traumatic stress

创伤性应激
  • 文章类型: Journal Article
    青少年暴露于暴力增加了持续到成年的不良心理和身体健康结果的风险。创伤压力是特别关注的结果,因为生理应激反应会影响发育中的大脑。最近,青少年接触警察暴力已被概念化为可能影响创伤压力的不良童年经历。为了检查这种可能性,我们进行了系统的审查,利用五个数据库,收集现有的定量和定性同行评审的关于青年接触警察暴力和创伤压力的研究。利用各种研究设计,搜索产生了27篇相关文章:13篇定量,十三定性,一种混合方法。27项研究中有26项发现了警察暴力暴露与青年创伤压力之间关系的证据。警察暴力与青年创伤压力相关,涉及三种类型的暴露:直接,替代,和预期。研究还探讨了种族和性别的不同影响。这篇评论揭示了目前文献中的差距,例如缺乏有关选定社会人口群体的数据(例如,农村青年,LGBTQ+青年)和潜在的保护因素(例如,韧性和学校连通性)。根据调查结果,我们提出了研究议程以及政策和实践建议,以改善警察与青年的互动,并为遭受警察暴力侵害的青年提供精神卫生服务。建议包括改进系统的数据收集,以跟踪所有类型的警察暴力暴露,为警察与青年的积极互动创造空间,并培训心理健康从业人员,以支持遭受警察暴力的年轻人。
    Youth exposure to violence increases the risk of poor mental and physical health outcomes lasting into adulthood. Traumatic stress is an outcome of particular concern as the physiological stress response impacts the developing brain. Recently, youth exposure to police violence has been conceptualized as an adverse childhood experience that may impact traumatic stress. To examine this possibility, we conducted a systematic review, drawing upon five databases to gather the existing quantitative and qualitative peer-reviewed research on exposure to police violence and traumatic stress in youth. Searches yielded 27 relevant articles utilizing various study designs: thirteen quantitative, thirteen qualitative, and one mixed method. Twenty-six of the 27 studies found evidence of a relationship between police violence exposure and traumatic stress in youth. Police violence was associated with youth traumatic stress across three types of exposures: direct, vicarious, and anticipated. Studies also explored differential impacts by race and gender. The review revealed current gaps in the literature, such as a lack of data on select sociodemographic groups (e.g., rural youth, LGBTQ+ youth) and potential protective factors (e.g., resilience and school connectedness). In line with the findings, we put forth a research agenda as well as policy and practice recommendations to improve police interactions with youth and mental health services for youth who have been exposed to police violence. Recommendations include improving systematic data collection to track all types of police violence exposure, creating spaces for positive police interactions with youth, and training mental health practitioners to support youth exposed to police violence.
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  • 文章类型: Journal Article
    背景:在全球范围内,被迫流离失所的人越来越多,其中超过40%是儿童。无人陪伴的寻求庇护儿童(UASC)有遭受心理困扰和发展心理健康困难的风险。然而,在英国,法定精神卫生服务的方法在不同地理区域不一致。
    目的:本报告概述了与UASC合作相关的英国法定精神卫生服务建议。
    方法:采用快速评估方法,包括采访15名关键信息提供者以及回顾现有的临床指南。主要线人包括临床医生,服务经理,社会工作者和地方当局的专员,国家卫生服务,第三部门的合作伙伴。建议使用叙述性综合进行综合。
    结论:总结了现有的服务提供和实施干预措施的障碍,并与现有指南进行了比较。该报告提出了关于评估的建议,筛选工具,和心理干预措施,为法定服务范围内的UASC开发途径。
    全球,寻求庇护者和难民呈上升趋势,其中40%是儿童。无人陪伴的寻求庇护儿童(UASC)有遭受心理困扰和发展心理健康困难的风险。然而,英国不同地区为该人群提供的服务不一致,可能不足以满足他们的社会心理需求。我们希望通过回顾现有文献,为英格兰的服务提供有关如何更好地支持UASC的建议,临床指南,并采访该国的不同服务提供商,以确定服务方面的差距。我们采访了主要的线人,包括临床医生,服务经理,社会工作者和地方当局的专员,国家卫生服务,第三部门的合作伙伴。我们介绍了如何改进当前评估的结果,UASC的筛查和心理干预。
    BACKGROUND: Globally, there is an increasing trend of forcibly displaced people, of which over 40% are children. Unaccompanied asylum-seeking children (UASC) are at risk of experiencing psychological distress and developing mental health difficulties. However, in the UK, the approach from statutory mental health services is inconsistent across different geographical areas.
