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Lewis BR, Byrne K. A Review of MDMA-Assisted Therapy for Posttraumatic Stress Disorder. FOCUS (AMERICAN PSYCHIATRIC PUBLISHING) 2023; 21:247-256. [PMID: 37404966 PMCID: PMC10316220 DOI: 10.1176/appi.focus.20220088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/06/2023]
Abstract
Posttraumatic stress disorder (PTSD) is a common chronic and disabling psychiatric disorder that may develop after exposure to a traumatic life event. There are existing evidence-based psychotherapies and pharmacotherapies for PTSD; however, these treatments have significant limitations. 3,4-methylenedioxymethamphetamine (MDMA) was granted "breakthrough therapy" status by the U.S. Food and Drug Administration (FDA) in 2017 for the treatment of PTSD in conjunction with psychotherapy after preliminary Phase II results. This treatment is currently being investigated in Phase III trials with anticipated FDA approval of MDMA-assisted psychotherapy for PTSD in late 2023. This article reviews the evidence base for MDMA-assisted psychotherapy for PTSD, pharmacology and the proposed causal mechanisms of MDMA, risks and limitations of the current evidence, and challenges and future directions for the field.
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Affiliation(s)
| | - Kevin Byrne
- Department of Psychiatry, University of Utah, Salt Lake City
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Lucre K, Clapton N. The Compassionate Kitbag: A creative and integrative approach to compassion-focused therapy. Psychol Psychother 2021; 94 Suppl 2:497-516. [PMID: 32639097 DOI: 10.1111/papt.12291] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 05/28/2020] [Indexed: 12/16/2022]
Abstract
PURPOSE This paper outlines the concept of the 'Compassionate Kitbag', a novel multi-sensory-based means of helping draw together the various elements of compassionate mind training and processes within compassion-focused therapy (CFT), to help clients cultivate and facilitate their capacities for compassion. Building on the work of Lucre and Corten (2013, Psychology and Psychotherapy: Theory, Research and Practice, 86, 387), this is the first published work exploring this concept and the theoretical underpinnings, with a specific focus on how this can be used to support people with attachment and relational trauma. METHODS A narrative review of the literature on multi-sensory stimulation in facilitating people's capacities for compassion was conducted, coupled with a review of the literature of the use of non-human and transitional objects as explained by attachment theory and the broader scientific research underpinning the CFT model. RESULTS Clinical examples of how to use the Compassionate Kitbag to help stimulate compassionate therapeutic processes demonstrate the benefits of and how to begin utilizing this approach in compassion-focused work with clients with complex needs. CONCLUSIONS The Compassionate Kitbag's potential therapeutic value lies in offering multifarious creative and tangible means of accessing compassion to a wide range of individuals whom are typically fearful of, blocked, and/or resistant to compassion. Further research into the wider application of the concept of the Compassionate Kitbag is needed. PRACTITIONER POINTS Many patients with ruptured and/or traumatized early attachment relationships can find more traditional talking therapies difficult to access. Compassion-focused therapy (CFT) can offer an evolutionary-based understanding of interpersonal difficulties which can be helpful for such patients. Creatively harnessing and utilizing multi-sensory and non-linguistic social signals in CFT is key to exercising the care-giving and care-receiving social mentalities that facilitate compassionate flow. There is considerable evidence to support the use of a multi-sensory component to the therapeutic work to help patients cultivate and facilitate their capacities for compassion. The Compassionate Kitbag can be a way of supporting patients to create concrete representations of compassion in the context of the compassionate mind training component of the therapeutic work. Some of these objects can become transitional objects which can aid the therapeutic work.
