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The Australian and New Zealand Journal... Oct 2022Borderline Personality Disorder (BPD) is frequently complicated by the presence of dissociative symptoms. Pathological dissociation is linked with earlier and more... (Review)
Review
BACKGROUND
Borderline Personality Disorder (BPD) is frequently complicated by the presence of dissociative symptoms. Pathological dissociation is linked with earlier and more severe trauma exposure, emotional dysregulation and worse treatment outcomes in Posttraumatic Stress Disorder and Dissociative Disorders, with implications for BPD.
OBJECTIVE
A systematic scoping review was conducted to assess the extent of current literature regarding the impact of dissociation on BPD and to identify knowledge gaps.
METHODS
Four electronic databases (MEDLINE, APA PsycINFO, EMBASE, CINAHL Plus) were searched, and English peer-reviewed studies with adults with BPD were included, following Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA) extension for scoping reviews (PRISMA-ScR) 2018 guidelines.
RESULTS
Most of the 70 included studies were observational (98%) with first authors from Germany (59%). Overall, dissociation was associated with increased BPD symptom severity, self-harm and reduced psychotherapy treatment response; findings regarding suicide risk were mixed. Dissociation was associated with working memory and cognitive deficits, decreased pain perception, altered body ownership, no substance abuse or the abuse of sedative substances, increased fantasy proneness, personality fragmentation, fearful attachment, dream anxiety, perceived stress and altered stress responses, increased cumulative body mass index, decreased water consumption, several neurological correlates and changes in gene expression.
CONCLUSION
BPD with significant dissociative symptoms may constitute a more severe and at-risk subgroup of BPD patients. However, there are significant research gaps and methodological issues in the area, including the possibility of unrecognized Dissociative Disorders in BPD study populations confounding results. Further studies are needed to better understand the impact of dissociation on BPD course and treatment, and to clarify the most appropriate assessment tools for clinical practice. In addition, interventional studies are needed to develop dissociation-specific BPD treatments to determine whether targeting dissociation in BPD can improve treatment outcomes.
Topics: Adult; Borderline Personality Disorder; Dissociative Disorders; Humans; Hypnotics and Sedatives; Psychotherapy; Self-Injurious Behavior
PubMed: 35152771
DOI: 10.1177/00048674221077029 -
The American Journal of Psychiatry Oct 2015The authors conducted a systematic review and meta-analysis of ketamine and other N-methyl-d-aspartate (NMDA) receptor antagonists in the treatment of major depression. (Review)
Review
OBJECTIVE
The authors conducted a systematic review and meta-analysis of ketamine and other N-methyl-d-aspartate (NMDA) receptor antagonists in the treatment of major depression.
METHOD
Searches of MEDLINE, PsycINFO, and other databases were conducted for placebo-controlled, double-blind, randomized clinical trials of NMDA antagonists in the treatment of depression. Primary outcomes were rates of treatment response and transient remission of symptoms. Secondary outcomes included change in depression symptom severity and the frequency and severity of dissociative and psychotomimetic effects. Results for each NMDA antagonist were combined in meta-analyses, reporting odds ratios for dichotomous outcomes and standardized mean differences for continuous outcomes.
RESULTS
Ketamine (seven trials encompassing 147 ketamine-treated participants) produced a rapid, yet transient, antidepressant effect, with odds ratios for response and transient remission of symptoms at 24 hours equaling 9.87 (4.37-22.29) and 14.47 (2.67-78.49), respectively, accompanied by brief psychotomimetic and dissociative effects. Ketamine augmentation of ECT (five trials encompassing 89 ketamine-treated participants) significantly reduced depressive symptoms following an initial treatment (Hedges' g=0.933) but not at the conclusion of the ECT course. Other NMDA antagonists failed to consistently demonstrate efficacy; however, two partial agonists at the NMDA coagonist site, d-cycloserine and rapastinel, significantly reduced depressive symptoms without psychotomimetic or dissociative effects.
CONCLUSIONS
The antidepressant efficacy of ketamine, and perhaps D-cycloserine and rapastinel, holds promise for future glutamate-modulating strategies; however, the ineffectiveness of other NMDA antagonists suggests that any forthcoming advances will depend on improving our understanding of ketamine's mechanism of action. The fleeting nature of ketamine's therapeutic benefit, coupled with its potential for abuse and neurotoxicity, suggest that its use in the clinical setting warrants caution.