    OBJECTIVE: This report outlines recommendations for statutory mental health services in the UK in relation to working with UASC.
    METHODS: A rapid evaluation method was adopted including interviewing fifteen key informants as well as reviewing existing clinical guidelines. Key informants included clinicians, service managers, social workers and commissioners from Local Authorities, National Health Services, and third sector partners. Recommendations were synthesised using narrative synthesis.
    CONCLUSIONS: Existing service provision and barriers to the implementation of interventions were summarised and compared against existing guidelines. The report presents recommendations on assessments, screening tools, and psychological interventions for developing a pathway for UASC within statutory services.
    Globally, there is an increasing trend of asylum seekers and refugees, and 40% of which are children. Unaccompanied asylum-seeking children (UASC) are at risk of experiencing psychological distress and developing mental health difficulties. Yet, service provision for this population is inconsistent across different regions in the UK and may not be sufficient to meet their psychosocial needs. We hope to provide recommendations for services in England on how to better support UASC through reviewing the existing literature, clinical guidelines, and interviewing different service providers in the country in order to identify gaps in services. We interviewed key informants, including clinicians, service managers, social workers and commissioners from Local Authorities, National Health Services, and third sector partners. We present findings on how to improve the current assessment, screening and psychological interventions for UASC.
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  • 文章类型: Journal Article
    不良的童年经历(ACE)可能有害,长期健康影响。尽管初级保健提供者(PCP)可以帮助减轻这些影响,没有研究回顾ACE培训的影响,筛选,和初级保健的反应。
    本系统综述搜索了四个电子数据库(PubMed,WebofScience,APAPsycInfo,CINAHL)关于ACE培训的同行评审文章,筛选,和/或初级保健的反应在1998年1月1日至2023年5月31日之间发表。搜索仅限于初级保健环境中报告提供者相关结果的主要研究文章(知识,信心,筛选行为,临床护理)和/或患者相关结果(满意度,转介约定,健康结果)。摘要数据是从已发表的报告中提取的。
    在6532条记录中,58符合纳入标准。52例报告与提供者相关的结果;21例报告与患者相关的结果。50包括儿科人群,包括12名成年人。大多数人讨论了筛查干预措施(n=40)。讨论培训和临床反应干预措施的人数相等(n=25)。证据强度(SOE)普遍较低,尤其是成人研究。这是由于对观察证据的依赖,小样本,和异质结果的自我报告措施。中度SOE的例外包括培训干预对提供者信心/自我效能的影响以及筛查干预对筛查摄取和患者满意度的影响。
    初级保健代表了解决ACE的潜在战略设置,但是关于患者和提供者相关结局的证据仍然很少.
    加州卫生保健服务部和加州外科医生办公室。
    UNASSIGNED: Adverse childhood experiences (ACEs) can have harmful, long-term health effects. Although primary care providers (PCPs) could help mitigate these effects, no studies have reviewed the impacts of ACE training, screening, and response in primary care.
    UNASSIGNED: This systematic review searched four electronic databases (PubMed, Web of Science, APA PsycInfo, CINAHL) for peer-reviewed articles on ACE training, screening, and/or response in primary care published between Jan 1, 1998, and May 31, 2023. Searches were limited to primary research articles in the primary care setting that reported provider-related outcomes (knowledge, confidence, screening behavior, clinical care) and/or patient-related outcomes (satisfaction, referral engagement, health outcomes). Summary data were extracted from published reports.
    UNASSIGNED: Of 6532 records, 58 met inclusion criteria. Fifty-two reported provider-related outcomes; 21 reported patient-related outcomes. 50 included pediatric populations, 12 included adults. A majority discussed screening interventions (n = 40). Equal numbers (n = 25) discussed training and clinical response interventions. Strength of evidence (SOE) was generally low, especially for adult studies. This was due to reliance on observational evidence, small samples, and self-report measures for heterogeneous outcomes. Exceptions with moderate SOE included the effect of training interventions on provider confidence/self-efficacy and the effect of screening interventions on screening uptake and patient satisfaction.
