Psychedelic-Assisted Psychotherapy: When Two Traditions Meet

Introduction

After a long moratorium since the Controlled Substances Act was passed in 1970, there has been a resurgence of research on the potential therapeutic benefits of psychedelic (PE) compounds. It has been widely believed that the PE effect is a result of the interaction between the drug and the mindset of the patient (the “set”) with the external physical and social conditions (the “setting”). In order to control non-pharmacological variables and improve therapeutic outcome two types of psychological approaches to PE use have emerged traditionally. One is based on psychoanalytically informed talk therapy with low to moderate doses of a PE agent with the goal of facilitating a discharge of emotionally charged mental contents (psycholytic therapy). The other used one or several high doses of a PE to create an “overwhelming experience,” which was then followed up in integrative sessions (psychedelic therapy).

Objectives

Currently, it is unclear which one is better than another, these two methods are frequently mixed, and all-together carry the name of psychedelic-assisted psychotherapy. There has also been some discrepancy about what is the right “set” and “setting”.

Methods

To add some anchor points for (and at the same time warn about the limitations of ) the reemerging field of psychedelic-assisted psychotherapy the authors refer to anthropological observations in cultures, where PE use has a long practice historically.

Results

As part of healing ceremonials PE has usually been administered in a tight community with shared cosmology (“set”) and ritual context (“setting”).

Conclusions

These are difficult-to-reach conditions for someone coming from Western tradition.

Disclosure

No significant relationships.

Effects of ayahuasca on binocular rivalry with dichoptic stimulus alternation

RATIONALE

During binocular rivalry, two incompatible images are presented to each eye and these monocular stimuli compete for perceptual dominance, with one pattern temporarily suppressed from awareness. One variant of stimulus presentation in binocular rivalry experiments is dichoptic stimulus alternation (DSA), when stimuli are applied to the eyes in rapid reversals. There is preliminary report that in contrast with healthy controls, schizophrenic patients can maintain binocular rivalry even at very high DSA rates.

OBJECTIVE

The study was undertaken to investigate whether binocular rivalry survives high rates of DSA induced by the South American hallucinogenic beverage ayahuasca.

METHODS

Ten individuals who were participating in ayahuasca ceremonials were requested to volunteer for binocular rivalry tests (DSA=0, 3.75, 7.5, 15 and 30 Hz) without and after drinking the brew.

RESULTS

Ingestion of ayahuasca increased mean dominance periods both in standard binocular rivalry conditions (no DSA) and tests with DSA. At higher DSA rates (15 and 30 Hz) the total length of dominance periods was longer on the brew.

CONCLUSION

It is discussed that ayahuasca-induced survival of binocular rivalry at high DSA rates may be related to slow visual processing and increased mean dominance periods may result from hallucinogen-induced alteration of gamma oscillations in the visual pathways.

Ventricular enlargement in poor-outcome schizophrenia

BACKGROUND

A subset of patients with schizophrenia, defined on the basis of longitudinal deficits in self-care, may show a classic ("Kraepelinian") degenerative course. An independent validator of the phenomenologically defined Kraepelinian subtype might be provided by a structural indicator of possible brain degeneration: ventricular size as measured by computed tomography (CT).

METHODS

To examine whether Kraepelinian patients would show a differential increase in ventricular size over time, two CT scans were conducted at intervals separated by > 4 years, an average of 5 years. Fifty-three male patients with DSM-III-R diagnoses of chronic schizophrenia were subdivided into Kraepelinian (n = 22; mean age = 42 +/- 6 years) and non-Kraepelinian (n = 31; mean age = 38 +/- 12.2 years) subgroups. Kraepelinian patients were defined on the basis of longitudinal criteria: > 5 years of complete dependence on others for life necessities and care, lack of employment, and sustained symptomatology. Thirteen normal elderly volunteers (mean age = 60 +/- 17.8) were also scanned at 4-year intervals. CT measurements were made by raters without knowledge of subgroup membership. A semiautomated computer program was used to trace the anterior horn, lateral ventricles, and temporal horns for each slice level on which they were clearly seen.

