Exploring serotonergic psychedelics as a treatment for personality disorders

Both psychotherapeutic interventions and pharmacological agents have demonstrated limited efficacy in the treatment of personality disorders (PDs). Emerging evidence suggests that psychedelic therapy, already showing promise in treating various psychiatric conditions commonly comorbid with PDs, may exert therapeutic effects by promoting adaptive changes in personality. Thus, psychedelic therapy could hold potential for addressing core features of PDs through shared mechanisms of personality modulation. Although historical literature and observational studies suggest the potential clinical utility of psychedelics in treating PDs, rigorous research is lacking, and individuals with PDs are often excluded from modern psychedelic therapy trials. In the present review, we first discuss research on the effects of psychedelics in individuals with a PD through the conventional lens of the Diagnostic and Statistical Manual of Mental Disorders (5th ed., text rev.; DSM-5-TR) categorical model. Next, using the dimensional DSM Alternative Model of Personality Disorders (DSM-AMPD) as a framework, we examine how psychedelics may affect self-functioning, interpersonal functioning, and pathological personality traits. We conclude by discussing the clinical relevance of psychedelic therapy as a treatment for personality pathology, including safety considerations, gaps and limitations, and recommendations for approaching psychedelic therapy within these more complex clinical populations.

Evaluating the effectiveness of psilocybin in alleviating distress among cancer patients: A systematic review

OBJECTIVES

Psychological and existential distress is prevalent among patients with life-threatening cancer, significantly impacting their quality of life. Psilocybin-assisted therapy has shown promise in alleviating these symptoms. This systematic review aims to synthesize the evidence on the efficacy and safety of psilocybin in reducing cancer-related distress.

METHODS

We searched MEDLINE, APA PsycINFO, Cochrane database, Embase, and Scopus from inception to February 8, 2024, for randomized controlled trials (RCTs), open-label trials, qualitative studies, and single case reports that evaluated psilocybin for cancer-related distress. Data were extracted on study characteristics, participant demographics, psilocybin and psychotherapy intervention, outcome measures, and results. Two authors independently screened, selected, and extracted data from the studies. Cochrane Risk of Bias for RCTs and Methodological Index for Non-Randomized Studies criteria were used to evaluate study quality. This study was registered with PROSPERO (CRD42024511692).

RESULTS

Fourteen studies met the inclusion criteria, comprising three RCTs, five open-label trials, five qualitative studies, and one single case report. Psilocybin therapy consistently showed significant reductions in depression, anxiety, and existential distress, with improvements sustained over several months. Adverse effects were generally mild and transient.

SIGNIFICANCE OF RESULTS

This systematic review highlights the potential of psilocybin-assisted therapy as an effective treatment for reducing psychological and existential distress in cancer patients. Despite promising findings, further large-scale, well-designed RCTs are needed to confirm these results and address existing research gaps.

Psilocybin-Assisted suppoRtive psychoTherapy IN the treatment of prolonged Grief (PARTING) trial: protocol for an open-label pilot trial for cancer-related bereavement

INTRODUCTION

Prolonged grief disorder (PGD) represents a substantial public health issue, especially in oncology settings where it affects up to 30% of bereaved carers. Current best-practice treatments are lengthy, and up to 50% of participants have persistent PGD. Building on encouraging recent research with psychedelic-assisted therapies, the Psilocybin-Assisted suppoRtive psychoTherapy IN the treatment of prolonged Grief (PARTING) trial is the first study to consider psilocybin-assisted psychotherapy as a potential treatment for prolonged grief.

METHODS AND ANALYSIS

PARTING is an open-label pilot trial of psilocybin-assisted psychotherapy for approximately 15 people with cancer-related PGD. It aims to investigate feasibility, safety, acceptability, participant experience and participant-reported therapeutic effects. Over a 5-week intervention period, participants will undergo three preparation sessions before receiving a psychoactive (25 mg) dose of psilocybin alongside non-directive supportive guidance, followed by four integration sessions. All sessions will be delivered by a psychologist and either a nurse or Indigenous Therapist. An artificial intelligence-assisted tool will be used to create an artwork of participants' psychedelic experience.Outcomes will be investigated over a 12-month follow-up period. Feasibility will be assessed through recruitment/retention rates and completion of follow-up assessments. Safety will be evaluated via adverse events over 12 months and the comparison of physiological measures (vital signs, biochemistry, haematology, ECG) recorded during screening and 1 day after the psilocybin dose. Qualitative thematic analysis of semistructured interviews with participants and trial therapists will assess acceptability and the therapeutic potential of the treatment. Diagnostic clinical interviews for PGD and quantitative participant-reported measures of therapeutic effects are also being collected. Participant-reported measures include grief severity, depression, anxiety, grief avoidance, psychological flexibility, connectedness, and quality of life.

ETHICS AND DISSEMINATION

Ethics approval has been obtained from QIMR Berghofer Medical Research Institute Human Research Ethics Committee (P3801). Dissemination of results will occur via conference presentations, peer-reviewed publications and media.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry (ACTRN12623000827639).

Acute subjective effects of psychedelics in naturalistic group settings prospectively predict longitudinal improvements in trauma symptoms, trait shame, and connectedness among adults with childhood maltreatment histories

Studies of psychedelic use in naturalistic and clinical settings have suggested safety and mental health benefits for adults with histories of childhood maltreatment. Acute psychological mechanisms that predict therapeutic benefits in this population, however, have yet to be determined. Two common group settings of naturalistic psychedelic use - organized ceremonies and raves or other electronic dance music events - might facilitate therapeutic psychedelic effects because of the unique psychosocial environments they comprise. This prospective, longitudinal study sought to investigate 2 primary questions: first, whether adults with maltreatment histories planning to use psychedelic drugs with therapeutic intent at ceremonies or raves would see enduring psychological benefits after their experiences; and second, whether subjective dimensions of the acute psychedelic experience would be associated with lasting psychological benefits. Eighty-five participants completed self-report measures in the month before, within 2 days after, and approximately 2 months after a planned psychedelic experience with therapeutic intent at a ceremony or rave assessing childhood maltreatment history; trauma symptoms, internalized (trait) shame, and connectedness at baseline and follow-up; and various dimensions of the acute subjective psychedelic experience. Mean scores in posttraumatic stress disorder (PTSD) symptoms, complex PTSD symptoms, trait shame, social connectedness, and general connectedness significantly improved from baseline to 2-month follow-up (ds = 0.73-1.12). Longitudinal changes in outcomes significantly correlated with acute subjective effects of the psychedelic experience. These findings have implications regarding both the potential clinical benefit of psychedelic use among adults with childhood maltreatment histories as well as the psychological mechanisms of therapeutic action of psychedelics.

The road to Aha: A recipe for mental breakthroughs

We present a novel framework for understanding the diverse spectrum of mental breakthrough events, ranging from problem-solving insights to profound personal transformations. We propose that these events, while varied in expression and impact, share common underlying mechanisms of representational change. We also hypothesise that the differences in phenomenological intensity can be conceptualized along a continuum. Central to our model are three core components - tension, altered salience, and enhanced flexibility - which we identify as essential prerequisites for significant cognitive restructuring. These components interact within an iterative cycle, influencing both the emergence and nature of insight experiences. Drawing on examples from different fields, we explore how a conflict between existing models can trigger this cycle, wherein mechanisms of attention allocation and relaxation of constraints work in tandem to facilitate the emergence of insights. Furthermore, we propose that the intensity of the "aha-moment" and the breadth of its impact are contingent on how central the conflict is within one's conceptual landscape and the extent to which existing mental models are challenged. Thus, the model accounts for both the subtle, momentary insights in problem-solving and the transformative realizations that reshape core beliefs and self-perception. By synthesising insights from various domains, including psychotherapy, contemplative science, and psychedelic research, we present a theoretical account with broad scope, aiming to shed light on the complex processes that can lead to a wide array of mental breakthroughs, thereby contributing to the understanding of insight phenomena across disciplines.

Motivation and retrospective appraisal of psychedelic study participation: a qualitative study in healthy volunteers

RATIONALE

Little is known about motives of healthy volunteers to participate in psychedelic trials and how they appraise their study experience retrospectively.