    UNASSIGNED: Primary care represents a potentially strategic setting for addressing ACEs, but evidence on patient- and provider-related outcomes remains scarce.
    UNASSIGNED: The California Department of Health Care Services and the Office of the California Surgeon General.
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  • 文章类型: Journal Article
    背景:尽管虐待儿童(CM)与健康问题和不良的社会心理功能有关,并非所有暴露于CM的个体在以后的生活中都会发展或经历负面后果。这表明一些个体在暴露于CM后表现出韧性。然而,结论受到不同CM亚型和弹性域的不一致发现的限制。目的:制定一个方案,用于进行系统评价和荟萃分析,以量化成年期CM(整体及其亚型)和弹性(全球及其多个领域)之间的关联,并检查这些协会的主持人和调解人。方法:PubMed,PsycINFO,Embase,Scopus,和WebofScience将进行搜索,以确定有关成人(≥18岁)的CM(暴露)和弹性(结果)之间关联的相关研究。数据将由至少两名独立审稿人筛选和提取。纳入研究的方法学质量将通过改良版本的纽卡斯尔-渥太华量表(NOS)进行独立评估。如果认为可行,将使用随机效应模型进行荟萃分析.证据的异质性将用I2统计量来估计,和出版偏见将被评估。潜在调节剂的影响(例如CM的时机和严重程度,年龄,性别,家庭凝聚力,社会经济地位,国家/地区)将使用荟萃回归和亚组分析进行分析,元分析结构方程模型将用于综合间接中介效应。候选主持人和调解员(例如遗传因素,大脑功能,附件样式,人格特质,身体活动,和社会支持)也将进行定性检查。结论:该方案将促进系统评价和荟萃分析,有可能增强我们对早年CM暴露与成年期弹性之间关联的认识。了解CM和韧性之间的关联和潜在机制对于告知具有CM病史的成年人的预防和干预措施以维持健康和改善结果可能很重要。PROSPERO注册:CRD42023394120。
    在本研究方案中,我们建议定量总结现有文献中关于虐待儿童与心理弹性之间的关系,涉及心理健康后果和以后生活中的心理社会功能。这项预先注册的系统审查和荟萃分析将建立程序,以调查儿童虐待的总体分类与其不同的相关亚型之间的关联。以及成人复原力及其不同领域的全球/特征分类。该协议将进一步确定分析方法,以探索和总结成年期儿童虐待与复原力之间关联的效果调节者和调解者。由此产生的合成,这将基于这个协议,可以增强我们对虐待儿童和复原力之间关联强度的理解,并为预防策略和临床干预措施提供信息,以改善成年幸存者的健康和社会心理功能。
    Background: Although child maltreatment (CM) has been linked to health problems and poor psychosocial functioning, not all individuals exposed to CM develop or experience negative consequences later in life. This suggests that some individuals show resilience after being exposed to CM. However, conclusions have been limited by inconsistent findings across different CM subtypes and resilience domains.Objective: To develop a protocol for conducting a systematic review and meta-analysis to quantify associations between CM (overall and its subtypes) and resilience (global and its multiple domains) in adulthood, and to examine moderators and mediators of these associations.Method: PubMed, PsycINFO, Embase, Scopus, and Web of Science will be searched to identify relevant studies on the association between CM (exposure) and resilience (outcome) in adults (≥ 18 years). Data will be screened and extracted by at least two independent reviewers. The methodological quality of the included studies will be independently assessed with a modified version of the Newcastle-Ottawa Scale (NOS). If deemed viable, a meta-analysis will be conducted using a random effects model. Heterogeneity of evidence will be estimated with the I2 statistic, and publication bias will be assessed. The effects of potential moderators (e.g. timing and severity of CM, age, sex, family cohesion, socio-economic status, country/region) will be analysed using meta-regression and subgroup analyses, and meta-analytical structural equation modelling will be employed to synthesise indirect mediation effects. Candidate moderators and mediators (e.g. genetic factors, brain functioning, attachment style, personality traits, physical activity, and social support) will be also examined qualitatively.Conclusions: This protocol will facilitate a systematic review and meta-analysis that has the potential to enhance our knowledge about the association between CM exposure in early life and resilience in adulthood. Understanding associations and underlying mechanisms between CM and resilience is potentially important in informing prevention and interventions to sustain health and improve outcomes among adults with a history of CM.PROSPERO registration: CRD42023394120.