RESULTS

The ventricles showed a bilateral increase in size over the 4-year interval in the Kraepelinian subgroup, more marked in the left hemisphere than the right. By contrast, neither the non-Kraepelinian subgroup nor the normal volunteers showed significant CT changes from scan 1 to scan 2.

CONCLUSIONS

Thus, the longitudinal dysfunctions in self-care that characterize the Kraepelinian patients were associated with an independent indicator of brain abnormality.

Regional brain metabolic response to lorazepam in alcoholics during early and late alcohol detoxification

Changes in GABA function have been postulated to be involved in alcohol tolerance, withdrawal and addiction. In this study we measured regional brain metabolic responses to lorazepam, to indirectly assess GABA function (benzodiazepines facilitate GABAergic neurotransmission), in alcoholics during early and late withdrawal. Brain metabolism was measured using PET and 2-deoxy-2[18F]fluoro-D-glucose after placebo (baseline) and after lorazepam (30 micrograms/kg intravenously) in 10 alcoholics and 16 controls. In the alcoholics evaluations were performed 2 to 3 weeks after detoxification and were repeated 6 to 8 weeks later. Controls were also evaluated twice at a 6 to 8 weeks interval. While during the initial evaluation metabolism was significantly lower for most brain regions in the alcoholics than in controls in the repeated evaluation the only significant differences were in cingulate and orbitofrontal cortex. Lorazepam-induced decrements in metabolism did not change with protracted alcohol withdrawal and the magnitude of these changes were similar in controls and alcoholics except for a trend towards a blunted response to lorazepam in orbitofrontal cortex in alcoholics during the second evaluation. Abnormalities in orbitofrontal cortex and cingulate gyrus in alcoholics are unlikely to be due to withdrawal since they persist 8 to 11 weeks after detoxification. The fact that there was only a trend of significance for an abnormal response to lorazepam in orbitofrontal cortex indicates that mechanisms other than GABA are involved in the brain metabolic abnormalities observed in alcoholic subjects.

The Dose Reduction in Schizophrenia (DORIS) Study: a final report

Twenty-one medication-free chronic schizophrenics were randomly assigned to three treatment groups: 50% blockade of the bromocriptine growth hormone (GH) response, 100% blockade or 10 ng/ml haloperidol. Only seven of the 21 patients showed a significant improvement after 6 weeks in positive psychotic symptoms; six of the seven responders came from the 50 and 100% blockade groups, suggesting greater efficacy at lower doses. Fifty percent blockade was associated with an average daily haloperidol dose of 3.2 mg and plasma haloperidol levels below the limit of detection (< 1 ng/ml). 100% blockade was associated with a daily dose of 6.5 mg and a plasma haloperidol level of 1 ng/ml. Negative symptoms significantly improved in only four of the 21 patients, and three of these patients were from the 100% blockade group. Twenty-nine patients currently receiving 20 mg/day haloperidol were randomly assigned to three treatment groups: placebo, 100% blockade of the GH response and 10 ng/ml. Patients in the placebo group showed significant deterioration along both the positive and negative symptom dimensions. There were no significant symptom differences between the 100% blockade and the 10 ng/ml groups. The patients in the 100% blockade group had on average a daily dose reduction from 20 to 11 mg/day and a 65% reduction in the plasma haloperidol level. There was a 70% difference in the average daily dose for 100% blockade between the two study arms. The higher daily dose in the dose-reduction arm may reflect receptor up-regulation and/or other "tolerance'-like mechanisms associated with chronic neuroleptic administration.

Severity of symptoms in chronically institutionalized geriatric schizophrenic patients

OBJECTIVE

The goal of this study was to characterize the symptoms of geriatric, chronically ill, institutionalized schizophrenic patients and investigate age-related differences in schizophrenic symptoms and cognitive performance from early adulthood to late senescence.

METHOD

The Positive and Negative Syndrome Scale and the Mini-Mental State examination were used to assess the schizophrenic symptoms and cognitive performance, respectively, of 393 institutionalized schizophrenic patients stratified into seven groups designated by 10-year age intervals from 25 years to over 85 years.

