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Term for Trance During Violent Episodes

Term for Trance During Violent Episodes


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I recently read the book, Violent Mind, The 1976 Psychological Assessment of Ted Bundy" : Dr. Al Carlisle.

In the book Dr. Carlisle mentions that Ted Bundy went into trance like states during his killing sprees. Bundy would later explain that he couldn't recall specific details of his killings and how he would feel instant remorse thereafter. Bundy went on say that even though he felt remorseful and disturbed for what he did, he would repeat the same violent patterns, killing more.

I found it fascinating how the brain can go into these trance like states for some of these killers, as if it overrides their cognitive empathy, guilt.

I am looking for a scientific term similar to "trance".


The hypothesis

The idea that

Ted Bundy went into trance like states during his killing sprees

is an anecdotal observation which can be true or it may be false. If we are to be considering it to be true, you could say that what is being described is a severe pathological form of dissociation or compartmentalisation.

I covered the idea of compartmentalisation in a totally unrelated question whereby;

Compartmentalisation is often employed, for example, by people within the emergency services (fire officers, paramedics, police officers, coastguard etc.) in order for them to concentrate on the immediate task whilst temporarily isolating themselves from their emotions.

Compartmentalisation is a form of dissociation in a sense because dissociation is a psychological defence mechanism (Cardeña, 1994) which helps the person to get through the situation with as little harm as possible. The difference between compartmentalisation and dissociation is that when you are compartmentalising, you are very much aware of what you are doing.

So in conclusion

What is being described fits the description of dissociation but it would have to be a severe pathological form of dissociation.

If Ted Bundy did have real empathy, dissociation would have helped him to disconnect from conscious reasoning and empathy with what he was doing. During the state of dissociation, you can appear to be in a trance because you are "throwing a switch on conscious awareness" so that you cannot connect with the event alone at any time after the event.

References

Cardeña, E. (1994) The domain of dissociation. In: Dissociation: Clinical and theoretical aspects, Edited by: Lynn, S. J. and Rhue, J. W. 5-31. New York, NY: Guildford Press.


Aggression: Prevention, Control and Management of Aggression

The Frustration – Aggression hypothesis formulated by Miller Dollard and associates hailed that aggression accumulates in an individual as a result of his frustrating experiences and out bursts of a particular point where it becomes severe. In order to avoid aggressive out bursts accumulation of frustrating experience should be discouraged.

This can be done by allowing the individual to express his tension and pent up emotions in between. If the anger, hostility and tension etc. are not released and suppressed aggressive act and violence becomes unmanageable.

i. Catharses:

That is why, Freud has recommended catharsis or out let of pent up emotions as the most suitable way of releasing tension. In psychotherapy this principle of catharsis is very much used even now a day. It is every body’s experience that the principles of catharsis minimizes aggressive experience. Everyone in day to day life must have found that when mild anger and feelings of anguish are expressed one feels relieved, otherwise there is anxiety.

ii. Talking Therapy:

When one feels hostility or annoyance against someone, if he tells this to some one of confidence like a good friend, a spouse, son or daughter or any well wisher his aggression is released without harming the enemy or target of aggression.

By talking out ones suppressed and repressed urges the expression of aggression can be managed aggressiveness will be expressed without doing otherwise continuous but unexpressed aggressive anxiety and mental illness. When others experiences of the victim the victim gets relaxed.

iii. Writing Therapy:

When a less dominant person is insulted = dominant person, the less powerful person will aggression towards the aggressor. Take the examples wife in Indian society. If the husband maltreats the wife or frustrates her she cannot express her aggression towards her- society does not appreciate it.

In such a situation the wife can write down her aggressive feelings towards her husband in can be released and give her peace of mind. Otherwise this may lead to depression, anxiety and neurosis. Management and control of aggressive tendencies can thus be possible through writing therapy.

Daily diary writing is a kind of writing therapy. That is why o said diary writing is maintained by mentally ill persons. By this technique hostile feeling can be relieved without target of aggression.

iv. Displacement:

Aggression of children can be relieved through displacement or transfer of aggression to some objects like toy, doll or any non living object. So children are given toys and big dolls to express their aggression on these objects, instead of expressing, suppressing and repressing it.

Various observations and experimental studies do indicate that when children are given the chance to express their anger and aggression in course of their growth, they become less hostile afterwards.

Hence, in order to control one’s aggression which is dangerous for the society, one has to learn to express the pent up emotions in small degrees as and when the occasion so demands. Non aggression can be possible through displacement of anger.

v. Catherses:

Fishback conducted an experiment on some college student who was subjected to derogatory remarks and insults. Among them one group was allowed to express his pent up emotions through T.A.T cards and the second group through writing stories on some T.A.T. cards.

These subjects showed less hostility and aggression compared to the third group which was administered with an aptitude test and hence did not get the chance to release his aggressive feeling. Similar evidences are found in many other studies which indicate that catharsis can be very useful in reducing and controlling the feelings of hostility and control.

vi. Judicious Early Childhood Training:

Aggressive behaviour can be prevented to some extent by judicious early childhood training, proper parental care, and adequate parenting style. By trying to fulfill the basic needs of the child, the child can be exposed to less frustration inducing situations.

