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The Lancet. Psychiatry May 2020Developmental trauma is associated with an increased risk of psychosis and predicts poor prognosis. Despite this association, little is known about which treatments work...
Developmental trauma is associated with an increased risk of psychosis and predicts poor prognosis. Despite this association, little is known about which treatments work best for survivors of developmental trauma with psychosis. We sought to do the first review, to our knowledge, to investigate treatments for people with psychotic and dissociative symptoms who have a history of developmental trauma. We searched MEDLINE, PsychINFO, and Google Scholar for studies reporting psychological and pharmacological treatments of psychotic or dissociative symptoms in adult survivors of developmental trauma. We identified 24 studies, most of which investigated various modalities of psychotherapy with two case reports of pharmacological treatments. There is preliminary evidence in favour of third wave cognitive therapies. However, because of low methodological quality and reporting in most of the studies found, it remains unknown which treatments are most effective in this clinical group. Nonetheless, our findings of potential treatment targets, including emotion regulation, acceptance, interpersonal skills, trauma re-processing, and the integration of dissociated ego states, could guide future work in this area. Methodologically rigorous studies are needed to enable clinicians and patients to collaboratively form evidence-based treatment plans. Our Review is registered with PROSPERO, number CRD42018104533.
Topics: Adult; Adult Survivors of Child Abuse; Dissociative Disorders; Humans; Psychological Trauma; Psychotherapy; Psychotic Disorders; Surveys and Questionnaires
PubMed: 32004444
DOI: 10.1016/S2215-0366(20)30041-9 -
The Journal of ECT Jun 2020Electroconvulsive therapy (ECT) remains the most effective treatment for major depressive disorder. Ketamine is an anesthetic gaining attention for its rapid... (Meta-Analysis)
Meta-Analysis
Effects of Ketamine Anesthesia on Efficacy, Tolerability, Seizure Response, and Neurocognitive Outcomes in Electroconvulsive Therapy: A Comprehensive Meta-analysis of Double-Blind Randomized Controlled Trials.
Electroconvulsive therapy (ECT) remains the most effective treatment for major depressive disorder. Ketamine is an anesthetic gaining attention for its rapid antidepressant effect. Numerous randomized controlled trials have investigated the effect of ketamine anesthesia in ECT on various clinical outcomes. Previous systematic reviews have not found benefit for overall depression response, although some have found evidence of benefit early in the ECT course. Clear quantitative conclusions have not been established regarding other outcomes, particularly while only using data from high-quality studies. We aimed to examine all data from double-blind randomized controlled trials comparing ketamine to other anesthetics via meta-analysis, to make recommendations regarding ECT practice and future research. Data were extracted for depressive symptoms, seizure duration and electrical dose, neuropsychological performance, and adverse effects. Effect sizes were calculated using Hedge's g and odds ratios. Eighteen studies (n = 915) were included in the meta-analysis. Ketamine was not found to enhance improvement of depressive symptoms, either early in ECT course or at end of study. Ketamine had a large effect on increasing seizure duration both overall (Hedge's g = 0.71, P = 0.038) and in the subgroup receiving ketamine in combination with another anesthetic (Hedge's g = 0.78, P < 0.01), and on decreasing electrical dose (Hedge's g = 1.98, P = 0.039). There was no significant effect of ketamine on any individual neuropsychological domain. Ketamine was not associated with increased adverse effects, except for hypertension in patients receiving ketamine monotherapy. Significant heterogeneity was present for many outcomes, and sensitivity analyses suggested a relation to methodological variation in most cases. This study supports the finding that ketamine does not enhance ECT's antidepressant effect, including on early improvement, but provides substantial evidence for enhancing seizure duration and reducing electrical dose. No significant benefit was found on neurocognitive outcomes, but analysis was limited by small sample sizes and high heterogeneity. Ketamine is generally safe in ECT, particularly as a coanesthetic. Our findings provide meta-analytic support to the recommendations in ECT clinical guidelines for use of coadjuvant ketamine in ECT where seizures are suboptimal. Further studies targeting neurocognitive outcomes are encouraged.
