psychobiological disposition to BPD is likely to include a constitutional diathesis for relational reactivity, that is, for hypersensitivity to interpersonal stressors. Data relevant to this disposition's manifestations in adult clinical samples and to its heritability and neurobiology will be reviewed. We then consider how such a psychobiological disposition for interpersonal reactivity might contribute to the development of a disorganized-ambivalent form of attachment, noting especially the likely contributions of both the predisposed child and of parents who are themselves predisposed to maladaptive responses, leading to an escalation of problematic transactions. Evidence concerning both the genetics and the developmental pathways associated with disorganized attachments will be considered. Emerging links between such developmental pathways and adult BPD will be described, in particular the potential appearance by early- to middle-childhood of controlling-caregiving or controlling-punitive interpersonal strategies. Some implications from this gene-environment interactional theory for a better developmental understanding of BPD's etiology are discussed.

M.C. Zanarini, F.R. Frankenburg, D.B. Reich, K.R. Silk, J.I. Hudson, L.B McSweeney. .Am J Psychiatry2007; 164:929–935

Objective: The purpose of this study was to characterize the course of 24 symptoms of borderline personality disorder in terms of time to remission. Method: The borderline psychopathology of 362 patients with personality disorders, all recruited during inpatient stays, was assessed using two semistructured interviews of proven reliability. Of these, 290 patients met DSM-III-R criteria as well as Revised Diagnostic Interview for Borderlines criteria for borderline personality disorder, and 72 met DSM-III-R criteria for another axis II disorder. Over 85% of the patients were reinterviewed at five distinct 2-year follow-up waves by interviewers blind to all previously collected information. Results: Among borderline patients, 12 of the 24 symptoms studied showed patterns of sharp decline over time and were reported at 10-year follow-up by less than 15% of the patients who reported them at baseline. The other 12 symptoms showed patterns of substantial but less dramatic decline over the follow-up period. Symptoms reflecting core areas of impulsivity (e.g. self-mutilation and suicide efforts) and active attempts to manage interpersonal difficulties (e.g. problems with demandingness/entitlement and serious treatment regressions) seemed to resolve the most quickly. In contrast, affective symptoms reflecting areas of chronic dysphoria (e.g. anger and loneliness/emptiness) and interpersonal symptoms reflecting abandonment and dependency issues (e.g. intolerance of aloneness and counterdependency problems) seemed to be the most stable. Conclusions: The results suggest that borderline personality disorder may consist of both symptoms that are manifestations of acute illness and symptoms that represent more enduring aspects of the disorder.

K.S. Kendler, N. Czajkowski, K. Tambs, S. Torgersen, S.H. Aggen, M.C. Neale, T Reichborn-Kjennerud. .Psychol Med2006; 36:1583–1591

Background: The ‘odd' or ‘Cluster A' personality disorders (PDs) - paranoid, schizoid and schizotypal PDs - were created in DSM-III with little empirical foundation. We have examined the relationship between the genetic and environmental risk factors for dimensional representations of these three personality disorders. Method: These personality disorders were assessed using the Structured Interview for DSM-IV Personality (SIDP-IV) in 1386 young adult twin pairs from the Norwegian Institute of Public Health Twin Panel. Using Mx, a single-factor independent pathway twin model was fitted to the number of endorsed criteria for the three disorders. Results: The best-fit model included genetic and unique environmental common factors and genetic and unique environmental effects specific to each personality disorder. Total heritability was modest for these personality disorders and ranged from 21% to 28%. Loadings on the common genetic and unique environmental factors were substantially higher for schizotypal than for paranoid or schizoid PD. The proportion of genetic liability shared with all Cluster A disorders was estimated at 100, 43 and 26% respectively for schizotypal, paranoid and schizoid PDs. Conclusion: In support of the validity of the Cluster A construct, dimensional representations of schizotypal, paranoid and schizoid PD are all modestly heritable and share a portion of their genetic and environmental risk factors. No evidence was found for shared environmental or sex effects for these PDs. Schizotypal PD most closely reflects the genetic and environmental liability common to all three Cluster A disorders. These results should be interpreted in the context of the limited power of this sample.

A.E. Skodol, J.M. Oldham, D.S. Bender, I.R. Dyck, R.L. Stout, L.C. Morey, M.T. Shea, M.C. Zanarini, C.A. Sanislow, C.M. Grilo, T.H. McGlashan, J.G Gunderson. .Am J Psychiatry2005; 162:1919–1925

Objective: This study compared three-dimensional representations of DSM-IV personality disorders and standard categories with respect to their associations with psychosocial functioning. Method: Six hundred sixty-eight patients with semistructured interview diagnoses of schizotypal, borderline, avoidant, or obsessive-compulsive personality disorders or with major depressive disorder and no personality disorder completed questionnaires assessing three-factor and five-factor dimensional models of personality. Personality disorder categories, dimensional representations of the categories based on criteria counts, and three- and five-factor personality dimensions were compared on their relationships to impairment in seven domains of functioning, as measured by the Longitudinal Interval Follow-up Evaluation-Baseline Version. Results: Both the categorical and dimensional representations of DSM-IV personality disorders had stronger relationships to impairment in functioning in the domains of employment, social relationships with parents and friends, and global social adjustment and to DSM-IV axis V ratings than the three- and five-factor models. DSM-IV dimensions predicted functional impairment best of the four approaches. Although five-factor personality traits captured variance in functional impairment not predicted by DSM-IV personality disorder dimensions, the DSM-IV dimensions accounted for significantly more variance than the measures of personality. Conclusions: Scores on dimensions of general personality functioning do not appear to be as strongly associated with functional impairment as the psychopathology of DSM personality disorder. A compromise in the ongoing debate over categories versus dimensions of personality disorder might be the dimensional rating of the criteria that comprise traditional categories.