RESULTS

In the comparisons of the seven age groups, significant differences between groups in positive and negative subscale scores on the Positive and Negative Syndrome Scale and in Mini-Mental State scores were revealed. Significant correlations between Mini-Mental State scores and Positive and Negative Syndrome Scale negative symptom scores, but not positive symptom scores, were found for all age groups, except for the youngest patients studied. Current treatment with neuroleptics and prior treatment with ECT, insulin coma, or leukotomy could not account for the poor cognitive performance of the older schizophrenic patients.

CONCLUSIONS

The older schizophrenic patients continued to experience psychotic and nonpsychotic symptoms in senescence. Their positive symptoms were moderately less severe and their negative symptoms and cognitive impairment were significantly more severe than those of the younger patients. Somatic treatment appeared not to be responsible for the severe cognitive impairment and negative symptoms of the older patients. These data are relevant to chronically hospitalized geriatric schizophrenic patients but not necessarily to all geriatric schizophrenic patients.

Serotonergic interhemispheric asymmetry: gender difference in the orbital cortex

The asymmetry of tritiated imipramine (IMI) binding sites (which are associated with serotonergic mechanisms) were investigated in the orbital frontal cortex in 6 women and men who died of natural causes, and who did not have a history of mental disorders. There was significant interhemispheric asymmetry in both sexes, higher Bmax on the right side compared with the left. The Bmax values of IMI binding in the right orbital cortex in women were significantly higher than in men. Our preliminary findings--gender difference of serotonergic mechanisms in some area of the human brain--are in accordance with the observed gender differences in a variety of serotonin-regulated behaviors (sexual behavior, aggression and impulse control), and serotonergic mental disorders (eating disorders, suicidal behavior, anxiety disorders and depression).

Effects of adjunctive verapamil administration in chronic schizophrenic patients

1. The efficacy of adjunctive verapamil on psychopathological symptoms and tardive dyskinesia was investigated in 22 chronic schizophrenic patients, who had partially responded to neuroleptics. 2. After 28 days verapamil administration (240 mg/day) a significant improvement was found in anxiety-depression, and in some positive and negative symptoms. Three of the 22 patients showed clinically pronounced global improvement. 3. The treatment was ineffective in tardive dyskinesia.

Serotonergic interhemispheric asymmetry: neurochemical and pharmaco-EEG evidence

1. Postmortem neurochemical investigations revealed interhemispheric asymmetry in the mediofrontal region of human brain. Significantly higher right hemisphere serotonin metabolite (5HIAA) content as well as increased maximal imipramine binding (IB) were found in the right hemisphere than in the left side. 2. IB did not show a gender difference in the mediofrontal area. However, women had higher IB in the right orbital frontal cortex than did men. 3. In vivo pharmaco-EEG results tend to support the postmortem neurochemical data. Intravenous chlorimipramine resulted in an asymmetric topographic distribution of the P300 auditory evoked potential, peak amplitudes were shifted to the right hemisphere.

Predicting neuroleptic response from a combination of multilevel variables in acute schizophrenic patients

A predetermined set of 22 sociodemographic, psychosocial, clinical, neurocognitive and biochemical potential predictor variables was tested in 98 schizophrenic patients admitted for relapse. The patients were treated with neuroleptics, mostly with haloperidol, for 28 d. Ten of the 22 variables correlated significantly with the neuroleptic response. Using stepwise multiple regression analyses, an optimal combination of 5 predictors was found to be in hierarchical order: disturbances of premorbid adjustment, intensity of positive symptoms at admission, family history of schizophrenia, working ability during the year before admission and serum dopamine-beta-hydroxylase. The 5 best predictors explained 29% of outcome variance, and all 22 variables together explained 35%. Such neurological characteristics as neurological soft signs, handedness, abnormal voluntary movements, spontaneous blink rate and cognitive impairment did not predict the treatment response. Several psychopathological, psychosocial and clinical predictors known from the literature could also be confirmed by cross-validation.