Topics: Anesthesia; Anesthetics, Dissociative; Cognition; Double-Blind Method; Electroconvulsive Therapy; Humans; Ketamine; Randomized Controlled Trials as Topic; Seizures; Treatment Outcome
PubMed: 31725054
DOI: 10.1097/YCT.0000000000000632 -
World Journal of Psychiatry Oct 2019Dissociation, which is defined as the failure to associate consciousness, memory, identity, emotion, perception, body representation, motor control, and behavior into an...
BACKGROUND
Dissociation, which is defined as the failure to associate consciousness, memory, identity, emotion, perception, body representation, motor control, and behavior into an integrated whole, has long been assumed to be generated by trauma. If dissociation is a product of trauma exposure, then dissociation would be a major mental health outcome observed in studies of disaster survivors. Although some studies have examined dissociation in disasters, no systematic literature reviews have been conducted to date on the topic.
AIM
To systematically evaluate the literature on the association between disaster and dissociation to determine the prevalence and incidence of dissociation after exposure to disaster and further examine their relationship.
METHODS
EMBASE, Medline, and PsychINFO were searched from inception to January 1, 2019 to identify studies examining dissociative disorders or symptoms related to a disaster in adult or child disaster survivors and disaster responders. Studies of military conflicts and war, articles not in English, and those with samples of 30 or more participants were excluded. Search terms used were "disaster*" and dissociation ("dissociat*," "multiple personality," "fugue," "psychogenic amnesia," "derealization," and "depersonalization"). Reference lists of identified articles were scrutinized to identify studies for additional articles.
RESULTS
The final number of articles in the review was 53, including 36 articles with samples of adults aged 18 and above, 5 of children/adolescents under age 18, and 12 of disaster workers. Included articles studied several types of disasters that occurred between 1989 and 2017, more than one-third (38%) from the United States. Only two studies had a primary aim to investigate dissociation in relation to disaster and none reported data on dissociative disorders. All of the studies used self-report symptom scales; none used structured interviews providing full diagnostic assessment of dissociative disorders or other psychopathology. Several studies mixed exposed and unexposed samples or did not differentiate outcomes between exposure groups. Studies examining associations between dissociation and disaster exposure have been inconclusive. The majority (75%) of the studies compared dissociation with posttraumatic stress, with inconsistent findings. Dissociation was found to be associated with a wide range of other psychiatric disorders, symptoms, and negative emotional, cognitive, and functional states.
CONCLUSION
The studies reviewed had serious methodological limitations including problems with measurement of psychopathology, sampling, and generation of unwarranted conclusions, precluding conclusions that dissociation is an established outcome of disaster.
PubMed: 31649861
DOI: 10.5498/wjp.v9.i6.83 -
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 -
Neurotoxicology Sep 2019Cannabidiol (CBD) and Δ9-tetrahydrocannabinol (THC) are the most represented phytocannabinoids in Cannabis sativa plants. However, CBD may present with a different... (Review)
Review
Cannabidiol (CBD) and Δ9-tetrahydrocannabinol (THC) are the most represented phytocannabinoids in Cannabis sativa plants. However, CBD may present with a different activity compared with the psychotomimetic THC. Most typically, CBD is reported to be used in some medical conditions, including chronic pain. Conversely, the main aim of this systematic review is to assess and summarise the available body of evidence relating to both efficacy and safety of CBD as a treatment for psychiatric disorders, alone and/or in combination with other treatments. Eligible studies included randomized controlled trials (RCT) assessing the effect of CBD in a range of psychopathological conditions, such as substance use; psychosis, anxiety, mood disturbances, and other psychiatric (e.g., cognitive impairment; sleep; personality; eating; obsessive-compulsive; post-traumatic stress/PTSD; dissociative; and somatic) disorders. For data gathering purposes, the PRISMA guidelines were followed. The initial search strategy identified some n = 1301 papers; n = 190 studies were included after the abstract's screening and n = 27 articles met the inclusion criteria. There is currently limited evidence regarding the safety and efficacy of CBD for the treatment of psychiatric disorders. However, available trials reported potential therapeutic effects for specific psychopathological conditions, such as substance use disorders, chronic psychosis, and anxiety. Further large-scale RCTs are required to better evaluate the efficacy of CBD in both acute and chronic illnesses, special categories, as well as to exclude any possible abuse liability.