OBJECTIVES

This paper explored reasons why healthy people register for psychedelic trials, factors that they considered to contribute to either positive or negative study experiences, and under which circumstances they would seek a psychedelic experience again.

METHODS

This study used the data of 151 healthy volunteers who had ingested serotonergic psychedelics in one of six randomized, double-blind, placebo-controlled crossover trials at the same research site under similar conditions. The data were analyzed through qualitative content analysis.

RESULTS

The predominant motivations to participate in a trial were interest in psychedelics and an appealing setting. Expectations involved personal development and the occurrence of typical psychedelic effects. Hopes included transformative processes. The setting factors that promoted a positive experience were music and access to nature, whereas the sterile hospital environment was considered bothersome. Most participants valued the trusting relationship with their investigator. The most commonly criticized investigator characteristics were a perceived lack of support and investigator-induced psychological discomfort. Most participants considered their expectations exceeded and would take the study substances again, preferably in a setting in nature with friends.

CONCLUSIONS

This paper identified four pivotal factors to be considered for psychedelic study experiences: (1) a secure interpersonal relationship, (2) an aesthetically pleasing environment, (3) access to nature, and (4) the use of music. This analysis reveals subjective views of volunteers in psychedelic Phase-I trials and may improve research standards.

A prospective ecological momentary assessment study of an ayahuasca retreat: exploring the salutary impact of acute psychedelic experiences on subacute affect and mindfulness skills in daily life

RATIONALE

To examine the acute effects of ayahuasca use and their relationship to sub-acute changes in affect and mindfulness in a non-clinical sample, addressing the need for a better understanding of ayahuasca's immediate and short-term impacts as interest in its use grows.

OBJECTIVES

Using prospective ecological assessment, this study investigates how ayahuasca used at a 4-day retreat affects positive/negative affect and mindfulness skills in daily living compared to pre-retreat. Additionally, we explore acute psychedelic experiences during the ayahuasca retreat, assessed retrospectively 1-2 days post-retreat, as potential mechanisms for theorized effects in daily living post-retreat.

METHODS

Thirty-six participants reported positive/negative affect and mindfulness skills three times daily for 5 days before and after the retreat. Baseline assessments included lifetime psychedelic experience, and post-retreat assessments covered acute ayahuasca experiences. Mixed-effect linear models were used to analyze the data.

RESULTS

Post-retreat, we observed reduced negative affect, increased positive affect, and enhanced mindfulness skills in daily living. Ayahuasca-induced acute experiences, such as time/space transcendence, emotional breakthrough and challenging experiences predicted greater subacute positive affect. Notably, none of these experiences were linked to subacute improvements in negative affect or mindfulness. No participants showed clinically significant adverse responses post-retreat, and only 5.5% exhibited some degree of potentially clinically significant deterioration in affect.

CONCLUSIONS

Ayahuasca use may lead to improvement in mood and mindfulness skills, and key acute psychedelic experiences induced by ayahuasca may be important to some of these salutary effects, positive affect in particular.

Shame, Guilt and Psychedelic Experience: Results from a Prospective, Longitudinal Survey of Real-World Psilocybin Use

The classic psychedelic psilocybin has attracted special interest across clinical and non-clinical settings as a potential tool for mental health. Despite increasing attention to challenging psychedelic experiences, few studies have explored the relevance of shame-related processes with psychedelic use. This prospective, longitudinal study involved sequential, automated, web-based surveys that collected data from 679 adults planning to use psilocybin in naturalistic settings at timepoints before and after psilocybin use. State and trait shame and feelings of guilt were collected using validated measures and assessed alongside other measurements of psychological health. Acute feelings of shame or guilt during psilocybin experiences were commonly reported (68.2% of users) and difficult to predict. Ratings of participant ability to constructively work through these feelings predicted wellbeing 2-4 weeks after psilocybin use. Psilocybin on average produced a small but significant decrease in trait shame that was maintained 2-3 months after use (Cohen's dz = 0.37). Trait shame increased in a notable minority of participants (29.8%). The activation of self-conscious emotions with psychedelics deserves further attention as a challenging experience subcategory that may be relevant to psychological outcomes. Such experiences could pose a unique and context-dependent learning condition for both therapeutic and detrimental forms of shame-related memory reconsolidation.

The Role of Music in Psychedelic-Assisted Therapy: A Comparative Analysis of Neuroscientific Research, Indigenous Entheogenic Ritual, and Contemporary Care Models

Music is deeply rooted in the human experience as well as a fundamental part of psychedelic-assisted therapies (PAT) and entheogenic ceremonies. Although a large body of research exists highlighting the importance of music from rehabilitative, psychological, neurobiological, anthropological, religious, and sociological contexts, there is limited scientific literature regarding the specific relevance of music in PAT and indigenous entheogenic ritual as a means of enhancing clinical outcomes. As demand for mental health services continues to grow and awareness of the medicinal benefits of psychedelic substances to treat mental and neurological conditions increases, a new wave of interest has emerged to support the development of care models, including how music is used during PAT. Music is a reliable cornerstone in therapeutic and ritualistic spaces using psychedelics, however there is still an immense opportunity to cultivate PAT models with interdisciplinary, evidence-informed perspectives and thoughtful analysis of music use in treatment. To contribute to this development, this review evaluates neuroscientific, psychological, and anthropological research on the neural and cognitive underpinnings of music as well as music use with psychedelics both in modern research settings and indigenous entheogenic ceremonies. In addition, personalized approaches to music protocols in PAT, how music use in traditional rituals may help inform best practices, and the need for researchers to specify music protocols in treatment models are detailed. Consideration of carefully respecting the bridging of indigenous practices and current medical models is discussed to highlight areas for future development.

Impact of psilocybin on cognitive function: A systematic review

Psilocybin is a classic psychedelic with demonstrated preliminary clinical efficacy in a range of psychiatric disorders. Evaluating the impact of psilocybin on cognitive function is essential to unravel its potential benefits and risks. In this systematic review, we assessed psilocybin's effect on cognitive function through a comprehensive search of electronic databases from inception to January 2024, identifying 20 articles involving 2,959 participants. While 85% of studies were conducted in healthy volunteers, most of these studies (85%) used macrodoses, ranging from 45 μg/kg to 30 mg/70 kg. Various cognitive aspects were evaluated and yielded mixed results. Global cognitive function, and processing speed remained mostly unchanged in healthy individuals; However, a limited number of studies reported improvements in certain areas such as sustained attention, working memory, and executive function especially in patients with treatment-resistant depression (TRD). Emotional processing was positively modified, particularly in TRD patients. Psilocybin was observed to enhance emotional empathy without significantly altering cognitive empathy and social cognition. Cognitive flexibility and creative cognition were noted to initially decline but could potentially improve over time. Additionally, with respect to learning and memory skills, psilocybin showed promise in improving specific memory types such as semantic associations and associative learning, while its effects on episodic and verbal memory have been less pronounced compared to other cognitive enhancers. The observed mixed findings underscore the complexity of psilocybin's cognitive influence. Further research is essential to provide a clearer understanding of psilocybin's impact on cognitive domains and to guide the development of safe and effective interventions.

Masking Influences: A Systematic Review of Placebo Control and Masking in Psychedelic Studies

Psychedelic-assisted therapy is becoming increasingly acknowledged as an effective therapeutic intervention for various psychiatric illnesses. However, the evaluation of masking success is rarely reported in trials. The objective of the present systematic review was to evaluate placebo-control and masking in studies exploring psychedelic-assisted therapy. Nine (k = 9) studies dating between January 2010 and March 2023 were retrieved using six databases, following strict inclusion and exclusion criteria. The results show that almost 78% of the studies had, at best, "poor" masking success. At the same time, 60% of active placebo and 75% of inactive placebo studies showed large effect sizes. In other words, masking influences, including benign unmasking, cannot be excluded. We therefore conclude that efficacy of psilocybin, Ayahuasca, or LSD is only one of the possible interpretations of large, positive changes in symptomatology for patients suffering from, for example, alcohol use disorder, anxiety with or without life-threatening disease, anxiety and/or depression with life-threatening cancer, treatment-resistant depression or major depressive disorder. We recommend care be taken to increase successful masking procedures and discuss alternative treatment designs to better control for potential masking influences.

