Neurofeedback for post-traumatic stress disorder: systematic review and meta-analysis of clinical and neurophysiological outcomes.

Background: Posttraumatic stress disorder (PTSD) is a debilitating condition affecting millions of people worldwide. Existing treatments often fail to address the complexity of its symptoms and functional impairments resulting from severe and prolonged trauma. Electroencephalographic Neurofeedback (NFB) has emerged as a promising treatment that aims to reduce the symptoms of PTSD by modulating brain activity.Objective: We conducted a systematic review and meta-analysis of ten clinical trials to answer the question: how effective is NFB in addressing PTSD and other associated symptoms across different trauma populations, and are these improvements related to neurophysiological changes?Method: The review followed the Preferred Reporting Items for Systematic Reviews and Meta analyses guidelines. We considered all published and unpublished randomised controlled trials (RCTs) and non-randomised studies of interventions (NRSIs) involving adults with PTSD as a primary diagnosis without exclusion by type of trauma, co-morbid diagnosis, locality, or sex. Ten controlled studies were included; seven RCTs and three NRSIs with a total number of participants n = 293 (128 male). Only RCTs were included in the meta-analysis (215 participants; 88 male).Results: All included studies showed an advantage of NFB over control conditions in reducing symptoms of PTSD, with indications of improvement in symptoms of anxiety and depression and related neurophysiological changes. Meta-analysis of the pooled data shows a significant reduction in PTSD symptoms post-treatment SMD of -1.76 (95% CI -2.69, -0.83), and the mean remission rate was higher in the NFB group (79.3%) compared to the control group (24.4%). However, the studies reviewed were mostly small, with heterogeneous populations and varied quality.Conclusions: The effect of NFB on the symptoms of PTSD was moderate and mechanistic evidence suggested that NFB leads to therapeutic changes in brain functioning. Future research should focus on more rigorous methodological designs, expanded sample size and longer follow-up.

Neurofeedback (NFB) was found to have moderate beneficial effects on PTSD symptoms, and positive effects on secondary outcomes such as depression and anxiety, according to a meta-analysis of seven randomised controlled trials (RCTs).The beneficial effects of NFB were observed across diverse populations, including those with different types of trauma (military and civilians) and from different ethnic backgrounds.Results suggest that modulation of alpha rhythm might be a viable NFB protocol in patients with PTSD, as changes in neurophysiological functioning, such as connectivity in the Default Mode Network (DMN) and Salience Network (SN), were observed post-NFB and were correlated with a decrease in PTSD severity.

Asian students in the anglosphere - unravelling the unique familial pressures contributing to eating pathology: a systematic review.

BACKGROUND: There is no clear consensus on the specific familial pressures affecting Asian students in the Anglosphere, despite the validation of the Tripartite Influence model of eating disturbances in this group. However, traditional familial risk factors for disordered eating can be elevated for immigrant Asians with collectivistic-oriented familial dynamics, necessitating an examination of the culture-specific risk profile for eating pathology in student-aged Asians. This systematic review aims to consolidate and critically examine the literature on the most widely studied familial pressures related to disordered eating in Asian students in the Anglosphere. METHODS: A systematic search was conducted in five databases for peer-reviewed articles measuring familial pressures and eating pathology in Asian students > 10 years old from an Anglosphere country. Following PRISMA guidelines, papers were screened by title, abstract and full text based on the eligibility criteria. Eligible studies were qualitatively analysed and synthesised narratively to assess the relationship between familial pressures and eating pathology. RESULTS: In total, 14 papers were eligible for inclusion in the review. Eight topics related to familial stressors were identified (1) intergenerational conflict; (2) lack of familial cohesion; (3) parental overprotection; (4) low parental care; (5) familial achievement orientation; (6) parental expectations; (7) parental criticism; and (8) direct parental influence. In multiple studies, intergenerational conflict, maternal overprotection, and familial achievement orientation were significantly elevated and associated with disordered eating in US and UK Asian students, compared to white students. The studies examining parental criticism and familial cohesion had more heterogeneous findings. CONCLUSION: The findings demonstrate the perception of Asian parenting styles as overprotective and incompatible with individualist-oriented Western values could increase eating pathology in adolescent and university students living in Anglosphere countries. The synthesised findings of the literature also indicate disordered eating acts as a compensatory mechanism for the ongoing psychological distress generated from intergenerational conflict and familial achievement orientation. Conversely, traditional eating disorder literature on familial cohesion and low parental care may not be applicable to young Asians. Future research should focus on how social appearance anxiety and psychological factors can mediate the link between disordered eating and familial stressors in Asian students.