Topics: Antidepressive Agents; Depressive Disorder, Major; Excitatory Amino Acid Antagonists; Humans; Ketamine; Receptors, N-Methyl-D-Aspartate
PubMed: 26423481
DOI: 10.1176/appi.ajp.2015.15040465 -
Journal of Affective Disorders Jun 2024Electrophysiologic measures provide an opportunity to inform mechanistic models and possibly biomarker prediction of response. Serotonergic psychedelics (SPs) (i.e.,... (Review)
Review
Spectral signatures of psilocybin, lysergic acid diethylamide (LSD) and ketamine in healthy volunteers and persons with major depressive disorder and treatment-resistant depression: A systematic review.
BACKGROUND
Electrophysiologic measures provide an opportunity to inform mechanistic models and possibly biomarker prediction of response. Serotonergic psychedelics (SPs) (i.e., psilocybin, lysergic acid diethylamide (LSD)) and ketamine represent new investigational and established treatments in mood disorders respectively. There is a need to better characterize the mechanism of action of these agents.
METHODS
We conducted a systematic review investigating the spectral signatures of psilocybin, LSD, and ketamine in persons with major depressive disorder (MDD), treatment-resistant depression (TRD), and healthy controls.
RESULTS
Ketamine and SPs are associated with increased theta power in persons with depression. Ketamine and SPs are also associated with decreased spectral power in the alpha, beta and delta bands in healthy controls and persons with depression. When administered with SPs, theta power was increased in persons with MDD when administered with SPs. Ketamine is associated with increased gamma band power in both healthy controls and persons with MDD.
LIMITATIONS
The studies included in our review were heterogeneous in their patient population, exposure, dosing of treatment and devices used to evaluate EEG and MEG signatures. Our results were extracted entirely from persons who were either healthy volunteers or persons with MDD or TRD.
CONCLUSIONS
Extant literature evaluating EEG and MEG spectral signatures indicate that ketamine and SPs have reproducible effects in keeping with disease models of network connectivity. Future research vistas should evaluate whether observed spectral signatures can guide further discovery of therapeutics within the psychedelic and dissociative classes of agents, and its prediction capability in persons treated for depression.
Topics: Humans; Psilocybin; Ketamine; Lysergic Acid Diethylamide; Depressive Disorder, Major; Depression; Healthy Volunteers; Hallucinogens
PubMed: 38570038
DOI: 10.1016/j.jad.2024.03.165 -
Journal of Trauma & Dissociation : the... 2024Dissociative Identity Disorder (DID) is a highly disabling diagnosis, characterized by the presence of two or more personality states which impacts global functioning,... (Review)
Review
A Systematic Review and Narrative Analysis of the Evidence for Individual Psychodynamically Informed Psychotherapy in the Treatment of Dissociative Identity Disorder in Adults.
Dissociative Identity Disorder (DID) is a highly disabling diagnosis, characterized by the presence of two or more personality states which impacts global functioning, with a substantial risk of suicide. The International Society for the Study of Trauma and Dissociation (ISSTD) published guidelines for treating DID in 2011 that noted individual Psychodynamically Informed Psychotherapy (PDIP) was a cornerstone of treatment. This paper systematically reviews the evidence base for PDIP in the treatment of adults with DID according to the 2009 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Thirty-five articles were located and reviewed: seven prospective longitudinal publications, 13 case series and 15 case studies. Results suggested that PDIP has been widely deployed in DID to reported good effect with a range of treatment protocols and using multiple theoretical models. Despite the positive findings observed, the evidence base remains at the level of observational-descriptive design. Creative approaches in recent years have been developed, which add empirical weight to the use of PDIP as an effective treatment. The elevation to observational-analytic designs in the Evidence-Based Medicine hierarchy has yet to take place. Bearing in mind the challenges of research in PDIP, suggestions are offered for how the evidence base might develop.