Neurological features, cognitive impairment and neuroleptic response in schizophrenic patients

The relationship between neurological and cognitive features and the outcome of a 28-day neuroleptic treatment were studied in 98 chronic schizophrenic patients admitted for relapse. Handedness, neurological soft signs, and the cognitive rating on the Mini Mental State assessed in a stable state did not correlate with the neuroleptic response. The findings do not provide a basis for predicting the short-term outcome of the treatment.

A pilot study of the role of prophylactic antiparkinson treatment during neuroleptic therapy

The authors administered haloperidol 4.5 mg t.i.d. to 33 drug-free schizophrenic patients. Ten patients did not receive anything else (group HPL), while ten patients received procyclidine 5 mg t.i.d., and 13 patients were given promethazine 25 mg t.i.d. (groups HPRC and HPRM respectively) in addition. Seven patients dropped out of the HPL group and three out of the HPRM group, but none out of the HPRC group. These drop outs were due to the development of early extrapyramidal side effects, which were absent in the HPRC group. The findings suggest that antiparkinson prophylaxis is useful during commencement of therapy with high-potency neuroleptic agents.

Prolactin response to fentanyl in depression

Ten unmedicated female inpatients with major depression (DSM-III) and 10 healthy volunteer women were given an intravenous injection of 0.1 mg fentanyl at 9:00 AM and 9:00 PM on different days. The prolactin secretory response to this opioid agonist was investigated for 1 h with serial blood sampling. Repeated measures Analysis of Variance yielded a significant effect of fentanyl administration on prolactin secretion (p less than 0.0001), and there were elevated hormone responses in the evening (p less than 0.005). No group difference was seen between healthy volunteers and depressed patients, but four of the depressives showed the most blunted response, and three of these low responders committed suicide within 1 year.

Multivariate analysis of monoamine indices in patients with chronic schizophrenia

Levels of dopamine (DA), dihydroxyphenylacetic acid (DOPAC), homovanillic acid (HVA), noradrenaline (NA), 5-hydroxyindoleacetic acid (5-HIAA) in cerebrospinal fluid and serum levels of prolactin (PRL) and dopamine-beta-hydroxylase (DBH) were measured in 42 chronic schizophrenic inpatients grouped according to their scores on the Brief Psychiatric Rating Scale (BPRS) and the Abnormal Involuntary Movement Scale (AIMS). Factor analysis was carried out on various combinations of variables. In patients with tardive dyskinesia (TD), cerebrospinal fluid DA, DOPAC, HVA, NA, and serum DBH were distributed into three factors; in patients without TD, these substances were assembled in only one factor. Cerebrospinal fluid DA, DOPAC, and HVA were dispersed in two factors in patients with severe positive symptoms versus one factor in subjects with mild productive signs. Factor structures diverged only when the variables listed above were included in the analysis. These findings support the hypothesis that both the dopaminergic and the noradrenergic system contribute to TD and that positive schizophrenic symptoms are associated with dopaminergic dysregulation.

Diurnal variation in fentanyl-induced hormone responses and side effects

The prolactin (PRL) and thyrotropin (TSH) secretory response to the opioid agonist fentanyl (0.1 mg IV) was investigated with serial blood sampling in ten healthy women at 9 AM and 9 PM on different days. In five subjects saline control trials were also performed. A repeated-measures analysis of variance yielded a highly significant effect of fentanyl administration both on PRL and TSH secretion. In every case there were elevated hormone responses in the evening, and more drug-related subjective symptoms were reported at this time than before noon. These findings indicate a diurnal variation of opioid responsiveness, with lower sensitivity in the morning.