Family influences are known to contribute to disturbances in eating behaviours in white people and people of colour, despite cultural differences in family pressures. The Anglosphere, which describes a group of English-speaking countries with shared political and cultural heritage, has seen an increase in student-aged Asians who are vulnerable to the simultaneous pressures of Asian and Anglosphere cultures. Given this demographic is a historically underdiagnosed and undertreated group for eating disorders, this necessitates an examination of the family pressures that contribute to eating disorders which has been relatively understudied thus far. This systematic review found that cultural conflict with parents, overprotective maternal behaviours and achievement-oriented family backgrounds are consistently related to eating disturbances in Asian students in the Anglosphere. These findings also suggest that assimilation into Anglosphere culture plays a significant role in the perception of Asian family influences, and its contribution to eating pathology in this demographic. Asians in secondary and tertiary institutions internalise individual-oriented Anglosphere values through exposure to peers and media, which may conflict with community and family-oriented values of their Asian households. Continued investigation into influential factors may help inform development of culturally-sensitive guidelines for diagnosing and assessing Asian patients for eating disorders.

Chew and spit (CHSP) in a large adolescent sample: prevalence, impact on health-related quality of life, and relation to other disordered eating features.

A recent general population study of Chew and Spit (CHSP) behavior in adults found a 0.4% prevalence, predominantly in females. The current study explores this further by examining the same phenomenon in secondary-school aged adolescents. This study also explores the relationship between CHSP and other demographic and eating disorder (ED) features in 5111 adolescents (11-to-19 years of age) from 13 schools in New South Wales, Australia. Participants completed measures of ED symptoms and behaviors and change to impairment with two components: psychological distress (K-10) and health related quality of life (HRQoL; PedsQL). CHSP was found to have a 12.2% (95% CI 0.114, 0.132]) point-prevalence rate. Participants who indicated engaging in CHSP reported significantly higher levels of psychological distress (K-10) and lower HRQoL scores (PedsQL) compared to those that did not report CHSP. There was a dose-response relationship between CHSP frequency, psychological distress and HRQoL physical scores but not for HRQoL emotional and HRQoL social scores. Participants who reported regular CHSP were more likely to be female, younger, and to engage in compensatory behaviors such as purging. The high frequency of CHSP behavior in adolescents with disordered eating could suggest that CHSP should be considered in routine ED screening practices. Future studies may examine how to treat CHSP or investigate more focused treatment approaches, in order to target the behavior of CHSP more directly.

Chew and Spit (CHSP): An interpretative phenomenological analysis (IPA).

Chew and Spit (CHSP) is a prevalent disordered eating symptom and has been thought to be associated with a number of adverse effects. In the current study, 18 participants (>90% female, aged between 18 and 51) took part in answering questions about their experiences, struggles, concerns, methods of coping, and personal meaning of CHSP and how it has impacted their lives. Data collection and analysis were conducted in accordance with Interpretative Phenomenological Analysis (IPA) methodology. Findings revealed 7 primary themes of CHSP, which highlighted that CHSP may be: (1) associated with negative emotions - primarily shame; (2) exacerbated by stress and may be a mechanism to help regain control; (3) temporarily provides pleasure; (4) a distraction or form of escapism; (5) a self-soothing or coping mechanism; (6) addictive, ritualistic, and similar to other eating disorders in that it can become part of an individual's self-identity; and (7) adversely impacting psychological, physiological, and social health. Some of the identified superordinate themes were in line with previous studies hypotheses. However, overall the findings indicated that individuals who CHSP are often embroiled in what they may perceive as a struggle, with no specific, efficacious, approach to helping them control the behavior. Future studies should focus on the treatment of CHSP, including treatment of CHSP as a potential primary symptom of pathological eating. Moreover, the perceived implications of engaging in CHSP should be examined more closely, with clinicians screening for the behavior and carefully considering their approach when attempting to treat patients for CHSP.