Understanding Psychedelic-Assisted Psychotherapy Providers' Perspective and Insights: A Qualitative Analysis

Background

There is increasing interest in the use of psychedelics for therapeutic and recreational use. Research has been hindered by federal prohibition, put in place in 1970. Despite the regulatory difficulty, research has rapidly expanded in the past decade. Multiple states and cities have drafted their own policies regarding the use of psychedelics. Assuming interest in psychedelics continues to expand; every opportunity should be explored to better understand how psychedelics may be helping or harming people.

Objective

This study examined underground psychedelic-assisted psychotherapy providers' protocols and perspectives, to better inform policy and public health, as psychedelics increasingly are used in the United States.

Methods

Transcripts of interviews were examined through qualitative content analysis.

Results

The following four themes were identified: (1) personal experiences and self-healing motivated sharing and promotion of the positive effects of psychedelics as an expression of altruism, (2) guides articulated consistent, yet flexible processes, (3) guides believed that the client benefit was actualized through their own intrinsic ability to heal themselves, and (4) guides expressed an overwhelming sense of dissonance regarding psychedelic legalization, not only desiring increased access and decreased risk but also expressing concern about potential negative impacts on provider flexibility, and depersonalization that could come with standardizing this field of practice.

Conclusion

In order for current research and policy to be best informed, information must be gathered from both clinical trials and observational studies of current practice. This study identified themes within the latter to provide perspectives, practices, and insights of current underground practice, so it can be used to inform research and policy moving forward.

Psychotomimetic compensation versus sensitization

It is a paradox that psychotomimetic drugs can relieve symptoms that increase risk of and cooccur with psychosis, such as attention and motivational deficits (e.g., amphetamines), pain (e.g., cannabis) and symptoms of depression (e.g., psychedelics, dissociatives). We introduce the ideas of psychotomimetic compensation and psychotomimetic sensitization to explain this paradox. Psychotomimetic compensation refers to a short-term stressor or drug-induced compensation against stress that is facilitated by engagement of neurotransmitter/modulator systems (endocannabinoid, serotonergic, glutamatergic and dopaminergic) that mediate the effects of common psychotomimetic drugs. Psychotomimetic sensitization occurs after repeated exposure to stress and/or drugs and is evidenced by the gradual intensification and increase of psychotic-like experiences over time. Theoretical and practical implications of this model are discussed.

An Integrated theory of false insights and beliefs under psychedelics

Psychedelics are recognised for their potential to re-orient beliefs. We propose a model of how psychedelics can, in some cases, lead to false insights and thus false beliefs. We first review experimental work on laboratory-based false insights and false memories. We then connect this to insights and belief formation under psychedelics using the active inference framework. We propose that subjective and brain-based alterations caused by psychedelics increases the quantity and subjective intensity of insights and thence beliefs, including false ones. We offer directions for future research in minimising the risk of false and potentially harmful beliefs arising from psychedelics. Ultimately, knowing how psychedelics may facilitate false insights and beliefs is crucial if we are to optimally leverage their therapeutic potential.

Meaningfulness and attachment: what dreams, psychosis and psychedelic states tell us about our need for connection

The human need to find meaning in life and the human need for connection may be two sides of the same coin, a coin forged in the developmental crucible of attachment. Our need for meaningfulness can be traced to our developmental need for connection in the attachment relationship. The free energy principle dictates that in order to resist a natural tendency towards disorder self-organizing systems must generate models that predict the hidden causes of phenomenal experience. In other words, they must make sense of things. In both an evolutionary and ontogenetic sense, the narrative self develops as a model that makes sense of experience. However, the self-model skews the interpretation of experience towards that which is predictable, or already "known." One may say it causes us to "take things personally." Meaning is felt more acutely when defenses are compromised, when the narrative self is offline. This enables meaning-making that is less egocentrically motivated. Dreams, psychosis, and psychedelic states offer glimpses of how we make sense of things absent a coherent narrative self. This has implications for the way we understand such states, and lays bare the powerful reach of attachment in shaping what we experience as meaningful.

Review of Psilocybin Use for Depression among Cancer Patients after Approval in Oregon

Despite the legalization of psilocybin therapy for depression in terminal illnesses such as advanced cancer through Oregon's Measure 109 in 2020, significant challenges have impeded its implementation. This review synthesizes the empirical data supporting the utilization of psilocybin therapy for addressing cancer-related depression, including an evaluation of its purported benefits and potential adverse effects. It provides a comprehensive examination of therapeutic strategies, dosing regimens, and barriers to ensuring responsible and equitable access. Salient issues explored include the development of ethical protocols, integration within healthcare systems, ensuring statewide availability, resolving legal ambiguities, and defining clinical standards. Oregon's pioneering role serves as a case study, highlighting the necessity of addressing regulatory, logistical, and ethical obstacles to ensure the establishment of rigorous and equitable psilocybin care models.

Post-traumatic stress symptoms, post-traumatic stress disorder, and post-traumatic growth among cancer survivors: a systematic scoping review of interventions

The detrimental effects of Post-Traumatic Stress Symptoms (PTSS) and Post-Traumatic Stress Disorder (PTSD) and the benefits of Post-Traumatic Growth (PTG) are well established for cancer survivors. Increased cancer survival rates necessitate an understanding of how these two paradoxical outcomes, PTSS/PTSD and PTG, are targeted through interventions. This systematic scoping review aims to (a) examine existing evidence on interventions targeting PTSS/PTSD and/or PTG among cancer survivors and (b) identify knowledge gaps to inform future research. Following the six steps of a scoping review, 76 articles met the inclusion criteria. Quantitative articles were examined using descriptive analysis. Frequency counts of the collated data were tabulated into summary tables. Qualitative articles were reviewed using meta-synthesis. Most articles were quantitative (n = 52) and targeted PTG (n = 68) through promising intervention approaches such as psychotherapy, mindfulness, physical activity, and psilocybin-assisted therapy. Three key implications for future research and practice were synthesized: (1) mechanistic considerations for intervention design that provide a roadmap for rigorous and theoretically-grounded research; (2) the need for improved representation of cancer survivors in trials; and (3) potential facilitators of intervention efficacy. Together, these findings can direct future research to optimize interventions to reduce PTSS/PTSD and promote PTG achievement among cancer survivors.

Clarifying and measuring the characteristics of experiences that involve a loss of self or a dissolution of its boundaries

Mystical experience, non-dual awareness, selflessness, self-transcendent experience, and ego-dissolution have become increasingly prominent constructs in meditation and psychedelic research. However, these constructs and their measures tend to be highly overlapping, imprecise, and poorly integrated with similar pathological experiences. The present study seeks to clarify the common factors involved in the characteristics of these experiences using precise distinctions across an array of experience contexts (including meditation, psychedelics, and psychopathology). Participants (N = 386) completed an online survey about an experience that involved either a dissolution of self-boundaries or a loss of selfhood. Confirmatory factor analyses resulted in 16 experience characteristics, including multiple types of changes in sense of self, co-occurring phenomenology, and cognitive and affective responses. Qualitative thematic analysis provided rich descriptions of experience characteristics. Taken together, results lead to a more specific measurement model and descriptive account of experiences involving a loss of self or self-boundary.

Giving Consent to the Ineffable

A psychedelic renaissance is currently taking place in mental healthcare. The number of psychedelic-assisted therapy trials is growing steadily, and some countries already grant psychiatrists special permission to use psychedelics in non-research contexts under certain conditions. These clinical advances must be accompanied by ethical inquiry. One pressing ethical question involves whether patients can even give informed consent to psychedelic-assisted therapy: the treatment's transformative nature seems to block its assessment, suggesting that patients are unable to understand what undergoing psychedelic-assisted therapy actually means for them and whether it aligns with their values. The present paper argues that patients often have sufficient knowledge to give informed consent because they know that they want to change their negative status quo and that psychedelic-assisted therapy offers an effective way to do so. Accordingly, patients can understand what the transformative nature of psychedelic-assisted therapy means for them and a make a value-aligned choice even if they are unable to anticipate the manifestation of a psychedelic experience.