    In this study protocol, we propose to quantitatively summarise the existing literature on the relationship between child maltreatment and resilience with regard to mental health consequences and psychosocial functioning later in life.This preregistered systematic review and meta-analysis will establish the procedures to investigate associations between an overall classification of child maltreatment and its different associated subtypes, and a global/trait classification of resilience and its different domains in adults.This protocol will further determine the analytical approach to explore and summarise effect moderators and mediators of the association between child maltreatment and resilience in adulthood.The resulting synthesis, that will be based on this protocol, could enhance our understanding of the strength of the association between child maltreatment and resilience and inform prevention strategies and clinical interventions to improve health and psychosocial functioning in adult survivors.
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  • 文章类型: Journal Article
    创伤后应激障碍(PTSD)可成为慢性和严重致残的疾病,导致生活质量下降和经济负担增加。这种疾病与暴露于创伤性事件直接相关,例如,真正的或威胁的伤害,死亡,或者性侵犯.广泛的研究已经完成了潜在的神经生物学改变疾病及其相关的表型,揭示大脑回路中断,神经递质失调,下丘脑-垂体-肾上腺(HPA)轴功能障碍。鉴于其良好的疗效,心理治疗仍然是创伤后应激障碍的一线治疗选择,虽然药物治疗也可以单独使用或与心理治疗结合使用。为了减少疾病的患病率和负担,已经开发了多层次的预防模型,以尽早发现疾病,并降低已确定疾病的发病率。尽管有临床诊断依据,人们越来越关注发现可以预测易感性的可靠生物标志物,辅助诊断,或监控治疗。一些潜在的生物标志物与PTSD相关的病理生理变化有关。鼓励进一步研究以确定可行的目标。这篇综述强调了目前关于病理生理学的文献,疾病发展模型,治疗方式,以及从公共卫生角度出发的预防模式,并讨论了生物标志物研究的现状。
    Post-traumatic stress disorder (PTSD) can become a chronic and severely disabling condition resulting in a reduced quality of life and increased economic burden. The disorder is directly related to exposure to a traumatic event, e.g., a real or threatened injury, death, or sexual assault. Extensive research has been done on the neurobiological alterations underlying the disorder and its related phenotypes, revealing brain circuit disruption, neurotransmitter dysregulation, and hypothalamic-pituitary-adrenal (HPA) axis dysfunction. Psychotherapy remains the first-line treatment option for PTSD given its good efficacy, although pharmacotherapy can also be used as a stand-alone or in combination with psychotherapy. In order to reduce the prevalence and burden of the disorder, multilevel models of prevention have been developed to detect the disorder as early as possible and to reduce morbidity in those with established diseases. Despite the clinical grounds of diagnosis, attention is increasing to the discovery of reliable biomarkers that can predict susceptibility, aid diagnosis, or monitor treatment. Several potential biomarkers have been linked with pathophysiological changes related to PTSD, encouraging further research to identify actionable targets. This review highlights the current literature regarding the pathophysiology, disease development models, treatment modalities, and preventive models from a public health perspective, and discusses the current state of biomarker research.
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  • 文章类型: Journal Article
    家庭关系对于来自集体主义文化的受创伤影响的难民至关重要。持续推广基于证据的家庭干预措施,以支持遭受创伤应激源的家庭的一系列精神和关系健康需求;然而,关于文化适应以及在被迫流离失所后对一些最被剥夺权利的人口进行这些干预措施的有效性测试的研究仍然有限。进行这项系统审查是为了审查对全球新安置的难民实施的现有基于证据的家庭干预措施的范围。本综述中包含的研究包括通过干预前后评估来测试系统治疗有效性的研究。有或没有对照组的研究,以及除目标参与者外还包括至少一名家庭成员的研究。12项研究符合纳入标准。讨论了对流离失所的难民人口进行随机对照试验的障碍。对未来的研究提出了建议,包括关注科学严谨的多方法设计,特定的文化适应框架,以及关系方面的整合,而不是只关注个人调整。全球流离失所人数继续上升;因此,流离失所人口的心理健康和福祉必须得到全面的治疗,多层次框架。
    Family connections are crucial for trauma-affected refugees from collectivistic cultures. Evidence-based family interventions are consistently promoted to support a host of mental and relational health needs of families exposed to traumatic stressors; however, there is still limited research focused on cultural adaptation and the testing of the effectiveness of these interventions on some of the most disenfranchised populations in the aftermath of forced displacement. This systematic review was conducted to examine the reach of existing evidence-based family interventions implemented with newly resettled refugees globally. Studies included in this review include those testing the effectiveness of a systemic treatment with pre and post intervention evaluation, studies with or without control groups, and studies that include at least one family member in addition to the target participants. Twelve studies met the inclusion criteria. Barriers to conducting randomized control trials with displaced refugee populations are discussed. Recommendations are made for future studies to include a focus on scientifically rigorous multi-method designs, specific cultural adaptation frameworks, and the integration of relational aspects rather than focusing only on individual adjustment. Global displacement continues to rise; therefore, it is imperative that the mental health and wellbeing of displaced populations be treated with a comprehensive, multi-level framework.