Financial and caregivers' stressors in Australian law students - a qualitative analysis.

Australian law students exhibit high levels of psychological distress compared to the general population. In 2013, The University of Sydney Law School conducted a survey to examine the level of distress in students, what factors were associated with their distress and what strategies might mitigate student distress. This article reports on the survey's qualitative findings relating to financial stressors and care-giving responsibilities. The findings provide further insights into the context of financial stressors for law students and how they may undermine students' candidacy. The study found that financial stress, work commitments, caring for dependents, illnesses and death in the family can be potential reasons for students suspending studies or withdrawing from their studies altogether. In view of the findings, possible solutions to alleviate stress and support students with their work-study and care-giving concerns are discussed.

Prevalence of chew and spit and its relation to other features of disordered eating in a community sample.

BACKGROUND: Until recently, research into Chew and Spit (CHSP) behavior has predominantly focused on clinical samples, and little is known of its prevalence in the community. The current study aimed to bridge this gap by exploring CHSP features in a representative sample of the general population. We hypothesized that the point-prevalence of CHSP would be less than 1%; concurrent with other eating disorder symptomology, and associated with poorer health related quality of life (HRQoL). METHODOLOGY: Using the 2016, respondent-based, South Australian Health Omnibus Survey (HOS), data were collected on 3047 participants aged ≥15 years old. HRQoL was assessed with the Short-Form health-questionnaire-v1 (SF-12). RESULTS: CHSP point prevalence was 0.4% (95% CI .23 to .69%; n = 13), and was more prevalent in people with compensatory disordered eating behaviors. The median age of those with CHSP was 39, and both mental and physical HRQoL were reduced compared with the general population (Mdn: MHQoL = 49; HRQoL = 50), with MHQoL being significantly lower in those with symptoms of a clinically diagnosable ED and concurrently engaged in CHSP (z = -2.33, p = .020). CONCLUSIONS: Due to the low prevalence of CHSP, the reliability of inferential statistics may increase the chance of Type II errors, therefore, future studies should use larger samples. Although CHSP is not "common" in a wider community sample, its prevalence appears to be similar to other ED associated symptoms.

Expanding collaborative care: integrating the role of dietitians and nutrition interventions in services for people with mental illness.

OBJECTIVE: This article aims to draw mental health clinicians' attention to the connections between nutrition and mental health, and the roles that Accredited Practising Dietitians play in improving mental and physical health through dietary change. METHODS: Selective narrative review. RESULTS: Unhealthy dietary practices are common in high prevalence and severe mental illness. Epidemiological evidence demonstrates that nutrients and dietary patterns impact on mental health. In addition, poor physical health is well documented in people with mental illness and the greatest contributor to the mortality gap. Dietary intervention studies demonstrate improved mental and physical health outcomes. Accredited Practising Dietitians translate nutrition science into practical advice to improve the nutritional status of patients with mental illness, and prevent and manage comorbidities in a variety of care settings. CONCLUSIONS: Medical Nutrition Therapy offers opportunities to improve the physical and mental health of people living with mental illness.

Chew and Spit (CHSP): a systematic review.

BACKGROUND: This systematic review is an evaluation of the empirical literature relating to the disordered eating behaviour Chew and Spit (CHSP). Current theories postulate that CHSP is a symptom exhibited by individuals with recurrent binge eating and Bulimia Nervosa. AIMS: The review aimed to identify and critically assess studies that have examined the distribution of CHSP behaviour, its relationship to eating disorders, its physical and psychosocial consequences and treatment. METHODS: A systematic database search with broad inclusion criteria, dated to January 2016 was conducted. Data were extracted by two authors and papers appraised for quality using a modified Downs and Black Quality Index. RESULTS: Nine studies met the inclusion criteria. All were of clinical samples and majority (n = 7) were of low quality. The pathological action of chewing food but not swallowing was reported more often in those with restrictive type eating disorders, such as Anorexia Nervosa, than binge eating type disorders. CHSP also was reported to be an indicator of overall severity of an eating disorder and to appear more often in younger individuals. No studies of treatment were found. CONCLUSIONS: Conclusions were limited due to the low quality and small numbers of studies based on clinical samples only. Further research is needed to address gaps in knowledge regarding the physiological, psychological, social, socioeconomic impact and treatment for those engaging in CHSP.