Trauma-Informed Care in Psychedelic Therapy Research: A Qualitative Literature Review of Evidence-Based Psychotherapy Interventions in PTSD and Psychedelic Therapy Across Conditions

Introduction

Post-traumatic stress disorder (PTSD) is associated with significant patient burden. While pharmacotherapies and evidence-based psychotherapy interventions (EBPI) are effective, studies consistently highlight inadequate outcomes and high treatment dropout. Psychedelic therapy (PT) has shown preliminary promise across difficult-to-treat conditions, including MDMA-assisted therapy for PTSD, however trials of classical psychedelics in PTSD are lacking. Understanding patients' experiences of EBPI could help promote safety in PT.

Aim

To systematically review qualitative research on patients' subjective experience of EBPI for PTSD, and of PT, and examine areas of overlap and divergence between them.

Methods

Systematic literature searches for studies published between 2010 and 2023 were conducted on OVID, PubMed, Web of Science, and PsycInfo. Included were original studies in English that presented qualitative data of patient experiences of EBPI in PTSD, or PT for any indication. Extracted data from included studies were analysed using thematic synthesis. Syntheses were completed separately for EBPI and PT, before similarities and differences between the therapies were identified.

Results

40 research articles were included for review: 26 studies on EBPI for PTSD, and 14 studies on PT. EBPI studied were CBT, EMDR, CPT and PE. Psychedelic compounds studied were psilocybin, ibogaine, LSD, MDMA and ketamine, for treatment of substance use disorders, anxiety relating to physical illness, depression, and PTSD. Core themes from patient experiences of EBPI: 1) patient burden in PTSD treatment; 2) readiness; 3) key mechanisms of change; 4) psychological safety and trust. Themes identified in the review of PT: 1) indirect trauma processing; 2) reorganisation of self-narratives via processes of relatedness and identification; 3) key treatment characteristics.

Conclusion

This study suggests overlap between patients' experience of EBPI and PT in terms of key mechanisms of change, the importance of psychological safety and readiness to engage in treatment. Trauma-informed care paradigms and practices may improve safety and acceptability of PT research.

Psilocybin and Other Classic Psychedelics in Depression

Psychedelic drugs such as psilocybin and ketamine are returning to clinical research and intervention across several disorders including the treatment of depression. This chapter focusses on psychedelics that specifically target the 5-HT2A receptor such as psilocybin and DMT. These produce plasma-concentration related psychological effects such as hallucinations and out of body experiences, insightful and emotional breakthroughs as well as mystical-type experiences. When coupled with psychological support, effects can produce a rapid improvement in mood among people with depression that can last for months. In this chapter, we summarise the scientific studies to date that explore the use of psychedelics in depressed individuals, highlighting key clinical, psychological and neuroimaging features of psychedelics that may account for their therapeutic effects. These include alterations in brain entropy that disrupt fixed negative ruminations, a period of post-treatment increased cognitive flexibility, and changes in self-referential psychological processes. Finally, we propose that the brain mechanisms underlying the therapeutic effect of serotonergic psychedelics might be distinct from those underlying classical serotonin reuptake-blocking antidepressants.

Older adults in psychedelic-assisted therapy trials: A systematic review

BACKGROUND

Growing clinical interest in psychedelic-assisted therapies has led to a second wave of research involving psilocybin, lysergic acid diethylamide (LSD), 3,4-methylenedioxymethamphetamine (MDMA) and other substances. Data suggests that these compounds have the potential to treat mental health conditions that are especially prevalent in older adults such as depression, anxiety, existential distress, and posttraumatic stress disorder.

AIMS

The goal of this study was to quantify the prevalence of older adults enrolled in psychedelic clinical trials and explore safety data in this population.

METHODS

A systematic review was conducted following the 2020 PRISMA guidelines. Search criteria included all trials published in English using psychedelic substances to treat psychiatric conditions, including addiction as well as existential distress related to serious illness. Articles were identified from literature searches on PubMed, EBSCO, and EMBASE.

RESULTS

4376 manuscripts were identified, of which 505 qualified for further review, with 36 eventually meeting eligibility criteria. Of the 1400 patients enrolled in the 36 studies, only 19 were identified as 65 or older, representing less than 1.4% of all trial participants. For 10 of these 19 older adults, detailed safety data was obtained. No serious adverse events (AEs) occurred in any older adults and only transient mild-to-moderate AEs related to anxiety, gastrointestinal upset, and hypertension were reported during the psychedelic dosing sessions.

CONCLUSIONS

While existing data in older adults is limited, it suggests that psychedelic-assisted psychotherapy can be safe and well tolerated in older adults. Therefore, psychedelic-assisted psychotherapy should be more rigorously investigated for the treatment of psychiatric conditions in this population.

Ayahuasca: A review of historical, pharmacological, and therapeutic aspects

Ayahuasca is a psychedelic plant brew originating from the Amazon rainforest. It is formed from two basic components, the Banisteriopsis caapi vine and a plant containing the potent psychedelic dimethyltryptamine (DMT), usually Psychotria viridis. Here we review the history of ayahuasca and describe recent work on its pharmacology, phenomenological responses, and clinical applications. There has been a significant increase in interest in ayahuasca since the turn of the millennium. Anecdotal evidence varies significantly, ranging from evangelical accounts to horror stories involving physical and psychological harm. The effects of the brew on personality and mental health outcomes are discussed in this review. Furthermore, phenomenological analyses of the ayahuasca experience are explored. Ayahuasca is a promising psychedelic agent that warrants greater empirical attention regarding its basic neurochemical mechanisms of action and potential therapeutic application.

Psilocybin-assisted psychotherapy for treatment-resistant depression: Which psychotherapy?

This perspective paper explores the choice of psychotherapy for psilocybin-assisted psychotherapy for treatment-resistant depression. There is evidence to support the use of some psychotherapies in treating 'treatment-resistant' depression, and emerging evidence for the efficacy of psilocybin. The next step which is the focus of this paper is to identify psychotherapies that are both effective and congruent with the psilocybin experience. The evidence for the efficacy of the psychotherapies is drawn from a Cochrane review and the analysis of their congruence with the psilocybin experience is drawn from a qualitative meta-synthesis of the experience of psilocybin. The paper will examine whether three one-to-one psychotherapies identified as effective in the treatment of treatment-resistant depression are compatible with the psilocybin experience. Each psychotherapy will be examined in relation to its congruence with the qualitative evidence that suggests the choice of psychotherapy needs to give priority to the subjective experience, facilitate emotional processing, support connectedness with others, acceptance of the self as emotional and support change based on the person's insights into their relationships with others and the world in which they live. We conclude that interpersonal psychotherapy and intensive short-term dynamic psychotherapy align with that experience, although others are currently being trialled.

With great power comes great vulnerability: an ethical analysis of psychedelics' therapeutic mechanisms proposed by the REBUS hypothesis

Psychedelics are experiencing a renaissance in mental healthcare. In recent years, more and more early phase trials on psychedelic-assisted therapy have been conducted, with promising results overall. However, ethical analyses of this rediscovered form of treatment remain rare. The present paper contributes to the ethical inquiry of psychedelic-assisted therapy by analysing the ethical implications of its therapeutic mechanisms proposed by the relaxed beliefs under psychedelics (REBUS) hypothesis. In short, the REBUS hypothesis states that psychedelics make rigid beliefs revisable by increasing the influence of bottom-up input. Put differently, patients become highly suggestible and sensitive to context during a psychedelic session, amplifying therapeutic influence and effects. Due to that, patients are more vulnerable in psychedelic-assisted therapy than in other therapeutic interventions; they lose control during a psychedelic session and become dependent on the therapeutic setting (including the therapist). This enhanced vulnerability is ethically relevant and has been exploited by some therapists in the past. Therefore, patients in current research settings and starting mainstream medical settings need to be well informed about psychedelics' mechanisms and their implications to give valid informed consent to treatment. Furthermore, other security measures are warranted to protect patients from the vulnerability coming with psychedelic-assisted therapy.