Topics: Anxiety; Cannabidiol; Humans; Mental Disorders; Randomized Controlled Trials as Topic
PubMed: 31412258
DOI: 10.1016/j.neuro.2019.08.002 -
Journal of Affective Disorders May 2019Adjunctive ketamine with electroconvulsive therapy (ECT) has been investigated for treating major depressive disorder (MDD), but the findings have been inconsistent. (Meta-Analysis)
Meta-Analysis
BACKGROUND
Adjunctive ketamine with electroconvulsive therapy (ECT) has been investigated for treating major depressive disorder (MDD), but the findings have been inconsistent.
AIM
This is an updated meta-analysis of the efficacy and safety of ketamine augmentation of ECT in the treatment of MDD.
METHODS
Randomized controlled trials (RCTs) reporting on the efficacy and safety of ketamine and ECT were identified and analyzed.
RESULTS
Seventeen RCTs (n = 1,035) compared ketamine alone or ketamine plus other anesthetic drugs (n = 557) with other anesthetic agents (n = 478) in MDD patients who received ECT. Ketamine+other anesthetic drugs was superior in improving depressive symptoms over other anesthetic medications at early study time point, but not at post-ECT or end of study time points. Ketamine alone was not more efficacious in treating depressive symptoms than other anesthetic drugs at early study, post-ECT and end of study time points. Sensitivity analysis and 19 of the 20 subgroup analyses also confirmed the lack of significance of these findings. Eleven RCTs testing the effects of ketamine on neurocognitive functions with various test batteries found mixed results. Ketamine alone significantly increased blood pressure more than other anesthetic drugs in MDD treated with ECT.
CONCLUSION
Compared to other anesthetic agents, ketamine alone does not appear to improve the efficacy of ECT. However, ketamine+other anesthetic combinations may confer a short-term advantage in improving depressive symptom at the early stages of ECT.
Topics: Adult; Anesthetics, Dissociative; Combined Modality Therapy; Depression; Depressive Disorder, Major; Electroconvulsive Therapy; Female; Humans; Ketamine; Male; Randomized Controlled Trials as Topic; Treatment Outcome
PubMed: 30852364
DOI: 10.1016/j.jad.2019.02.044 -
Clinical Psychology & Psychotherapy May 2019Deliberate self-harm in adolescents is an increasing clinical problem, but there is a limited understanding of the mechanisms causing or maintaining this behaviour. One...
Deliberate self-harm in adolescents is an increasing clinical problem, but there is a limited understanding of the mechanisms causing or maintaining this behaviour. One proposed mechanism is that of dissociation. However, the role this mechanism may play is unclear: although some suggest that adolescents engage in self-harm to end the aversive experience of dissociation, others propose that self-harm is used to purposefully trigger a dissociative state to avoid emotional pain. This systematic review is the first to evaluate the available evidence regarding the relationship between dissociation and deliberate self-harm in adolescents (aged 18 or younger). Nineteen relevant studies were identified. These studies were limited by cross-sectional design and poor methods of measurement, but some important conclusions could be drawn. The majority of studies found a positive correlation between the severity of dissociation and the severity and frequency of deliberate self-harm in adolescents, and a small number of results suggest that dissociation mediates the relationship between childhood trauma and adolescent self-harm.
Topics: Adolescent; Adverse Childhood Experiences; Correlation of Data; Cross-Sectional Studies; Dissociative Disorders; Female; Humans; Male; Self-Injurious Behavior
PubMed: 30690804
DOI: 10.1002/cpp.2354 -
Journal of Trauma & Dissociation : the... 2019We analyze the empirical evidence for the association between the occurrence of dissociation and acting as a female sex worker (FSW). The ten screened databases included...
We analyze the empirical evidence for the association between the occurrence of dissociation and acting as a female sex worker (FSW). The ten screened databases included original research papers looking at the association between various abusive relationships and dissociation. From the initial 5942 records, we screened 554 full-text articles from which eleven studies met the inclusion criteria. Dissociation was mainly described as a strategy to cope with work related experiences, persisting from an early age in cases affected by childhood sexual abuse (CSA). Only one study investigated the occurrence of dissociative disorders. The other studies showed that the FSW population frequently exhibits dissociative symptoms. Most study participants were street FSW characterized by high rates of revictimization, a history of childhood sexual abuse, and of trauma-related and substance use disorders. Due to the selectivity of the study samples, conclusions cannot be generalized. Our findings disclose an important research gap. Further research on mental health among FSW should cover all fields of the sex industry in order to understand the roots of sex work (SW) and its sequelae. This could help develop and implement targeted interventions.