Effect of adjuvant reserpine treatment on catecholamine metabolism in schizophrenic patients under long-term neuroleptic treatment

The clinical and biochemical effects of adjuvant reserpine treatment were investigated in 12 chronic schizophrenic patients on long-term neuroleptic medication. The global severity of the symptoms using the Brief Psychiatric Rating Scale did not change significantly in the whole group, however, a moderate decrease in positive symptoms (factors though disturbance, activation and hostile-suspiciousness) was observed for 5 patients. Cerebrospinal fluid (CSF) noradrenaline levels showed a consistent decrease, but other biochemical parameters (CSF dopamine metabolites, platelet MAO and serum dopamine-beta-hydroxylase activities) did not change significantly. The changes of clinical symptoms and biochemical parameters did not show any correlation.

Dexamethasone suppression test and coping behavior in psychosocial stress

The dexamethasone suppression test (DST) and the Minnesota Multiphasic Personality Inventory (MMPI) were administered to 144 healthy inductees on day 2 of military service. One hundred and four of them completed a 120-item questionnaire describing their coping responses to this particular challenge. Thirty-six subjects (25%) failed to suppress plasma cortisol adequately. Their mean scores on the MMPI clinical standard scales were within the normal range. High postdexamethasone cortisol levels were associated with denial and passivity, and with low demand for social support. These results suggest that the DST might be more related to coping with a stressor than to a specific diagnosis. The authors speculate that high hypothalamic-pituitary-adrenal activity may have a primary role in psychological defense promoting inattention to the aversive aspects of stressful situations.

Dexamethasone suppression test and depressive symptoms in schizophrenics and endogenous depressed patients

Dexamethasone Suppression Test (DST) was given to 30 depressed and 30 schizophrenic patients. 10 depressed patients (33%) and 6 schizophrenics (20%) showed abnormal DST; the difference was not statistically significant. The DST-positive and DST-negative patients did not differ significantly in the total scores on anxiety-depression factor of the BPRS, either in the group of depressed patients or in schizophrenics.

The dexamethasone suppression test in panic disorder and major depressive episodes

Dexamethasone Suppression Tests (DST) were performed on 30 patients with panic disorder and on 30 patients treated for major depressive episodes in order to seek an answer to the question of whether or not the two disorders have a common biological background. The hypothesis was based on the results of family studies known from the literature and on the favorable therapeutic response obtained with tricyclic antidepressants. Normal suppressive (i.e., negative in our terminology) DSTs were found in 16.7% of the patients with panic disorder and in 56.7% of patients suffering from major depressive episodes. The anxiety indices of the two groups differed significantly from each other. The results do not suggest the possibility of a close genetic relationship between the two conditions.

Platelet MAO activity and the dexamethasone suppression test in bipolar depression

The correlation between postdexamethasone cortisol levels after the dexamethasone suppression test (DST) and platelet monoamine oxidase (MAO) activity was studied in 31 depressed female inpatients with Research Diagnostic Criteria primary, endogenous, bipolar depression (12 bipolar 1 and 19 bipolar 11). Out of the 31 patients, 25 showed abnormal DST results. Platelet MAO activity did not differ significantly from the matched control group. There was a trend that patients with higher MAO activity had lower postdexamethasone cortisol levels, but it was significant only for the 0800 hr cortisol levels.

CSF dopamine turnover and positive schizophrenic symptoms after withdrawal of long-term neuroleptic treatment

Dopamine (DA), dihydroxyphenylacetic acid (DOPAC), and homovanillic acid (HVA) were measured in cerebrospinal fluid (CSF) of 14 schizophrenic inpatients before and 2 weeks after withdrawal of long-term neuroleptic medication. Total neuroleptic-like activity (NLA) in serum was determined at the same times. DA and its metabolites (DOPAC and HVA) were significantly reduced after neuroleptic discontinuation. NLA was substantially diminished. The decrease in DA and DOPAC was positively correlated with positive symptoms of postwithdrawal deterioration, and low prewithdrawal DOPAC level predicted severe relapse. These results are compatible with the hypothesis linking an overregulated central DA system to the positive symptoms of schizophrenia.