When the Trial Ends: The Case for Post-Trial Provisions in Clinical Psychedelic Research

The ethical value-and to some scholars, necessity-of providing trial patients with post-trial access (PTA) to an investigational drug has been subject to significant attention in the field of research ethics. Although no consensus has emerged, it seems clear that, in some trial contexts, various factors make PTA particularly appropriate. We outline the atypical aspects of psychedelic clinical trials that support the case for introducing the provision of PTA within research in this field, including the broader legal status of psychedelics, the nature of the researcher-therapist/participant relationship, and the extended time-frame of the full therapeutic process. As is increasingly understood, the efficacy of psychedelic-assisted psychotherapy is driven as much by extrapharmacological elements and the cultural therapeutic container as by the drug itself. As such, we also advocate for a refocusing of attention from post-trial access to a broader concept encompassing other elements of post-trial care. We provide an overview of some of the potential post-trial care provisions that may be appropriate in psychedelic clinical trials. Although the World Medical Association's Declaration of Helsinki calls on researchers, sponsors, and governments to make provisions for post-trial access, such provision may feel impracticable or out-of-reach within psychedelic trials that are already constrained by a high resource demand and significant bureaucratic burden. We show how conceiving of post-trial provision as an integral site of the research process, and an appropriate destination for research funding, will serve to develop the infrastructure necessary for the post-legalisation psychedelic medicine ecosystem.

Acute Subjective Effects of Psychedelics within and Beyond WEIRD Contexts

Reports of psychedelic experiences may contain similarities and differences across cultural contexts, but most current characterizations and quantifications of psychedelic experiences come from Western medical and naturalistic settings. In this article, we begin with a brief history of the diversity of psychedelic use in non-Western settings. We then compare and contrast accounts of psychedelic experiences within and beyond Western, educated, industrialized, rich, and democratic (WEIRD) contexts. We focus on specific reports of direct testimony of the acute subjective effects of psychedelics experienced across these contexts. We compare themes from each of these various contexts, with special emphasis on psychometric measures such as the mystical experiences questionnaire (MEQ), the five-dimensional altered states of consciousness (5D-ASC) scale, the Survey of God Encounters, and the Survey of Entity Encounters, the Challenging Experiences Questionnaire, and the Inventory of Nonordinary Experiences (INOE). Finally, we offer recommendations for future research to quantify these similarities and differences across cultures to assess them empirically in the future.

Moving beyond a figurative psychedelic literacy: Metaphors of psychiatric symptoms in ayahuasca narratives

Metaphors, analogies, and similes commonly appear in narratives of drinking the potent psychedelic "ayahuasca", presenting an intriguing transcultural pattern. Based upon survey and field research at an ayahuasca healing center in Pucallpa, Peru, the article investigates conceptual metaphors in narratives of ayahuasca experiences made by the visiting international guests. Bodily metaphors and visionary analogies frequently appear in narrative plots where they can express the reappraisal, overcoming, and sometimes emboldening of symptoms diagnosed by psychiatry. Moving beyond the literal-figurative divide, the article explores the intrinsic "metaphoricity" of psychedelic experiences and advocates for a literacy of conceptual metaphors regarding both clinical and non-clinical psychedelic narratives. Developing this literacy can broaden approaches in psychedelic psychiatry that analyze and treat syndromes and disorders, while also being applicable to social science and humanities research that examine psychoactive drug use beyond medical frameworks.

Exploring the Potential Utility of Psychedelic Therapy for Patients With Amyotrophic Lateral Sclerosis

Background: Amyotrophic lateral sclerosis (ALS) is an aggressive, terminal neurodegenerative disease that causes death of motor neurons and has an average survival time of 3-4 years. ALS is the most common motor neuron degenerative disease and is increasing in prevalence. There is a pressing need for more effective ALS treatments as available pharmacotherapies do not reverse disease progression or provide substantial clinical benefit. Furthermore, despite psychological distress being highly prevalent in ALS patients, psychological treatments remain understudied. Psychedelics (i.e., serotonergic psychedelics and related compounds like ketamine) have seen a resurgence of research into therapeutic applications for treating a multitude of neuropsychiatric conditions, including psychiatric and existential distress in life-threatening illnesses. Methods: We conducted a narrative review to examine the potential of psychedelic assisted-psychotherapy (PAP) to alleviate psychiatric and psychospiritual distress in ALS. We also discussed the safety of using psychedelics in this population and proposed putative neurobiological mechanisms that may therapeutically intervene on ALS neuropathology. Results: PAP has the potential to treat psychological dimensions and may also intervene on neuropathological dimensions of ALS. Robust improvements in psychiatric and psychospiritual distress from PAP in other populations provide a strong rationale for utilizing this therapy to treat ALS-related psychiatric and existential distress. Furthermore, relevant neuroprotective properties of psychedelics warrant future preclinical trials to investigate this area in ALS models. Conclusion: PAP has the potential to serve as an effective treatment in ALS. Given the lack of effective treatment options, researchers should rigorously explore this therapy for ALS in future trials.

Psychedelics for Patients With Cancer: A Comprehensive Literature Review

OBJECTIVE

To assess the role of psychedelics in the treatment of anxiety or depression among patients with cancer.

DATA SOURCES

PubMed search from inception to March 11, 2022, using the terms anxiety, depression, psychedelics, psilocybin, lysergic acid, methylenedioxymethamphetamine, or ayahuasca.

STUDY SELECTION AND DATA EXTRACTION

Studies assessing patients with cancer receiving psychedelics for the treatment of anxiety or depression.

DATA SYNTHESIS

Five unique randomized, double-blind, placebo-controlled trials were conducted. Significant reductions were found in 2 trials with 2 anxiety scales (State-Trait Anxiety Inventory-State, State-Trait Anxiety Inventory-Trait) and in 1 trial with 2 additional anxiety scales (Hamilton Rating Scale-Anxiety, Hospital Anxiety and Depression Scale-Anxiety). Significant reductions were found in 2 trials in 2 depression scales (Hospital Anxiety and Depression Scale-Depression, Beck Depression Inventory) and in 1 trial with an additional depression scale (Hamilton Rating Scale-Depression). Two studies assessed for clinically relevant reductions in anxiety and depression scores, and they occurred much more commonly in psychedelic-treated patients than those given placebo.

RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE

There is a new potential option for treating patients with anxiety and depression along with cancer, which is important given the generally lackluster benefits with traditional antidepressants. Only a few sessions may also provide benefits extending out for 6 to 12 months and possibly beyond that. However, the studies were small, had many methodological limitations, and there were increases in blood pressure and heart rate.

CONCLUSIONS

Psychedelics have a unique mechanism of action that might be well suited for treating anxiety and depression associated with cancer. This offers new promise for patients who are not being sufficiently treated with current antianxiety or antidepressant medications.

Do Psychedelics Facilitate Emergence of Unconscious Psychological Processes?

Psychedelic substances have a long history of use in traditional healing and religious ceremonies worldwide and are increasingly being investigated for their possible therapeutic usage. However, there is still a lack of consensus regarding how best to characterize the psychological effects of psychedelics and how they bring about the positive therapeutic outcomes observed in clinical studies. The aim of this article is to review available evidence from quantitative and qualitative studies on psychedelic-assisted therapy, as well as neurobiological studies, in relation to the hypothesis that psychedelics facilitate the emergence of emotionally charged unconscious material, originally proposed by pioneering psychedelics researcher Stanislav Grof. The reviewed process studies of therapeutic mechanisms in psychedelic-assisted therapy and qualitative studies of treatment participants clearly indicate that the psychedelic experience is associated with the subjective experience of having increased access to and awareness of emotions, memories, and perceptions that are normally avoided or outside of conscious awareness. Brain-imaging studies point to several different neurobiological effects of psychedelics that might be related to these subjective psychological experiences. Available evidence also indicates that this process might constitute an important therapeutic mechanism in psychedelic-assisted therapy, worthy of further investigation.

Experiences of psilocybin treatment for clinical conditions: A qualitative meta-synthesis

There is increasing clinical interest in the use of psilocybin. There is emerging evidence of the efficacy of psilocybin for the treatment of a range of clinical conditions. Mental health nurses have a unique set of skills for caring for people who are hallucinating. To expand these skills to meet the developing clinical interest in the therapeutic use of psilocybin, it is helpful to understand the experience from the perspective of the person being treated with psilocybin. A qualitative meta-synthesis was conducted to examine how those with psilocybin described their experiences to identify whether its effects are similar across different health conditions. Ten studies were included in the review. The health conditions studied were cancer, depression, HIV, substance use disorder, smoking cessation and trauma. The synthesis of findings identified three themes that were common across the studies despite the health condition: acceptance, connection and transformation. The review provides helpful insights into how people experience psilocybin and its effects on their health condition.