Topics: Adult; Humans; Dissociative Identity Disorder; Prospective Studies; Psychotherapy; Suicide; Treatment Outcome
PubMed: 38146918
DOI: 10.1080/15299732.2023.2293802 -
Consciousness and Cognition Mar 2023Strange face illusions describe a range of visual apparitions that occur when an observer gazes at their image reflected in a mirror or at another person's face in a... (Review)
Review
BACKGROUND
Strange face illusions describe a range of visual apparitions that occur when an observer gazes at their image reflected in a mirror or at another person's face in a dimly lit room. The illusory effects range from mild alterations in colour, or contrast, to the perception of distorted facial features, or new strange faces.The current review critically evaluates studies investigating strange face illusions, their methodological quality, and existing interpretations.
METHOD
Searches conducted using Scopus, PubMed, ScienceDirect and the grey literature until June 2022 identified 21 studies (N = 1,132; healthy participants n = 1,042; clinical participants n = 90) meeting the inclusion criteria (i.e., providing new empirical evidence relating to strange face illusions). The total sample had a mean age of 28.3 years (SD = 10.31) and two thirds (67 %) of participants tested to date are female. Results are reported using the Preferred Reporting Items for Systematic Reviews and meta-Analyses (PRISMA) guidelines. The review was preregistered at the Open Science Framework (OSF: https://osf.io/ek48d).
RESULTS
Pooling data across studies, illusory new strange faces are experienced by 58% (95%CI 48 to 68) of nonclinical participants. Study quality as assessed by the Appraisal Tool for Cross-Sectional Studies (AXIS) revealed that 3/21 (14.28%) studies were rated as high, 9/21 (42.86%) as moderate and 9/21 (42.86%) as low quality. Whilst the items relating specifically to reporting quality scored quite highly, those relating to study design and possible biases were lower and more variable. Overall, study quality accounted for 87% of the variance in reporting rates for strange faces, with higher quality being associated with lower illusion rates. The prevalence of illusions was also significantly greater in samples that were older, had higher proportions of female participants and for the interpersonal dyad (IGDT) compared to the mirror gaze paradigm (MGT). The moderating impact of study quality persisted in a multiple meta-regression involving participant age, paradigm type (IGDT vs MGT) and level of feature distortion. Our review point to the importance of reduced light levels, face stimuli and prolonged eye fixation for strange face illusions to emerge.
CONCLUSION
Strange face illusions reliably occur in both mirror-gazing and interpersonal gazing dyad paradigms. Further research of higher quality is required to establish the prevalence and particularly, the mechanisms underpinning strange face illusions.
Topics: Humans; Female; Adult; Male; Illusions; Cross-Sectional Studies; Face; Fixation, Ocular; Dissociative Disorders
PubMed: 36764163
DOI: 10.1016/j.concog.2023.103480 -
Therapeutic Advances in... 2023The therapeutic potential of subanesthetic doses of ketamine appears promising in unipolar depression; however, its effectiveness in treating bipolar depression (BD)...
BACKGROUND
The therapeutic potential of subanesthetic doses of ketamine appears promising in unipolar depression; however, its effectiveness in treating bipolar depression (BD) remains uncertain.
OBJECTIVE
This systematic review aimed to summarize findings on the use of ketamine for the treatment of BD by assessing its efficacy, safety, and tolerability.
DESIGN
Systematic review.
METHODS
We conducted a systematic review of studies that investigated the use of ketamine for adults with BD. We searched PubMed and Embase for relevant randomized-controlled trials, open-label trials, and retrospective chart analyses published from inception to 13 March 2023.
RESULTS
Eight studies were identified [pooled = 235; mean (SD) age: 45.55 (5.54)]. All participants who received intravenous (IV) ketamine were administered a dose of 0.5-0.75 mg/kg as an adjunctive treatment to a mood-stabilizing agent, whereas participants who received esketamine were administered a dosage ranging from 28 to 84 mg. Flexible dosing was used in real-world analyses. A total of 48% of participants receiving ketamine achieved a response (defined as ⩾50% reduction in baseline depression severity), whereas only 5% achieved a response with a placebo. Real-world studies demonstrated lower rates of response (30%) compared to the average across clinical trials (63%). Reductions in suicidal ideation were noted in some studies, although not all findings were statistically significant. Ketamine and esketamine were well tolerated in most participants; however, six participants (2% of the overall sample pool, 5 receiving ketamine) developed hypomanic/manic symptoms after infusions. Significant dissociative symptoms were observed at the 40-min mark in some trials.