Experiences of Psychological Distress and Sources of Stress and Support During Medical Training: a Survey of Medical Students.

OBJECTIVE: The authors examine the prevalence of psychological distress, the stressors experienced, and the supports used by medical students and residents during their medical training at a Canadian university. METHOD: This study used an online survey that included a standardized instrument to evaluate psychological distress (Kessler-10) and Likert-based survey items that examined stress levels related to family relationships, living accommodations, commuting, finances, and program requirements. Depressive symptoms, substance use, and suicidal ideation were also measured, as were supports accessed (e.g., counseling) and students' perceptions of the overall supportiveness of the university. Non-parametric descriptive statistics were used to examine the prevalence of psychological distress, sources of stress, and supports accessed. RESULTS: Surveys were received from 381 students (37% response). Most students (60%) reported normal levels of psychological distress on the K10 (M = 19.5, SD = 6.25), and a subgroup reported high to very high levels of psychological distress. A small number also reported substance use, symptoms of depression, and/or suicidal ideation. CONCLUSION: These results indicate that students experience psychological distress from a number of stressors and suggest that medical schools should act as key partners in supporting student well-being by promoting self-care, educating students on the risks of burnout, and developing programs to support at-risk students.

Childhood cancer in the cinema: how the celluloid mirror reflects psychosocial care.

OBJECTIVE: This study aims to evaluate the childhood cancer experience in commercially produced, readily available films that include a character with childhood cancer, with a particular focus on psychosocial care. METHODS: We reviewed 29 films, using quantitative and qualitative content analysis, to identify the medical and psychosocial characteristics of the cinematic childhood cancer experience. We rated psychosocial support on a 5-point scale (0 to 4) based on the availability and efficacy of support characters in the categories of nonprofessional internal (eg, parent), nonprofessional external (eg, friend), professional medical (eg, oncologist), and professional psychosocial (eg, social worker) supports. RESULTS: Film depicts an unrealistic, bleak picture of childhood cancer, with a 66% mortality rate among the 35 characters evaluated. Psychosocial supports portrayed in film are generally limited to resources already available to families before the cancer diagnosis: mean ratings across films were 2.4 for both nonprofessional, 1.6 for professional medical, and 0.3 for professional psychosocial supports (Kruskal-Wallis χ3=43.1051, P<0.0001). Seven main themes emerged: disruption, social impact, psychological impact, physical toll, struggle/war/fight, coping, and barren landscape. Film generally depicts images of an isolated family courageously battling cancer alone with limited support from a treatment team solely dedicated to medical care. CONCLUSIONS: Commercially available films minimize the importance of the psychosocial dimension of care, which can perpetuate stigma around psychosocial needs and interventions. These films can be used to encourage discussion about how to optimize psychosocial care in pediatric oncology so that such care is not abandoned in actual practice as it is, for entertainment purposes, on the screen.

A validated questionnaire to assess the knowledge of psychiatric aspects of alcohol use disorder.