Perceived key change phenomena of MDMA-assisted psychotherapy for the treatment of severe PTSD: an interpretative phenomenological analysis of clinical integration sessions

Post-traumatic stress disorder (PTSD) is a prevalent psychiatric condition that significantly impacts daily functioning in patients but lacks adequate treatment options. 3,4-methylenedioxymethamphetamine (MDMA) as an adjunct to psychotherapy for the treatment of PTSD has been studied increasingly for the last two decades and has shown promising results through quantitative data. However, few qualitative studies have been conducted to investigate patients' experiences who participate in these trials. This study intends to complement and clarify the quantitative findings resulting from a Phase-II clinical trial for assessing the safety and efficacy of MDMA-assisted psychotherapy for PTSD by using a qualitative approach based on available material of 4 recorded and transcripted integrative sessions per participant. An Interpretative Phenomenological Analysis (IPA) was conducted for 7 participants who met criteria for severe PTSD to develop a deeper understanding of the treatment and its efficacy. Analysis results provided real-life statements from participants that reflect perceived mechanisms of change and showed to what extent their proposed working mechanisms integrate into daily life.

Critical Period Plasticity as a Framework for Psychedelic-Assisted Psychotherapy

As psychedelic compounds gain traction in psychiatry, there is a need to consider the active mechanism to explain the effect observed in randomized clinical trials. Traditionally, biological psychiatry has asked how compounds affect the causal pathways of illness to reduce symptoms and therefore focus on analysis of the pharmacologic properties. In psychedelic-assisted psychotherapy (PAP), there is debate about whether ingestion of the psychedelic alone is thought to be responsible for the clinical outcome. A question arises how the medication and psychotherapeutic intervention together might lead to neurobiological changes that underlie recovery from illness such as post-traumatic stress disorder (PTSD). This paper offers a framework for investigating the neurobiological basis of PAP by extrapolating from models used to explain how a pharmacologic intervention might create an optimal brain state during which environmental input has enduring effects. Specifically, there are developmental "critical" periods (CP) with exquisite sensitivity to environmental input; the biological characteristics are largely unknown. We discuss a hypothesis that psychedelics may remove the brakes on adult neuroplasticity, inducing a state similar to that of neurodevelopment. In the visual system, progress has been made both in identifying the biological conditions which distinguishes the CP and in manipulating the active ingredients with the idea that we might pharmacologically reopen a critical period in adulthood. We highlight ocular dominance plasticity (ODP) in the visual system as a model for characterizing CP in limbic systems relevant to psychiatry. A CP framework may help to integrate the neuroscientific inquiry with the influence of the environment both in development and in PAP. Appeared originally in Front Neurosci 2021; 15:710004.

Psychedelic unselfing: self-transcendence and change of values in psychedelic experiences

Psychedelic experiences have been shown to both facilitate (re)connection to one's values and change values, including enhancing aesthetic appreciation, promoting pro-environmental attitudes, and encouraging prosocial behavior. This article presents an empirically informed framework of philosophical psychology to understand how self-transcendence relates to psychedelic value changes. Most of the observed psychedelic value changes are toward the self-transcendent values of Schwartz's value theory. As psychedelics also reliably cause various self-transcendent experiences (STEs), a parsimonious hypothesis is that STEs change values toward self-transcendent values. I argue that STEs indeed can lead to value changes, and discuss the morally relevant process of self-transcendence through Iris Murdoch's concept of "unselfing". I argue that overt egocentric concerns easily bias one's valuations. Unselfing reduces egocentric attributions of salience and enhances non-egocentric attention to the world, widening one's perspective and shifting evaluation toward self-transcendent modes. Values are inherently tied to various evaluative contexts, and unselfing can attune the individual to evaluative contexts and accompanying values beyond the self. Understood this way, psychedelics can provide temporarily enhanced access to self-transcendent values and function as sources of aspiration and value change. However, contextual factors can complicate whether STEs lead to long-term changes in values. The framework is supported by various research strands establishing empirical and conceptual connections between long-term differences in egocentricity, STEs, and self-transcendent values. Furthermore, the link between unselfing and value changes is supported by phenomenological and theoretical analysis of psychedelic experiences, as well as empirical findings on their long-term effects. This article furthers understanding of psychedelic value changes and contributes to discussions on whether value changes are justified, whether they result from cultural context, and whether psychedelics could function as tools of moral neuroenhancement.

Transformative experience and informed consent to psychedelic-assisted psychotherapy

Just as psychedelic-assisted psychotherapy (PAP) represents a clinical innovation that may need to be accommodated with corresponding theoretical and methodological innovations, there is growing awareness that the tools, normative frameworks, and standard practices of our clinical ethics may also need to be adapted, renewed, or replaced to accommodate its unusual features. Drawing on L. A. Paul's work on "Transformative Experience," I argue that the acute and long-term effects that are repeatedly reported following the administration of psychedelic drugs, including in clinical contexts, are epistemically inaccessible at the point of deciding to take them. By virtue of both the so-called "mystical" experiences that frequently arise during PAP, and the long-term shifts to outlooks, values, and priorities that can follow treatment, the processes of decision-making that are normatively expected of patients run aground. If this framing is correct, then prospective patients cannot meet the requirement of understanding that is one of the principal analytic components of informed consent. The role of understanding in supporting two functions of informed consent-avoiding unauthorized trespass against patients and supporting values-aligned decision-making-is explored, and I argue that, while the normative standard for the first function may be met by extant suggestions for enhancing the consenting process for PAP, the latter function remains unattainable. In light of this, the consequences for the ethical preparation of prospective patients are considered.

How does psilocybin therapy work? An exploration of experiential avoidance as a putative mechanism of change

BACKGROUND

Psilocybin therapy is receiving attention as a mental health intervention with transdiagnostic potential. In line with psychotherapeutic research, qualitative research has highlighted the role of reductions in experiential avoidance (and increases in connectedness) within psilocybin therapy. However, no quantitative research has examined experiential avoidance as a mechanism underlying psilocybin therapy's therapeutic effects.

METHOD

Data was used from a double-blind randomized controlled trial that compared psilocybin therapy (two 25 mg psilocybin session plus daily placebo for six weeks) with escitalopram (two 1 mg psilocybin sessions plus 10-20 mg daily escitalopram for six weeks) among individuals with major depressive disorder (N = 59). All participants received psychological support. Experiential avoidance, connectedness, and treatment outcomes were measured at pre-treatment and at a 6 week primary endpoint. Acute psilocybin experiences and psychological insight were also measured.

RESULTS

With psilocybin therapy, but not escitalopram, improvements in mental health outcomes (i.e., well-being, depression severity, suicidal ideation, and trait anxiety) occurred via reductions in experiential avoidance. Exploratory analyses suggested that improvements in mental health (except for suicidal ideation) via reduction in experiential avoidance were serially mediated through increases in connectedness. Additionally, experiences of ego dissolution and psychological insight predicted reductions in experiential avoidance following psilocybin therapy.

LIMITATIONS

Difficulties inferring temporal causality, maintaining blindness to condition, and reliance upon self-report.

CONCLUSIONS

These results provide support for the role of reduced experiential avoidance as a putative mechanism underlying psilocybin therapy's positive therapeutic outcomes. The present findings may help to tailor, refine, and optimize psilocybin therapy and its delivery.

Optimizing outcomes in psilocybin therapy: Considerations in participant evaluation and preparation

Recent studies have demonstrated the promise of psilocybin therapies in creating positive changes for those with poor mental health across multiple diagnostic categories, including major depressive disorder (MDD), end-of-life anxiety, and obsessive-compulsive disorder (OCD). While there may be a large population that is eligible to participate in psilocybin therapy based on psychiatric diagnosis and medical clearance, little attention has been given to intrapersonal and interpersonal factors that might influence patient's readiness (i.e., eligibility and capacity) for psychedelic interventions. This paper proposes that readiness assessment includes both intrapersonal and interpersonal factors in order to improve safety, patient care, and treatment outcomes. While at the present time a reliable and valid instrument has not been developed, we propose that three specific areas of focus - patient presentation, therapeutic alliance, and patient safety - may be used to establish a patient's readiness for psilocybin therapy, thus increasing therapy optimization and personalization.