CONCLUSION
Preliminary evidence suggests IV ketamine as being safe and effective for the treatment of BD. Future studies should focus on investigating the effects of repeated acute and maintenance infusions using a randomized study design.
PubMed: 37771417
DOI: 10.1177/20451253231202723 -
Journal of Psychiatric Research Sep 2020There is currently no general agreement on how to best conceptualize dissociative symptoms and whether they share similar neural underpinnings across dissociative... (Review)
Review
INTRODUCTION
There is currently no general agreement on how to best conceptualize dissociative symptoms and whether they share similar neural underpinnings across dissociative disorders. Neuroimaging data could help elucidate these questions.
OBJECTIVES
The objective of this review is to summarize empirical evidence for neural aberrations observed in patients suffering from dissociative symptoms.
METHODS
A systematic literature review was conducted including patient cohorts diagnosed with primary dissociative disorders, post-traumatic stress disorder (PTSD), or borderline personality disorder.
RESULTS
Results from MRI studies reporting structural (gray matter and white matter) and functional (during resting-state and task-related activation) brain aberrations were extracted and integrated. In total, 33 articles were included of which 10 pertained to voxel-based morphology, 2 to diffusion tensor imaging, 10 to resting-state fMRI, and 11 to task-related fMRI. Overall findings indicated aberrations spread across diverse brain regions, especially in the temporal and frontal cortices. Patients with dissociative identity disorder and with dissociative PTSD showed more overlap in brain activation than each group showed with depersonalization/derealization disorder.
CONCLUSION
In conjunction, the results indicate that dissociative processing cannot be localized to a few distinctive brain regions but rather corresponds to differential neural signatures depending on the symptom constellation.
Topics: Brain; Diffusion Tensor Imaging; Dissociative Disorders; Gray Matter; Humans; Magnetic Resonance Imaging; Stress Disorders, Post-Traumatic
PubMed: 32480060
DOI: 10.1016/j.jpsychires.2020.05.006 -
Psychiatry Research Nov 2019Dissociative Disorder (DD) is a large group of disorders that shares common psychopathology. Psychopharmacological agents have sparse evidence in the treatment of DD in...
BACKGROUND
Dissociative Disorder (DD) is a large group of disorders that shares common psychopathology. Psychopharmacological agents have sparse evidence in the treatment of DD in general. Multiple pharmacotherapy options have been used without conclusive evidence.
METHODS
We conducted a systematic review of data in English language from 1967 to 2019 the protocol of which was registered under PROSPERO (Study ID CRD42019127235). Using PRISMA guidelines, 5 RCTs reporting data on 214 participants providing data on response to pharmacotherapy in dissociative disorder were included.
RESULTS
The treatment response rate of pharmacotherapy group as measured in reduction in dissociative symptoms was 68.42% (n = 65/95), significantly higher than that of 39.49% (n = 47/119) in the control group. And, the pooled RR was 1.59 (95% CI, 0.76-3.30; P = 0.21). The overall effect estimates are favourable to pharmacotherapy group over placebo.
CONCLUSION
It would be apt to conclude that Paroxetine and Naloxone are the only pharmacological agents studied through RCTs and found to have modest evidence for controlling depersonalization symptoms and dissociative symptoms that are comorbid with PTSD and BPD. Results of this meta-analysis should be interpreted with caution in view of high heterogeneity and scanty literature on RCTs on various subtypes of DD.
Topics: Dissociative Disorders; Female; Humans; Male; Naloxone; Paroxetine; Psychotropic Drugs; Randomized Controlled Trials as Topic; Treatment Outcome
PubMed: 31470213
DOI: 10.1016/j.psychres.2019.112529 -
Rand Health Quarterly Jun 2022Posttraumatic stress disorder (PTSD) is a condition that can emerge after exposure to a traumatic event. It involves several symptoms, including distressing memories or...
