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Recent research: acute stress disorder & CBT, ‘life skills’ for medical students, and borderline personality disorder prevalence

Bryant, R. A., J. Mastrodomenico, et al. (2008). "Treatment of Acute Stress Disorder: A Randomized Controlled Trial." Arch Gen Psychiatry 65(6): 659-667  [Abstract/Full Text
               Context Recent trauma survivors with acute stress disorder (ASD) are likely to subsequently develop chronic posttraumatic stress disorder (PTSD). Cognitive behavioral therapy for ASD may prevent PTSD, but trauma survivors may not tolerate exposure-based therapy in the acute phase. There is a need to compare nonexposure therapy techniques with prolonged exposure for ASD. Objective To determine the efficacy of exposure therapy or trauma-focused cognitive restructuring in preventing chronic PTSD relative to a wait-list control group. Design, Setting, and Participants A randomized controlled trial of civilians who experienced trauma and who met the diagnostic criteria for ASD (N = 90) seen at an outpatient clinic between March 1, 2002, and June 30, 2006. Intervention Patients were randomly assigned to receive 5 weekly 90-minute sessions of either imaginal and in vivo exposure (n = 30) or cognitive restructuring (n = 30), or assessment at baseline and after 6 weeks (wait-list group; n = 30). Main Outcome Measures Measures of PTSD at the 6-month follow-up visit by clinical interview and self-report assessments of PTSD, depression, anxiety, and trauma-related cognition. Results Intent-to-treat analyses indicated that at posttreatment, fewer patients in the exposure group had PTSD than those in the cognitive restructuring or wait-list groups (33% vs 63% vs 77%; P = .002). At follow-up, patients who underwent exposure therapy were more likely to not meet diagnostic criteria for PTSD than those who underwent cognitive restructuring (37% vs 63%; odds ratio, 2.10; 95% confidence interval, 1.12-3.94; P = .05) and to achieve full remission (47% vs 13%; odds ratio, 2.78; 95% confidence interval, 1.14-6.83; P = .005). On assessments of PTSD, depression, and anxiety, exposure resulted in markedly larger effect sizes at posttreatment and follow-up than cognitive restructuring. Conclusions Exposure-based therapy leads to greater reduction in subsequent PTSD symptoms in patients with ASD when compared with cognitive restructuring. Exposure should be used in early intervention for people who are at high risk for developing PTSD.

Campo, A. E., V. Williams, et al. (2008). "Effects of LifeSkills Training on Medical Students' Performance in Dealing with Complex Clinical Cases." Acad Psychiatry 32(3): 188-193.  [Abstract/Full Text]    
                OBJECTIVE: Sound clinical judgment is the cornerstone of medical practice and begins early during medical education. The authors consider the effect of personality characteristics (hostility, anger, cynicism) on clinical judgment and whether a brief intervention can affect this process. METHODS: Two sophomore medical classes (experimental, comparison) were assessed on several personality dimensions and responded to a series of clinical vignettes. The experimental group received cognitive behavior training to improve stress, coping, and interpersonal skills. Participants were reassessed within 1 week of the initial assessment. RESULTS: Significant associations between hostility and cynicism and maladaptive responses to the clinical vignettes were noted. Following the intervention, hostility, cynicism, anger, and aggression were significantly reduced, with concomitant reductions in maladaptive decision-making. CONCLUSION: The relationship between the quality of clinical decision-making and personality characteristics was confirmed. The potential to modify this relationship using a brief cognitive behavior intervention suggests that such interventions should be an essential component of medical education.

Grant, B. F., S. P. Chou, et al. (2008). "Prevalence, correlates, disability, and comorbidity of DSM-IV borderline personality disorder: results from the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions." J Clin Psychiatry 69(4): 533-45.  [PubMed]
                OBJECTIVES: To present nationally representative findings on prevalence, sociodemographic correlates, disability, and comorbidity of borderline personality disorder (BPD) among men and women. METHOD: Face-to-face interviews were conducted with 34,653 adults participating in the 2004-2005 Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions. Personality disorder diagnoses were made using the Wave 2 Alcohol Use Disorder and Associated Disabilities Interview Schedule-DSM-IV Version. RESULTS: Prevalence of lifetime BPD was 5.9% (99% CI = 5.4 to 6.4). There were no differences in the rates of BPD among men (5.6%, 99% CI = 5.0 to 6.2) and women (6.2%, 99% CI = 5.6 to 6.9). BPD was more prevalent among Native American men, younger and separated/divorced/widowed adults, and those with lower incomes and education and was less prevalent among Hispanic men and women and Asian women. BPD was associated with substantial mental and physical disability, especially among women. High co-occurrence rates of mood and anxiety disorders with BPD were similar. With additional comorbidity controlled for, associations with bipolar disorder and schizotypal and narcissistic personality disorders remained strong and significant (odds ratios > or = 4.3). Associations of BPD with other specific disorders were no longer significant or were considerably weakened. CONCLUSIONS: BPD is much more prevalent in the general population than previously recognized, is equally prevalent among men and women, and is associated with considerable mental and physical disability, especially among women. Unique and common factors may differentially contribute to disorder-specific comorbidity with BPD, and some of these associations appear to be sex-specific. There is a need for future epidemiologic, clinical, and genetically informed studies to identify unique and common factors that underlie disorder-specific comorbidity with BPD. Important sex differences observed in rates of BPD and associations with BPD can inform more focused, hypothesis-driven investigations of these factors.

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