Self-Care Practices with Psychedelics - A Qualitative Study of Users' Perspectives

This article explores the psychedelic experience from the users' point of view and through the lens of self-care, a concept within the domain of health and well-being. In a time of renewed interest in psychedelic-assisted psychotherapy, we aim to contribute to a better understanding of these substances by exploring their role in different settings. A phenomenological approach was used in this study. We conducted semi-structured interviews with 19 psychedelic users and inquired about the relationship between their experiences and self-care. Analysis of the interview data was based on inductive content analysis. Most participants reported using psychedelics with self-care intentions in ceremonial, recreational, or private settings. Self-perception and existential meaningfulness were identified as the main mechanisms of self-care. Participants also mentioned difficult experiences and adversities that impair self-care. The results suggest that for some people, the use of psychedelics may be experienced as part of a self-care process and may improve self-care abilities in naturalistic settings.

Restructuring insight: An integrative review of insight in problem-solving, meditation, psychotherapy, delusions and psychedelics

Occasionally, a solution or idea arrives as a sudden understanding - an insight. Insight has been considered an "extra" ingredient of creative thinking and problem-solving. Here we propose that insight is central in seemingly distinct areas of research. Drawing on literature from a variety of fields, we show that besides being commonly studied in problem-solving literature, insight is also a core component in psychotherapy and meditation, a key process underlying the emergence of delusions in schizophrenia, and a factor in the therapeutic effects of psychedelics. In each case, we discuss the event of insight and its prerequisites and consequences. We review evidence for the commonalities and differences between the fields and discuss their relevance for capturing the essence of the insight phenomenon. The goal of this integrative review is to bridge the gap between the different views and inspire interdisciplinary research efforts for understanding this central process of human cognition.

Psychedelic replications in virtual reality and their potential as a therapeutic instrument: an open-label feasibility study

Background

Recent research has shown promising results for the therapeutic benefits of psychedelics. One popular view claims that these benefits are mediated by the subjective experiences induced by these substances. Based on this, we designed a virtual reality experience, Psyrreal, that mimics the phenomenological components of psychedelic experiences.

Aims

We aimed to investigate the therapeutic efficacy of Psyrreal and psychedelic VR experiences in treating depressive symptoms as well as explore the effect of Psyrreal on subjective factors which have been suggested to mediate the therapeutic benefits of psychedelics.

Methods

In this open-label feasibility study, thirteen participants with mild-to-moderate depression underwent a 2-day therapeutic intervention implementing Psyrreal. Depressive symptoms were evaluated by the Emotional State Questionnaire (EST-Q2) at the start of the intervention and 2 weeks after. A thematic analysis of semi-structured interviews after Psyrreal was also conducted as an additional assessment of the method.

Results

A 2-day intervention implementing Psyrreal led to significant decreases in depressive symptoms at the 2-week follow-up (n = 10, p = 0.007, Hedges' g = 1.046) measured by the Emotional State Questionnaire (EST-Q2). The analysis of semi-structured interviews suggests that Psyrreal could lead to insight and alterations in the sense of self in some people.

Conclusion

This work proposes a novel method using virtual reality to augment the treatment of psychological disorders as well as to precisely investigate the mediating subjective factors of the therapeutic effects of psychedelic substances. Our preliminary results suggest that VR experiences combined with psychological support show potential in treating depressive symptoms and further research into similar methods is warranted.

A unified model of ketamine's dissociative and psychedelic properties

Ketamine is an N-methyl-d-aspartate antagonist which is increasingly being researched and used as a treatment for depression. In low doses, it can cause a transitory modification in consciousness which was classically labelled as 'dissociation'. However, ketamine is also commonly classified as an atypical psychedelic and it has been recently reported that ego dissolution experiences during ketamine administration are associated with greater antidepressant response. Neuroimaging studies have highlighted several similarities between the effects of ketamine and those of serotonergic psychedelics in the brain; however, no unified account has been proposed for ketamine's multi-level effects - from molecular to network and psychological levels. Here, we propose that the fast, albeit transient, antidepressant effects observed after ketamine infusions are mainly driven by its acute modulation of reward circuits and sub-acute increase in neuroplasticity, while its dissociative and psychedelic properties are driven by dose- and context-dependent disruption of large-scale functional networks. Computationally, as nodes of the salience network (SN) represent high-level priors about the body ('minimal' self) and nodes of the default-mode network (DMN) represent the highest-level priors about narrative self-experience ('biographical' self), we propose that transitory SN desegregation and disintegration accounts for ketamine's 'dissociative' state, while transitory DMN desegregation and disintegration accounts for ketamine's 'psychedelic' state. In psychedelic-assisted psychotherapy, a relaxation of the highest-level beliefs with psychotherapeutic support may allow a revision of pathological self-representation models, for which neuroplasticity plays a permissive role. Our account provides a multi-level rationale for using the psychedelic properties of ketamine to increase its long-term benefits.

Risks and benefits of psilocybin use in people with bipolar disorder: An international web-based survey on experiences of 'magic mushroom' consumption

BACKGROUND

Psilocybin, the primary psychoactive component of psychedelic 'magic mushrooms', may have potential for treating depressive symptoms, and consequent applications for bipolar disorder (BD). Knowledge of the risks and benefits of psilocybin in BD is limited to case studies.

AIM

To support the design of clinical trials, we surveyed experiences of psilocybin use in people with BD.

METHODS

An international web-based survey was used to explore experiences of psilocybin use in people with a self-reported diagnosis of BD. Quantitative findings were summarised using descriptive statistics. Qualitative content analysis was used to investigate free-text responses, with a focus on positive experiences of psilocybin use.

RESULTS

A total of 541 people completed the survey (46.4% female, mean 34.1 years old). One-third (32.2%; n = 174) of respondents described new/increasing symptoms after psilocybin trips, prominently manic symptoms, difficulties sleeping and anxiety. No differences in rates of adverse events overall were observed between individuals with BD I compared to BD II. Use of emergency medical services was rare (n = 18; 3.3%), and respondents (even those who experienced adverse effects) indicated that psilocybin use was more helpful than harmful. Quantitative findings elaborated on perceived benefits, as well as the potential for psilocybin trips to contain both positively and negatively received elements.

CONCLUSIONS

The subjective benefits of psilocybin use for mental health symptoms reported by survey participants encourage further investigation of psilocybin-based treatments for BD. Clinical trials should incorporate careful monitoring of symptoms, as data suggest that BD symptoms may emerge or intensify following psilocybin use.

The Safety and Efficacy of Psychedelic-Assisted Therapies for Older Adults: Knowns and Unknowns

Psychedelics and related compounds have shown efficacy for the treatment of a variety of conditions that are prevalent among older adults, including mood disorders, the psychological distress associated with a serious medical illness, post-traumatic stress disorder (PTSD), and prolonged grief disorder. Psychedelics also have properties that could help provide therapeutic benefits for patients with dementing disorders, as well as promoting personal growth among healthy older adults. This article focuses on psilocybin, a classic psychedelic, and MDMA, a substituted amphetamine with properties similar to classic psychedelics. Both act on the 5HT_2A receptor. Psychedelics can be safely administered to healthy adults in controlled conditions. However, both psilocybin and MDMA can increase blood pressure and heart rate, which could be a concern if used in older adults with cardiovascular disease. Very few older adults or patients with serious comorbidities have been included in clinical trials of psychedelics to date, raising the question of how generalizable study results are for the patients that most geropsychiatrists will be treating. Research on the neurophysiologic and mechanistic effects of psychedelics in older adults could also provide insights into the aging brain that could have clinical applications in the future. Given the potential of psychedelic compounds to benefit older adults, more research is needed to establish safety and efficacy among older adults, particularly those with multi-morbidity.

How Important Is a Guide Who Has Taken Psilocybin in Psilocybin-Assisted Therapy for Depression?