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  • 文章类型: Journal Article
    这项系统的审查旨在确定人口,儿童入住重症监护病房(ICU)后,与父母创伤后成长(PTG)相关的临床和心理因素。在搜索电子数据库(PubMed,Medline,WebofScience,PsycINFO,CINAHL,PTSDpubs和EMBASE)。如果研究涉及父母的样本,他们的孩子先前被送入ICU并报告了相关数据,则将其纳入研究。审查了1777篇论文。14项研究符合纳入条件;4项被认为具有良好的方法学质量,两个人很穷,其余8项研究是公平的。确定了与PTG相关的因素。母亲们,和大孩子的父母,经历了更大的PTG。认为孩子的病情更严重的父母有更大的PTG。发现PTG和创伤后应激之间有很强的关联,心理健康和应对。PTG通常是该人群所经历的。与人口统计学和临床因素相比,心理因素与PTG更常见。这表明父母的主观ICU体验可能比客观现实与PTG更大。
    This systematic review aims to identify the demographic, clinical and psychological factors associated with post-traumatic growth (PTG) in parents following their child\'s admission to the intensive care unit (ICU). Papers published up to September 2021 were identified following a search of electronic databases (PubMed, Medline, Web of Science, PsycINFO, CINAHL, PTSDpubs and EMBASE). Studies were included if they involved a sample of parents whose children were previously admitted to ICU and reported correlational data. 1777 papers were reviewed. Fourteen studies were eligible for inclusion; four were deemed to be of good methodological quality, two were poor, and the remaining eight studies were fair. Factors associated with PTG were identified. Mothers, and parents of older children, experienced greater PTG. Parents who perceived their child\'s illness as more severe had greater PTG. Strong associations were uncovered between PTG and post-traumatic stress, psychological well-being and coping. PTG is commonly experienced by this population. Psychological factors are more commonly associated with PTG in comparison with demographic and clinical factors, suggesting that parents\' subjective ICU experience may be greater associated with PTG than the objective reality.
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  • 文章类型: Journal Article
    目的:本范围审查的目的是绘制临床相关的危重事件及其对护理本科生的影响。
    背景:临床学习环境固有的不可预测性使护生面临可能导致长期后果的重大事件的风险。
    方法:使用JoannaBriggs研究所框架进行了范围审查。
    方法:使用CINAHL搜索主要研究来源和论文,PubMed,全球论文和论文,和MEDLINE数据库。资格标准包括与在临床环境中经历过严重事件的护理本科生相关的主要研究。
    结果:从总共66篇确定的文章中,只有一个符合纳入标准。总的来说,据确定,术语“压力”的定义不一致。研究人员主要关注来自学术和体验式学习的一般压力,而不是以临床经验为基础的突然和意外的重大事件。
    结论:范围审查结果发现,与临床相关的危重事件和护理本科生经历的相关影响相关的研究存在显著差距。
    结论:需要进一步的研究,以便在毕业前优先考虑危机干预措施,并制定增强复原力的策略。
    OBJECTIVE: The purpose of this scoping review was to map clinical-related critical incidents and their implications on undergraduate nursing students.
    BACKGROUND: The unpredictability inherent in the clinical learning environment places nursing students at risk of a critical incident that may lead to long-term consequences.
    METHODS: A scoping review was conducted using the Joanna Briggs Institute framework.