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Affiliation(s)
| | - Neil Clapton
- Avon and Wiltshire Mental Health Partnership NHS Trust, Swindon, UK
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Walsh KH, Das RK, Saladin ME, Kamboj SK. Modulation of naturalistic maladaptive memories using behavioural and pharmacological reconsolidation-interfering strategies: a systematic review and meta-analysis of clinical and 'sub-clinical' studies. Psychopharmacology (Berl) 2018; 235:2507-2527. [PMID: 30091003 PMCID: PMC6132663 DOI: 10.1007/s00213-018-4983-8] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Accepted: 07/23/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND Consolidated memories can undergo enduring modification through retrieval-dependent treatments that modulate reconsolidation. This represents a potentially transformative strategy for weakening or overwriting the maladaptive memories that underlie substance use and anxiety/trauma-related disorders. However, modulation of naturalistic maladaptive memories may be limited by 'boundary conditions' imposed on the reconsolidation process by the nature of these memories. METHODS We conducted a systematic review and meta-analyses of behavioural and pharmacological studies examining retrieval-dependent modulation of reward- and threat-related memories in (sub) clinical substance use and anxiety/trauma, respectively. RESULTS Of 4938 publications assessed for eligibility, 8 studies of substance use and 10 of anxiety (phobia)- and trauma-related symptoms were included in the meta-analyses. Overall, the findings were in the predicted direction, with most studies favouring the 'retrieval + treatment' condition. However, the magnitude of effects was dependent upon the nature of treatment, with pharmacological interventions showing a medium-sized effect (g = 0.59, p = 0.03) and behavioural treatments, a relatively small effect (g = 0.32, p = 0.10) in studies of phobia/trauma. Among studies of substance use, post-retrieval behavioural interventions yielded a larger effect (g = 0.60, p < 0.001) relative to pharmacological treatments (g = - 0.03, p = 0.91), with treatment type being a statistically significant moderator (χ2(1) = 4.20, p = 0.04). CONCLUSION Modification of naturalistic maladaptive memories during reconsolidation appears to be a viable treatment strategy for substance use and phobias/trauma disorders. However, high levels of heterogeneity and methodological variation limit the strength of conclusions that can be drawn from the reviewed studies at this stage.
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Affiliation(s)
- Katie H Walsh
- Clinical Psychopharmacology Unit, Research Department of Clinical, Educational and Health Psychology, University College London, Gower Street, London, WC1E 6BT, UK
| | - Ravi K Das
- Clinical Psychopharmacology Unit, Research Department of Clinical, Educational and Health Psychology, University College London, Gower Street, London, WC1E 6BT, UK
| | - Michael E Saladin
- Department of Health Sciences and Research, College of Health Professions, Medical University of South Carolina, Charleston, USA
| | - Sunjeev K Kamboj
- Clinical Psychopharmacology Unit, Research Department of Clinical, Educational and Health Psychology, University College London, Gower Street, London, WC1E 6BT, UK.
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Contractor AA, Brown LA, Caldas SV, Banducci AN, Taylor DJ, Armour C, Shea MT. Posttraumatic stress disorder and positive memories: Clinical considerations. J Anxiety Disord 2018; 58:23-32. [PMID: 30025253 DOI: 10.1016/j.janxdis.2018.06.007] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Revised: 06/02/2018] [Accepted: 06/22/2018] [Indexed: 12/31/2022]
Abstract
Encoding and retrieval difficulties, and avoidance of both traumatic and positive memories, are associated with posttraumatic stress disorder (PTSD) symptoms. However, most PTSD research and clinical work has solely examined the role of traumatic memories in the maintenance/resolution of PTSD symptoms. This review provides a comprehensive discussion of the literature on positive memories and PTSD. First, we review theories and evidence on the relations between trauma, PTSD, and memory processes (particularly positive memories). Next, we propose a conceptual model that integrates evidence from experimental and positive/memory-based intervention research and highlights hypothesized mechanisms underlying the potential effectiveness of targeting positive memories in PTSD interventions. Specifically, we discuss how targeting positive memories could (1) increase positive affect and reduce negative affect, (2) correct negative cognitions, (3) increase specificity of retrieving autobiographical memories, and (4) be effectively integrated/sequenced with and enhance the effects of trauma-focused interventions. Lastly, we suggest clinical research avenues for investigating the relations between positive memories and PTSD, to possibly alter the current PTSD intervention paradigm focused only on traumatic memories. Overall, our proposed model drawing from experimental and intervention research, and outlining potential effects of targeting positive memories to reduce PTSD severity, needs further empirical investigation.