Promising outcomes of Psilocybin-Assisted Therapy (PAT) for depression have generated concerted efforts to replicate, extend, and refine protocols to maximize efficacy. Psychotherapy research reveals that clients benefit most when important components of treatment align with their personal preferences. One open question related to PAT concerns the importance of the psilocybin experience of the guides (trained professionals present during acute effects). We sought to assess the importance of a guide who had used psilocybin to potential clients with depressive symptoms. Over 800 MTurk respondents with depressive symptoms rated the import of a guide who had used psilocybin relative to alternative characteristics in guides and cognitive behavioral (CBT) therapists. Importance ratings for guides who had used psilocybin significantly exceeded the "somewhat important" level (50 on a 0-100 scale), other guide-related qualities, and comparable ratings for a cognitive behavioral therapist who shared demographics, had experience with depression and received cognitive therapy personally. People of color (those who are not Caucasian) and those who had previous therapy gave significantly higher importance ratings for guides who had used psilocybin. Participants who chose to list other qualities important for guides listed very similar ones for CBT therapists, often emphasizing proper training and an empathic demeanor. Guides who have used psilocybin, who inform clients of the fact, might have advantages for facilitating PAT's antidepressant effects, as least in a subset of clients.

DNA Authentication and Chemical Analysis of Psilocybe Mushrooms Reveal Widespread Misdeterminations in Fungaria and Inconsistencies in Metabolites

The mushroom genus Psilocybe is best known as the core group of psychoactive mushrooms, yet basic information on their diversity, taxonomy, chemistry, and general biology is still largely lacking. In this study, we reexamined 94 Psilocybe fungarium specimens, representing 18 species, by DNA barcoding, evaluated the stability of psilocybin, psilocin, and their related tryptamine alkaloids in 25 specimens across the most commonly vouchered species (Psilocybe cubensis, Psilocybe cyanescens, and Psilocybe semilanceata), and explored the metabolome of cultivated P. cubensis. Our data show that, apart from a few well-known species, the taxonomic accuracy of specimen determinations is largely unreliable, even at the genus level. A substantial quantity of poor-quality and mislabeled sequence data in public repositories, as well as a paucity of sequences derived from types, further exacerbates the problem. Our data also support taxon- and time-dependent decay of psilocybin and psilocin, with some specimens having no detectable quantities of them. We also show that the P. cubensis metabolome possibly contains thousands of uncharacterized compounds, at least some of which may be bioactive. Taken together, our study undermines commonly held assumptions about the accuracy of names and presence of controlled substances in fungarium specimens identified as Psilocybe spp. and reveals that our understanding of the chemical diversity of these mushrooms is largely incomplete. These results have broader implications for regulatory policies pertaining to the storage and sharing of fungarium specimens as well as the use of psychoactive mushrooms for recreation and therapy. IMPORTANCE The therapeutic use of psilocybin, the active ingredient in "magic mushrooms," is revolutionizing mental health care for a number of conditions, including depression, posttraumatic stress disorder (PTSD), and end-of-life care. This has spotlighted the current state of knowledge of psilocybin, including the organisms that endogenously produce it. However, because of international regulation of psilocybin as a controlled substance (often included on the same list as cocaine and heroin), basic research has lagged far behind. Our study highlights how the poor state of knowledge of even the most fundamental scientific information can impact the use of psilocybin-containing mushrooms for recreational or therapeutic applications and undermines critical assumptions that underpin their regulation by legal authorities. Our study shows that currently available chemical studies are mainly inaccurate, irreproducible, and inconsistent, that there exists a high rate of misidentification in museum collections and public databases rendering even names unreliable, and that the concentration of psilocybin and its tryptamine derivatives in three of the most commonly collected Psilocybe species (P. cubensis, P. cyanescens, and P. semilanceata) is highly variable and unstable in museum specimens spanning multiple decades, and our study generates the first-ever insight into the highly complex and largely uncharacterized metabolomic profile for the most commonly cultivated magic mushroom, P. cubensis.

"A sense of the bigger picture:" A qualitative analysis of follow-up interviews with people with bipolar disorder who self-reported psilocybin use

OBJECTIVES

People with bipolar disorder (BD) spend more time depressed than manic/hypomanic, and depression is associated with greater impairments in psychosocial functioning and quality of life than mania/hypomania. Emerging evidence suggests psilocybin, the psychoactive compound in "magic mushrooms," is a promising treatment for unipolar depression. Clinical trials of psilocybin therapy have excluded people with BD as a precaution against possible adverse effects (e.g., mania). Our study centered the experiences of adults living with BD who consumed psilocybin-containing mushrooms, and aimed to (1) understand its subjective impacts on BD symptoms, (2) deepen understanding of Phase I survey results, and (3) elucidate specific contextual factors associated with adverse reactions in naturalistic settings.

METHODS

Following an international survey (Phase I), follow-up interviews were conducted with 15 respondents (Phase II) to further understand psilocybin use among adults with BD. As part of a larger mixed-methods explanatory sequential design study, reflexive thematic analysis was used to elaborate findings.

RESULTS

Three major themes containing sub-themes were developed. (1) Mental Health Improvements: (1.1) decreased impact and severity of depression, (1.2) increased emotion processing, (1.3) development of new perspectives, and (1.4) greater relaxation and sleep. (2) Undesired Mental Health Impacts: (2.1) changes in sleep, (2.2) increased mania severity, (2.3) hospitalization, and (2.4) distressing sensory experiences. (3) Salient Contextual Factors for psilocybin use included: (3.1) poly-substance use and psilocybin dose, (3.2) solo versus social experiences, and (3.3) pre-psilocybin sleep deprivation.

CONCLUSION

Our findings demonstrate both benefits and risks of psilocybin use in this population. Carefully designed clinical trials focused on safety and preliminary efficacy are warranted.

Music programming for psilocybin-assisted therapy: Guided Imagery and Music-informed perspectives

The psychedelic drug psilocybin has been successfully explored as a novel treatment for a range of psychiatric disorders. Administration of psilocybin requires careful attention to psychological support and the setting in which the drug is administered. The use of music to support the acute psychoactive effects of psilocybin is recommended in current guidelines, but descriptions of how to compile music programs for the 4-6 h long sessions are still scarce. This article describes the procedural steps and considerations behind the curation of a new music program, the Copenhagen Music Program, tailored to the intensity profile of a medium/high dose psilocybin. The method of Guided Imagery and Music is presented as a music therapeutic framework for choosing and sequencing music in music programming and the Taxonomi of Therapeutic Music is presented as a rating tool to evaluate the music-psychological intensity of music pieces. Practical examples of how to organize the process of music programming are provided along with a full description of the Copenhagen Music Program and its structure. The aim of the article is to inspire others in their endeavours to create music programs for psychedelic interventions, while proposing that an informed music choice may support the therapeutic dynamics during acute effects of psilocybin.

Self-Entropic Broadening Theory: Toward a New Understanding of Self and Behavior Change Informed by Psychedelics and Psychosis

The extremes of human experiences, such as those occasioned by classic psychedelics and psychosis, provide a rich contrast for understanding how components of these experiences impact well-being. In recent years, research has suggested that classic psychedelics display the potential to promote positive enduring psychologic and behavioral changes in clinical and nonclinical populations. Paradoxically, classic psychedelics have been described as psychotomimetics. This review offers a putative solution to this paradox by providing a theory of how classic psychedelics often facilitate persistent increases in well-being, whereas psychosis leads down a "darker" path. This will be done by providing an overview of the overlap between the states (i.e., entropic processing) and their core differences (i.e., self-focus). In brief, entropic processing can be defined as an enhanced overall attentional scope and decreased predictability in processing stimuli facilitating a hyperassociative style of thinking. However, the outcomes of entropic states vary depending on level of self-focus, or the degree to which the associations and information being processed are evaluated in a self-referential manner. We also describe potential points of overlap with less extreme experiences, such as creative thinking and positive emotion-induction. Self-entropic broadening theory offers a heuristically valuable perspective on classic psychedelics and their lasting effects and relation to other states by creating a novel synthesis of contemporary theories in psychology. SIGNIFICANCE STATEMENT: Self-entropic broadening theory provides a novel theory examining the psychedelic-psychotomimetic paradox, or how classic psychedelics can be therapeutic, yet mimic symptoms of psychosis. It also posits a framework for understanding the transdiagnostic applicability of classic psychedelics. We hope this model invigorates the field to provide more rigorous comparisons between classic psychedelic-induced states and psychosis and further examinations of how classic psychedelics facilitate long-term change. As a more psychedelic future of psychiatry appears imminent, a model that addresses these long-standing questions is crucial.