BACKGROUND: To the best of our knowledge, there is no validated instrument for measuring knowledge of psychiatric aspects of alcohol use disorder (AUD) amongst medical students. Our aim was to develop an instrument for this purpose and to describe the instrument's psychometric properties. We also investigated whether the instrument could demonstrate a significant change in scores following an educational intervention consisting of a 60-minute PowerPoint lecture on AUD, associated handouts, and role-plays. METHODS: The Knowledge of Psychiatric Aspects of Alcohol Questionnaire (KPAAQ) was developed from the Kaplan and Saddock textbook synopsis chapter on alcohol related disorders. The questionnaire included 6 categories of clinically relevant material: metabolism of alcohol, short-term effects of alcohol, long-term effects of alcohol, AUD, alcohol withdrawal, and alcohol use in pregnancy. The KPAAQ was administered to 75 medical students in Years 4 and 5 from the Hebrew University in Jerusalem, Israel, during a relevant clinical rotation. Following the initial administration of the KPAAQ, the students attended a 60-minute lecture (in Hebrew) based on material from the University of Sydney's learning module on alcohol. The KPAAQ was readministered to the students immediately following the lecture. RESULTS: The KPAAQ demonstrated good reliability (Cronbach α =.92 for all questions) and validity r(209) =.674, P <.001. Knowledge of alcohol and alcoholism significantly increased after the educational intervention (F(2, 154) = 151.60, P <.001). Post hoc comparisons using the Scheffe test revealed a significant positive change in knowledge after students received the intervention (mean difference = 33, P <.001). CONCLUSIONS: These initial findings suggest that the KPAAQ is a reliable and valid instrument for assessing medical student knowledge of psychiatric aspects of AUD over 6 clinical categories.

Four centuries of suicide in opera.

OBJECTIVE: To describe the depiction of completed suicide, non-fatal suicidal acts and suicidal thought in Western opera over the past four centuries. DESIGN AND SETTING: Examination of synopses all of the operas listed in a recent monograph covering a selection of operas written in the period 1607-2006. MAIN OUTCOME MEASURES: Frequency of completed suicides, non-fatal suicidal acts and suicidal thoughts over the entire 400-year period and in separate 100-year periods (1607-1706, 1707-1806, 1807-1906 and 1907-2006); circumstances of suicides; sex of the suicidal characters; and, for completed suicide, the method. RESULTS: There were 337 operas in total. In 112 (33%), there was completed suicide alone, non-fatal suicidal acts or suicidal thoughts alone, or both. There was at least one suicide in 74 operas (22%); female characters accounted for 56% of these. Non-fatal suicidal acts or suicidal thoughts were found in 48 operas (14%); male characters accounted for 57% of these. Suicide, non-fatal acts and suicidal thoughts always followed an undesirable event or situation. Cutting or stabbing was the most common method of suicide (26 cases). Other methods included poisoning (15 cases), drowning (10 cases), hanging (four cases), asphyxiation (four cases), "supernatural" methods (four cases), immolation (three cases), jumping from a height (two cases), shooting (one) and blunt trauma (one). Mass suicide occurred on two occasions. CONCLUSIONS: Over several centuries in opera, suicide has been frequently represented as an option when characters have been faced with a distressing event or situation. Historical fluctuations in the frequency of suicidal behaviour in opera may be explained by changes in attitudes towards suicide and its conceptualisation.

Medical students' subjective ratings of stress levels and awareness of student support services about mental health.

PURPOSE: To descriptively assess medical students' concerns for their mental and emotional state, perceived need to conceal mental problems, perceived level of support at university, knowledge and use of student support services, and experience of stresses of daily life. STUDY DESIGN: From March to September 2011, medical students at an Australian university were invited to complete an anonymous online survey. RESULTS: 475 responses were received. Students rated study and examinations (48.9%), financial concerns (38.1%), isolation (19.4%) and relationship concerns (19.2%) as very or extremely stressful issues. Knowledge of available support services was high, with 90.8% indicating they were aware of the university's medical centre. Treatment rates were modest (31.7%). Students' concerns about their mental state were generally low, but one in five strongly felt they needed to conceal their emotional problems. CONCLUSIONS: Despite widespread awareness of appropriate support services, a large proportion of students felt they needed to conceal mental and emotional problems. Overall treatment rates for students who were greatly concerned about their mental and emotional state appeared modest, and, although comparable with those of similarly aged community populations, may reflect undertreatment. It would be appropriate for universities to address stressors identified by students. Strategies for encouraging distressed students to obtain appropriate assessment and treatment should also be explored. Those students who do seek healthcare are most likely to see a primary care physician, suggesting an important screening role for these health professionals.