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Affiliation(s)
| | - Lily A Brown
- Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, USA
| | | | | | - Daniel J Taylor
- Department of Psychology, University of North Texas, Denton, TX, USA
| | - Cherie Armour
- Institute of Mental Health Sciences, School of Psychology, Ulster University, Northern Ireland, UK
| | - M Tracie Shea
- Providence Veterans Affairs Medical Center, Providence, USA; Department of Psychiatry and Human Behavior, Warren Alpert Medical School of Brown University, Providence, USA
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MDMA-assisted psychotherapy for PTSD: Are memory reconsolidation and fear extinction underlying mechanisms? Prog Neuropsychopharmacol Biol Psychiatry 2018. [PMID: 29524515 DOI: 10.1016/j.pnpbp.2018.03.003] [Citation(s) in RCA: 87] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
MDMA-assisted psychotherapy for treatment of PTSD has recently progressed to Phase 3 clinical trials and received Breakthrough Therapy designation by the FDA. MDMA used as an adjunct during psychotherapy sessions has demonstrated effectiveness and acceptable safety in reducing PTSD symptoms in Phase 2 trials, with durable remission of PTSD diagnosis in 68% of participants. The underlying psychological and neurological mechanisms for the robust effects in mitigating PTSD are being investigated in animal models and in studies of healthy volunteers. This review explores the potential role of memory reconsolidation and fear extinction during MDMA-assisted psychotherapy. MDMA enhances release of monoamines (serotonin, norepinephrine, dopamine), hormones (oxytocin, cortisol), and other downstream signaling molecules (BDNF) to dynamically modulate emotional memory circuits. By reducing activation in brain regions implicated in the expression of fear- and anxiety-related behaviors, namely the amygdala and insula, and increasing connectivity between the amygdala and hippocampus, MDMA may allow for reprocessing of traumatic memories and emotional engagement with therapeutic processes. Based on the pharmacology of MDMA and the available translational literature of memory reconsolidation, fear learning, and PTSD, this review suggests a neurobiological rationale to explain, at least in part, the large effect sizes demonstrated for MDMA in treating PTSD.
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Högberg G, Hällström T. Mood Regulation Focused CBT Based on Memory Reconsolidation, Reduced Suicidal Ideation and Depression in Youth in a Randomised Controlled Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2018; 15:ijerph15050921. [PMID: 29734740 PMCID: PMC5981960 DOI: 10.3390/ijerph15050921] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Revised: 04/25/2018] [Accepted: 04/30/2018] [Indexed: 11/28/2022]
Abstract
Suicide attempts and suicidal ideation in adolescence are considered to be related to suicide and psychiatric adversity later in life. Secondary prevention by improving the treatment of suicidal youth is a distinct possibility. In this study, treatment with a systematised mood-regulation focused cognitive behavioural therapy (MR-CBT) (n = 15) was compared with treatment as usual (TAU) (n = 12) in a group of depressed adolescents in a clinical setting. MR-CBT focuses on mood regulation by means of counter conditioning with memory reconsolidation being the proposed mechanism of change. Subjects practice keeping emotionally positive memories to diminish the emotional impact of negative memories. Symptoms of depression were tested with a short version of the Mood and Feelings Questionnaire (SMFQ), and wellbeing with the World Health Organization 5 Wellbeing Index (WHO-5). Suicidal events were rated according to the clinical interview Columbia Suicide Severity Rating Scale (C-SSRS). Suicidal events at the end of treatment were significantly reduced in the MR-CBT group, but not in the TAU group. Depression and wellbeing improved significantly in both treatment groups. While far from conclusive, the results are encouraging enough to suggest that further studies should be undertaken to examine whether psychotherapy focusing on mood regulation for young individuals at risk might enhance secondary prevention of suicide.