M.T. Shea, R.L. Stout, S. Yen, M.E. Pagano, A.E. Skodol, L.C. Morey, J.G. Gunderson, T.H. McGlashan, C.M. Grilo, C.A. Sanislow, D.S. Bender, M.C Zanarini. .Journal of Abnormal Psychology2004; 113:499–508

In this study, the authors examined time-varying associations between schizotypal (STPD), borderline (BPD), avoidant (AVPD), or obsessive-compulsive (OCPD) personality disorders and co-occurring Axis I disorders in 544 adult participants from the Collaborative Longitudinal Personality Disorders Study. The authors tested predictions of specific longitudinal associations derived from a model of crosscutting psychobiological dimensions (L. J. Siever & K. L. Davis, 1991) with participants with the relevant Axis I disorders. The authors assessed participants at baseline and at 6-, 12-, and 24-month follow-up evaluations. BPD showed significant longitudinal associations with major depressive disorder and posttraumatic stress disorder. AVPD was significantly associated with anxiety disorders (specifically social phobia and obsessive-compulsive disorder). Two of the four personality disorders under examination (STPD and OCPD) showed little or no association with Axis I disorders.

F. Leichsenring, E Leibing. .Am J Psychiatry2003; 160:1223–1232(Reprinted in FOCUS 2005; vol. 3, issue 3, pp 417-428)

Objective: The authors conducted a meta-analysis to address the effectiveness of psychodynamic therapy and cognitive behavior therapy in the treatment of personality disorders. Method: Studies of psychodynamic therapy and cognitive behavior therapy that were published between 1974 and 2001 were collected. Only studies that 1) used standardized methods to diagnose personality disorders, 2) applied reliable and valid instruments for the assessment of outcome, and 3) reported data that allowed calculation of within-group effect sizes or assessment of personality disorder recovery rates were included. Fourteen studies of psychodynamic therapy and 11 studies of cognitive behavior therapy were included. Results: Psychodynamic therapy yielded a large overall effect size (1.46), with effect sizes of 1.08 found for self-report measures and 1.79 for observer-rated measures. For cognitive behavior therapy, the corresponding values were 1.00, 1.20, and 0.87. For more specific measures of personality disorder pathology, a large overall effect size (1.56) was seen for psychodynamic therapy. Two cognitive behavior therapy studies reported significant effects for more specific measures of personality disorder pathology. For psychodynamic therapy, the effect sizes indicate long-term rather than short-term change in personality disorders. Conclusions: There is evidence that both psychodynamic therapy and cognitive behavior therapy are effective treatments of personality disorders. Since the number of studies that could be included in this meta-analysis was limited, the conclusions that can be drawn are only preliminary. Further studies are necessary that examine specific forms of psychotherapy for specific types of personality disorders and that use measures of core psychopathology. Both longer treatments and follow-up studies should be included.

J.M. Bloom, E.N. Woodward, T. Susmaras, D.W Pantalone. .Psychiatr Serv2012; 63:881–888

Objective: Dialectical behavior therapy (DBT) is an empirically supported treatment for outpatients with borderline personality disorder. However, the utility of DBT strategies for inpatients with the disorder is unclear. This review summarizes and synthesizes findings from trials of DBT in inpatient settings. Methods: Multiple research databases were searched for articles published through June 2011 that reported on any implementation of DBT in an inpatient setting to address symptoms related to borderline personality disorder, including suicidal and self-injurious behavior. Results: Eleven studies that reported pre- and posttreatment symptoms related to borderline personality disorder were evaluated. Studies indicated that many variations of standard DBT have been used in inpatient settings, including approaches that do not include phone consultation, that include group therapy only, and that vary in treatment duration (from two weeks to three months). Most studies reported reductions in suicidal ideation, self-injurious behaviors, and symptoms of depression and anxiety, whereas results for reducing anger and violent behaviors were mixed. Follow-up data indicated that symptom reduction was often maintained between one and 21 months posttreatment. On the basis of the evidence, the authors identify essential components of an inpatient DBT package and discuss its potential function as an “intensive orientation” to outpatient DBT services. Conclusions: There is considerable variation in the configuration and duration of DBT implementation for inpatients with borderline personality disorder. However, findings suggest that DBT may be effective in reducing symptoms related to borderline personality disorder in inpatient settings. Future research should standardize and systematically test inpatient DBT. (Psychiatric Services 63:881–888, 2012; doi: 10.1176/appi.ps.201100311).




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