Publications on cross-cultural aspects of eating disorders.

BACKGROUND: The prevalence of eating disorders in the non-Western world appears to be increasing and much research into the cross-cultural aspects of eating disorders is needed. This bibliometric study analyses the profile of cross-cultural studies into eating disorders published from 1970 through to 2011. RESULTS: 1,417 articles were indexed by Medline and PsychInfo from 1970 to 2011. There has been an exponential increase in publications in this field. Four articles were published in 1970-74 and this increased to 427 in 2004-9. Comparative and empirical studies were the most common types of publications. Of all the ethnic groups studied, Africans and African Americans were subject of the most publications. Pacific Islanders and South Europeans had the fewest publications. CONCLUSION: It is heartening that there has been a large increase in published studies about eating disorders across cultures. This suggests greater awareness and interest in the field. However, the results from one particular ethnic group cannot always be applied directly to another. Some ethnic and cultural groups have been poorly studied and warrant more research attention. As more patients from such backgrounds present for treatment, more research is needed to provide culturally appropriate and acceptable care.

Depression, financial problems and other reasons for suspending medical studies, and requested support services: findings from a qualitative study.

OBJECTIVES: This study aimed to qualitatively explore medical students' reasons for suspending, or thinking of suspending, their studies and the types of support services they request. METHOD: Data were collected through an anonymous online survey. Medical students' responses to open-ended questions were analyzed thematically. RESULTS: Responses were received from 475 students. Financial problems, doubts as to whether medicine was the right vocation, and depression were the most commonly reported themes. Students endorsed a wide range of other pressures and concerns, barriers to obtaining assistance, and also suggested solutions and services to address their concerns. CONCLUSIONS: Medical students' financial concerns and potential depressive symptoms should be addressed by university and faculty support services. Government financial support mechanisms for students should also be reviewed. Students' suggestions of the types of services and their location must be borne in mind when allocating resources.

Food for thought: comparison of citations received from articles appearing in specialized eating disorder journals versus general psychiatry journals.

OBJECTIVE: To conduct a bibliometric analysis of eating disorder journals to guide journal readers and researchers when submitting their manuscripts. METHOD: Several indices were used to compare journal impact and citations of articles appearing between 1996 and 2010 in six eating disorders journals and six leading general psychiatry journals. RESULTS: The International Journal of Eating Disorders (IJED) had the highest journal impact factor (JIF, 2.278) of the six eating disorders' journals. The general psychiatry journals had higher JIFs and received more citations per eating disorder article than the specialized journals. However, IJED published the highest number of eating disorder articles between 1996 and 2010, and 35 of these articles received at least 100 citations. DISCUSSION: Using the JIF alone to decide where to submit a manuscript is a poor strategy, as this does not take into consideration the impact an article can have within the eating disorder's field over time.

Staff experience, knowledge and attitudes regarding the management of adolescent patients in adult mental health units.

OBJECTIVE: Inpatient psychiatric care of adolescents should, where possible, be provided in specialized units. However, admission of adolescent patients to adult mental health units does occur. There is a paucity of data about this practice. This study collates information about the experience, attitudes and knowledge of clinical staff regarding the care of adolescent patients in adult psychiatry units within Northern Sydney Central Coast Area Health Service (NSCCHS). METHOD: A survey was emailed to all clinical staff with employer accessible email addresses in NSCCHS. RESULTS: The response rate was 29% (n = 108). The majority of respondents believed their wards were "not at all" (30.7%) or "only a little" (57.4%) equipped to care for adolescent patients. The majority felt "moderately" (39.6%) or "very" (16.8%) confident to care for these patients; however, a significant proportion (43.2%) lacked confidence. There was no significant difference across the responses of psychiatrists, psychiatry registrars and nursing staff to these questions. The majority felt the objectives of these admissions were met "only a little" (47.4%) or "not at all" (16.5%). Many concerns regarding the admission of adolescents to adult wards were reported. CONCLUSIONS: Generally, staff were not in favour of admitting adolescent patients to adult mental health units apart from in exceptional circumstances. Staff harboured concerns about several aspects of care for adolescents in adult wards.