Posttraumatic stress disorder (PTSD) is a condition that can emerge after exposure to a traumatic event. It involves several symptoms, including distressing memories or dreams and/or dissociative reactions; psychological distress at exposure to trauma cues; physiologic reactions to cues; avoidance of stimuli associated with the event; negative alterations in cognitions and mood associated with the trauma; and alterations in arousal and reactivity, including sleep disturbance. The purpose of this systematic review is to synthesize the evidence from randomized controlled trials on the effects that interventions for adults with PTSD have on sleep outcomes. The authors searched research databases and bibliographies of existing systematic reviews to identify pertinent trials published in English; literature was identified by the searches using predetermined eligibility criteria. The primary outcome domain included sleep quality, insomnia, and nightmares. Secondary outcomes were PTSD symptoms and adverse events. Risk of bias and the quality of evidence were assessed for each outcome. The identified interventions addressed pharmacological, psychological, behavioral, complementary, and integrative medicine treatments aimed at improving sleep or lessening other PTSD symptoms. Interventions in general showed an effect on sleep. Interventions explicitly targeting sleep-particularly psychotherapy targeting sleep-showed larger effects on sleep than did interventions not targeting sleep. Heterogeneity was considerable, but sleep effect estimates were not systematically affected by trauma type, setting, or modality. Comparative effectiveness studies are needed to support the findings.
PubMed: 35837535
DOI: No ID Found -
Psychopharmacology Sep 2014Ketamine's efficacy in depressive disorders has been established in several controlled trials. The aim of the present study was to determine whether or not ketamine... (Meta-Analysis)
Meta-Analysis Review
INTRODUCTION
Ketamine's efficacy in depressive disorders has been established in several controlled trials. The aim of the present study was to determine whether or not ketamine administration significantly improves depressive symptomatology in depression and more specifically in major depressive disorder (MDD), bipolar depression, resistant depression (non-ECT studies), and as an anesthetic agent in electroconvulsive therapy (ECT) for resistant depression (ECT studies). Secondary outcomes were the duration of ketamine's effect, the efficacy on suicidal ideations, the existence of a dose effect, and the safety/tolerance of the treatment.
METHODS
Studies were included if they met the following criteria (without any language or date restriction): design: randomized controlled trials, intervention: ketamine administration, participants: diagnosis of depression, and evaluation of severity based on a validated scale. We calculated standardized mean differences (SMDs) with 95 % confidence intervals (CIs) for each study. We used fixed and random effects models. Heterogeneity was assessed using the I2 statistic.
RESULTS
We included nine non-ECT studies in our quantitative analysis (192 patients with major depressive disorder and 34 patients with bipolar depression). Overall, depression scores were significantly decreased in the ketamine groups compared to those in the control groups (SMD = -0.99; 95 % CI -1.23, -0.75; p < 0.01). Ketamine's efficacy was confirmed in MDD (resistant to previous pharmacological treatments or not) (SMD = -0.91; 95 % CI -1.19,-0.64; p < 0.01), in bipolar depression (SMD = -1.34; 95 % CI -1.94, -0.75), and in drug-free patients as well as patients under medication. Four ECT trials (118 patients) were included in our quantitative analysis. One hundred and three patients were diagnosed with major depressive disorder and 15 with bipolar depression. Overall, depression scores were significantly improved in the 58 patients receiving ketamine in ECT anesthesia induction compared to the 60 patients (SMD = -0.56; 95 % CI -1.10, -0.02; p = 0.04; I2 = 52.4 %). The duration of ketamine's effects was assessed in only two non-ECT studies and seemed to persist for 2-3 days; this result needs to be confirmed. Three of four studies found significant decrease of suicidal thoughts and one found no difference between groups, but suicidal ideations were only studied by the suicide item of the depressive scales. It was not possible to determine a dose effect; 0.5 mg/kg was used in the majority of the studies. Some cardiovascular events were described (mostly transient blood pressure elevation that may require treatment), and ketamine's use should remain cautious in patients with a cardiovascular history.
CONCLUSION
The present meta-analysis confirms ketamine's efficacy in depressive disorders in non-ECT studies, as well as in ECT studies. The results of this first meta-analysis are encouraging, and further studies are warranted to detail efficacy in bipolar disorders and other specific depressed populations. Middle- and long-term efficacy and safety have yet to be explored. Extrapolation should be cautious: Patients included had no history of psychotic episodes and no history of alcohol or substance use disorders, which is not representative of all the depressed patients that may benefit from this therapy.
Topics: Anesthetics, Dissociative; Antidepressive Agents; Bipolar Disorder; Depressive Disorder, Major; Depressive Disorder, Treatment-Resistant; Electroconvulsive Therapy; Humans; Ketamine
PubMed: 25038867
DOI: 10.1007/s00213-014-3664-5