Changes in mental condition, hyperkinesias and biochemical parameters after withdrawal of chronic neuroleptic treatment

Neuroleptics were withdrawn abruptly from 14 hospitalized chronic schizophrenics. For 12 weeks the patients were observed from the aspect of psychic change and the development of withdrawal dyskinesia. Serum prolactin level, plasma dopamine-beta-hydroxylase activity, cerebrospinal fluid homovanillic acid and norepinephrine levels were measured on the day prior to withdrawal and on day 14 of the study. Psychic deterioration showed no association with any of the tested biochemical parameters. The decrease in the CSF HVA and NE levels of the patients displaying symptoms of withdrawal dyskinesia was significantly smaller than in those displaying no dyskinesia.

Tiapride in the treatment of tardive dyskinesia: a clinical and biochemical study

The effect of tiapride treatment was investigated in 10 patients with tardive dyskinesia. The effects of the drug on the symptoms of tardive dyskinesia, parkinsonian symptoms, and patients' mental conditions were evaluated using standardized rating scales before and weekly during the 28-day drug trial. Patients were reassessed 14 days after withdrawal of tiapride. The symptoms of tardive dyskinesia significantly improved during treatment and deteriorated after tiapride was withdrawn. Parkinsonian symptoms remained unchanged both during and after treatment. The patients' mental conditions significantly improved while they were taking tiapride, and did not appreciably deteriorate after treatment was discontinued. Plasma prolactin levels increased significantly during treatment, while plasma dopamine-beta-hydroxylase activity did not change.

Decrease in dopamine, its metabolites and noradrenaline in cerebrospinal fluid of schizophrenic patients after withdrawal of long-term neuroleptic treatment

Dopamine (DA), homovanillic acid (HVA), dihydroxyphenylacetic acid (DOPAC), noradrenaline (NA), and 5-hydroxyindolacetic acid (5HIAA) were measured in cerebrospinal fluid (CSF) of 15 chronic schizophrenic patients before and 2 weeks after withdrawal of long-term neuroleptic treatment. Total neuroleptic-like activity in serum (NLA) was determined at the same times. Levels of DA and its metabolites (DOPAC and HVA) and NA were significantly reduced after the discontinuation of neuroleptic treatment. No change was observed in 5HIAA values. NLA was substantially reduced, but still remained detectable. The decrease in DA, DOPAC, and HVA all showed positive correlations with each other, and correlated negatively with NLA measured after 2 weeks. Our data implies that the decrease in DA turnover is the result of the discontinuance of DA receptor blockade, while the change in NA level is independent of it.

Colour associations as predictors of the effectiveness of anti-depressant pharmacotherapy in endogenous depressive patients

The authors examined the number of associations given for the 8 Lüscher colours by 20 endogenous depressive patients (11 unipolar and 9 bipolar II) before anti-depressant pharmacotherapy and on the 7th, 14th and 21st day of treatment. The depressive patients gave significantly fewer total responses before treatment than the 15 healthy control persons. While the number of associations obtained from the control persons was unchanged at the end of the 1st week, the depressive patients responding to the treatment (responders, n = 15) furnished significantly more responses on the 7th day than before treatment, although there had been no change in the intervening period in the severity of their depression measured by Hamilton depression scale; their clinical state showed a gradual improvement only from the end of the 2nd week. The number of associations obtained from non-responder depressive patients (n = 5) increased only slightly (not significantly). Our preliminary findings suggest that this method could be used to follow changes in the state of depressive patients and to predict their response to anti-depressant pharmacotherapy.

Biochemical markers in the study of clinical effects and extrapyramidal side effects of neuroleptics

Neuroleptic treatment was instituted in 20 female schizophrenic patients, who had not received neuroleptics for at least the preceding 3 months. Both the therapeutic response to neuroleptics and the development of parkinsonian side effects were monitored in these patients. In addition, plasma dopamine-beta-hydroxylase (DBH) and platelet monoamine oxidase (MAO) activities were measured. None of the neuroleptic responders developed parkinsonian symptoms. During the course of the 28-day treatment, there was a significant decrease in platelet MAO activity. There was a tendency for responders without parkinsonian symptoms to have lower plasma DBH activity than did nonresponders with parkinsonian symptoms.