Topics: Dissociative Disorders; Female; Humans; Sex Workers
PubMed: 30689532
DOI: 10.1080/15299732.2019.1572044 -
Epilepsy & Behavior : E&B Dec 2018Comorbid epilepsy and psychogenic nonepileptic seizures (PNES) represent a serious challenge for the clinicians. However, the frequency, associations, and outcomes of... (Meta-Analysis)
Meta-Analysis
Comorbid epilepsy and psychogenic nonepileptic seizures (PNES) represent a serious challenge for the clinicians. However, the frequency, associations, and outcomes of dual diagnosis of epilepsy and PNES are unclear. The aim of the review was to determine the frequency, correlates, and outcomes of a dual diagnosis. A systematic review of all published observational studies (from inception to Dec. 2016) was conducted to determine the frequency, correlates, and outcomes of dual diagnosis. We included studies of individuals of any age reporting a dual diagnosis of epilepsy and PNES. All observational study designs were included with the exception of case reports and case series with fewer than 10 participants. The mean frequency of epilepsy in patients with PNES across all studies was 22% (95% confidence intervals [CI] 20 to 25%, range: 0% to 90%) while the mean frequency of PNES in patients with epilepsy was 12% (95% CI 10 to 14%, range: 1% to 62%). High heterogeneity means that these pooled estimates should be viewed with caution. A number of correlates of dual diagnosis were reported. Some studies delineated differences in semiology of seizures in patients with dual diagnosis vs. PNES or epilepsy only. However, most of the correlates were inconclusive. Only a few studies examined outcome in patients with dual diagnosis. Dual diagnosis is common in clinical practice, especially among patients referred to specialized services, and requires careful diagnosis and management.
Topics: Adult; Comorbidity; Diagnosis, Dual (Psychiatry); Electroencephalography; Epilepsy; Female; Humans; Male; Psychophysiologic Disorders; Seizures; Treatment Outcome
PubMed: 30384103
DOI: 10.1016/j.yebeh.2018.10.010 -
Epilepsia Jun 2018A recent systematic synthesis of qualitative research demonstrated that patients with psychogenic nonepileptic seizures (PNES) often experience unsatisfactory encounters...
A recent systematic synthesis of qualitative research demonstrated that patients with psychogenic nonepileptic seizures (PNES) often experience unsatisfactory encounters with health care practitioners (HCPs). It is important to understand such interactions from the perspective of those responsible for delivering care. This systematic review aimed to examine the attitudes and perceptions of HCPs toward PNES. A systematic search of 3 databases (Web of Science, PubMed, and CINAHL) was conducted in November 2017. Studies from around the world published after 1997 using qualitative or quantitative methodologies were reviewed. An interpretative stance was taken to analyze the data utilizing a grounded theory approach. The quality of studies included was assessed using the Mixed Methods Appraisal Tool. Overall, 30 separate studies capturing the views of at least 3900 professionals were included. Five concepts emerged from the analysis: (1) HCPs' responses demonstrated uncertainty about many aspects of PNES, including diagnosis and treatment; (2) HCPs understood PNES in dualistic terms, perceiving the condition as largely associated with psychological factors; (3) Patients with PNES were considered challenging and frustrating; (4) HCPs held mixed or contested views about who is responsible for treating patients with PNES; and (5) PNES was viewed as less severe or disabling than epilepsy and associated with a greater degree of volition. Although some HCPs have an excellent understanding of PNES, the views of many give rise to concern. The number of qualitative studies that directly ask HCPs about their perceptions of PNES is limited. Moreover, some professional groups (ie, mental health specialists) are underrepresented in current research. This study reveals a demand for additional training. However, effort is needed also to change the attitudes of some practitioners toward PNES.
Topics: Animals; Attitude of Health Personnel; Conversion Disorder; Databases, Bibliographic; Health Personnel; Humans; Perception; Psychophysiologic Disorders; Seizures; Somatoform Disorders
PubMed: 29750340
DOI: 10.1111/epi.14189