    METHODS: A search for primary research sources and dissertations was conducted using the CINAHL, PubMed, Dissertation and Thesis Global, and MEDLINE databases. Eligibility criteria included primary research related to undergraduate nursing students who had experienced critical incidents in the clinical setting.
    RESULTS: From a total of 66 identified articles, only one met the inclusion criteria. Overall, it was identified that the term \"stress\" was inconsistently defined. Researchers have primarily focused on general stress from academic and experiential learning rather than sudden and unexpected critical incidents underpinned by clinical experiences.
    CONCLUSIONS: The scoping review results identify a significant gap in the research relative to clinical-related critical incidents and the associated implications experienced by undergraduate nursing students.
    CONCLUSIONS: Further research is needed so that crisis interventions can be prioritized and strategies to enhance resilience can be addressed before graduation.
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  • 文章类型: Journal Article
    Healthcare staff across varied clinical settings are faced with varied stressors that can lead to compassion fatigue. However, there is currently no review examining the phenomenon in-depth in the burn unit. Thus, the current study sought to scope existing studies to ascertain the prevalence, contributing factors, and effects of compassion fatigue in the burn unit. Compassion fatigue was conceptualised as comprising of burnout and secondary traumatic stress. Arksey and O\'Malley scoping review approach was used and reported according to the PRISMA extension guidelines. Searches were undertaken across peer-reviewed databases and grey literature sources for quantitative studies. Following the search and screening process, nine studies were retained. Codes were formulated across studies following which narrative synthesis was undertaken. Majority of the studies (n=5) focused on burn care nurses. High levels of emotional exhaustion and depersonalization and comparatively low level of personal achievement were reported among burn care staff which is indicative of burnout. Compassion fatigue was also observed to be high among burn care staff. Contributing factors are varied albeit some variables such as age, staffing levels, remuneration, nature of the work environment, and number of years worked were consistent across some studies. In conclusion, working in the burn unit is challenging with significant stressors that can lead to burnout, traumatic stress, and subsequently, compassion fatigue. Interventions to promote resilience, hardiness, optimal working environment, peer, and psychosocial support are greatly needed.
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  • 文章类型: Journal Article
    基线呼吸性窦性心律失常(RSA)已被提出作为跨精神病理学的应激脆弱性的诊断生物标志物,和PTSD之间的可靠关联,发现强迫症和较低的静息RSA。沉思实践与迷走神经的激活以及RSA的增加有关,根据多迷走神经理论,反映了腹侧迷走神经复合体(VVC)的激活,并可能促进PTSD和OCD的恢复。选择PubMed和Scopus数据库根据2020年系统评价和荟萃分析(PRISMA)指南的首选报告项目进行搜索。并使用评估系统评论2(AMSTAR-2)的方法来评估此系统评论的方法学质量。六篇文章符合纳入标准(一项横断面研究,一项研究采用事后测量,两项队列研究和两项RCT研究)。正念相关干预促进副交感神经活动,迷走神经张力增加,创伤后应激障碍和强迫症症状改善。根据多迷走神经理论,与正念相关和与同情心相关的冥想将被概念化为神经锻炼,以扩大腹侧迷走神经复合体调节当前状态和促进恢复能力的能力。讨论了临床和方法学问题。
    Baseline respiratory sinus arrhythmia (RSA) has been proposed as a transdiagnostic biomarker of stress vulnerability across psychopathologies, and a reliable association between PTSD, OCD and lower resting RSA was found. Contemplative practices have been linked to the activation of the vagus as well as to an increased RSA that, according to the polyvagal theory, reflects the activation of the ventral vagal complex (VVC) and may promote PTSD and OCD recovery. PubMed and Scopus databases were selected to conduct a search following the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) 2020 guidelines, and A MeaSurement Tool to Assess systematic Reviews-2 (AMSTAR-2) was used to appraise the methodological quality for this systematic review. Six articles met the inclusion criteria (one cross-sectional study, one study with pre-post measurements, two cohort studies and two RCT studies). Mindfulness-related interventions promoted parasympathetic activity, an increased vagal tone and improvements in PTSD and OCD symptoms. According to the polyvagal theory, mindfulness-related and compassion-related meditations would be conceptualized as neural exercises expanding the capacity of the ventral vagal complex to regulate the present state and to promote resilience. Clinical and methodological issues are discussed.
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