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Affiliation(s)
- Göran Högberg
- Child Psychiatry, BUP Globen, Stockholm 12177, Sweden.
| | - Tore Hällström
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, 43141 Mölndal, Sweden.
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Post RM, Kegan R. Prevention of recurrent affective episodes using extinction training in the reconsolidation window: A testable psychotherapeutic strategy. Psychiatry Res 2017; 249:327-336. [PMID: 28152467 DOI: 10.1016/j.psychres.2017.01.034] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Revised: 09/12/2016] [Accepted: 01/15/2017] [Indexed: 01/22/2023]
Abstract
Stressors may initially precipitate affective episodes, but with sufficient numbers of recurrences, episodes can occur more autonomously. It is postulated the memory engram for these recurrent depressions moves from the conscious representational memory system to the unconscious habit memory system encoded in the striatum. If this were the case, cognitive behavior therapy targeted toward extinction of habit memories could be an effective maneuver for helping reverse the automaticity of affective episode recurrence. Extinction training in the reconsolidation window (which opens about 5min to 1h after active memory recall) can revise, reverse, or eliminate the long term memories associated with PTSD and other anxiety disorders and with drug abuse craving. We hypothesize that similar cognitive behavioral work in the reconsolidation window could inhibit stress-induced and spontaneous affective episodes. Some initial formulations of possible therapeutic strategies are presented and discussed, as well as caveats. It is hoped that preliminary exposition of this theoretical approach to recurrences in the affective disorders based on principles dependent on work in the reconsolidation window will lead to more detailed elaboration of the therapeutic maneuvers most likely to be successful and ones that can be specifically tested for their clinical efficacy.
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Affiliation(s)
- Robert M Post
- George Washington University, School of Medicine, Bipolar Collaborative Network, 5415 W. Cedar Lane Suite 201-B, Bethesda, MD 20814, USA.
| | - Robert Kegan
- Harvard University, Graduate School of Education, 205 Longfellow Hall, Appian Way, Cambridge, MA 02138, USA
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Fear extinction and memory reconsolidation as critical components in behavioral treatment for posttraumatic stress disorder and potential augmentation of these processes. Neurosci Lett 2017; 649:170-175. [PMID: 28065842 DOI: 10.1016/j.neulet.2017.01.006] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Revised: 01/03/2017] [Accepted: 01/04/2017] [Indexed: 12/20/2022]
Abstract
Posttraumatic stress disorder (PTSD) is associated with alterations in critical brain regions such as the amygdala, hippocampus, and prefrontal cortex. This brief review has two objectives: (1) to discuss research examining extinction and reconsolidation processes as mechanisms in PTSD psychotherapy, and (2) present possibilities for augmenting extinction and reconsolidation within treatment through alterations to therapeutic interventions and novel approaches. A key component of many effective PTSD therapies is exposure, which involves intentional confrontation and processing of the traumatic memory. Our review suggests that extinction and reconsolidation processes underlie effective exposure-based treatment, but the neurobiological mechanisms of these processes in behavioral treatments for PTSD remains unclear. We argue that enhancing extinction and/or disrupting reconsolidation of a feared memory may improve the efficacy of existing treatments (e.g., increased change for limited/non-responders, faster/greater changes for responders), which can be done through multiple channels. Potential avenues for augmentation of the processes of extinction and reconsolidation in PTSD psychotherapies are reviewed, including behavioral modifications, pharmacotherapy agents, and the use of devices during therapy. We further suggest that investigations towards understanding the extent to which extinction and reconsolidation processes are necessary in effective PTSD psychotherapy is an important future direction for enhancing clinical care among PTSD populations.
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Besnard A, Caboche J, Laroche S. Reconsolidation of memory: A decade of debate. Prog Neurobiol 2012; 99:61-80. [PMID: 22877586 DOI: 10.1016/j.pneurobio.2012.07.002] [Citation(s) in RCA: 109] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2012] [Revised: 06/13/2012] [Accepted: 07/08/2012] [Indexed: 10/28/2022]
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