The child should not be harashed on allowed to cry for a continuous period. He should be given the training from the early child to face frustration in an adoptive instead of mal adoptive manner. His training should be flexible rather than rigid.

vii. Good Parental Model:

The child should be exposed to good and normal models. Parents should try their best not to quarrel in the presence of a child. They should try to be beet models for the child to imitate. They should do what they preach. There should not be any gaff between preaching and actual practice.

viii. Training to Tolerate Frustration:

Instead of fulfilling all the required and unnecessary wishes of the child — under certain cases, he should be trained to tolerate frustration. Frustration tolerance can be generated in the child by not fulfilling what-ever he wishes. The genuine needs should be no doubt fulfilled.

But certain wishes which are undesirable should not be fulfilled and he should be trained gradually to tolerate the frustration of certain needs. Because of the difference in frustration tolerance capacity people differ in their aggressive reactions. In this case imitation of models tolerating frustration also helps a lot in the management and control of aggression.

Control of Television, Video Shows and Films showing Aggressive Models:

By controlling the child’s viewing of aggressive and violent models in T.V., Pictures and video a lot of aggressive behaviour can be controlled. This will be discussed in detail separate in a subsequent chapter.

i. Non Reinforcive Action:

If aggressive behaviour is encouraged it is reinforced. But through non reinforcive action arousal of anger and hostility can be reduced. If the too much aggressive behaviour of the child is discouraged through social learning and socialization process, the child will learn to reduce his hostile actions. If aggressive behaviour is mildly penalized it will be non reinforcive.

ii. Loss of Love:

When the child is involved in various hostile and violent activities he should be told by his parents, particularly the mother that she would not love him or take care of him if he is engaged in hostile activities. The child who never wants to loose the love of his mother would definitely try to do so. This I have experimented with my grand son Anuraag.

iii. Observation of Non Aggressive Models:

Aggression can be reduced effectively in highly aggressive boys by allowing them to observe models who behave in a restrained and non-aggressive manner in the face of provocation. This can be effectively done by the television and movie industries. Nonviolent movies and serials should be produced more and more and telecast in the television.

During the formative period of one’s personality imitation is maximum, and very quick. It is said by social psychologists that if the aggressive behaviour of children go unchecked or unrestricted in the early formative years, they are more probable to be reinforced and continue in his adult life which is dangerous for the society and nation.

iv. Teaching of Discipline and Morality:

By training the child to be, disciplined and develop positive values and morality a lot of aggressive behaviour can be controlled. Parents and teachers have to play an active role in this regard. A disciplined and socialized individual with moral values will not try to show frequent violence which is harmful for the family and the society.

v. Flexibility in Punishment during Childhood and No Rigid Training:

The life history of several convicts and criminals in jails has shown that those who have been jailed for their aggressive acts most of them were severely punished during childhood and punished repeatedly. That is why there is a saying that a woman who has been severely punished by his mother in law she also punishes her daughter in law severely when she becomes a mother in law.

vi. Control of Parental Aggression:

It is very often said that angry parents have angry children. So parents must try to control their frequent anger, irritation and hostility. Children should be taught that there are other non aggressive or mildly aggressive reactions to frustration which can be used while reacting to a frustrating situation. Parents must try to be an ideal model for their children.

Finally every parent must try to develop a socially acceptable personality of their children so that their aggressiveness can be controlled to a remarkable degree for ensuring peace and happiness in the society. Extreme form of aggression becomes pathological.

It undoubtedly ruins the personality of the individual. When aggression becomes a trait in the personality of such people, it becomes a sort of character disorder and stands on the way of normal and integrated personality development.

Therefore it is essential that aggressive behaviour should be prevented from early childhood by basically preventing exposure to frustration. It should also be controlled and managed for the development of normal personality and society friendly personality.

Though nonaggression is helpful for a healthy and happy society, too much of non aggression is not desirable. Aggression to some degree is essential for self protection and security, for managing one’s self in the society, for release of tension and hostility.

Aggression therefore, should be expressed in a limited degree as and when required. Aggression can be turned to non aggression through various defence mechanisms like sublimation, rationalization, projection and socially accepted behaviour like sports, mountaineering, athletics and other acts of courage and adventure.


Intervention research

There are implications of these media effects studies for intervention work with young children. My colleagues Greta Massetti, PhD (now at the Centers for Disease Control and Prevention) and former graduate student Kirstin Gros, PhD (now at the Medical University of South Carolina) and I have developed an intervention program called the Early Childhood Friendship Project. In designing this intervention, we were mindful that any “friendship problems” or aggressive behavior that we depicted via puppet shows or stories would need to be connected to a resolution in close temporal proximity. We also made sure to keep our program developmentally appropriate and use behavioral reinforcement or developmentally appropriate labeled praise to encourage children to adopt our social skills and lessons rather than aggressive behavior.

Our first intervention study (Ostrov et al., 2009) was designed using available best practices and evidence-based models to reduce aggression and peer victimization and increase social skills, prosocial behavior and friendship formation skills (e.g., Reid & Webster-Stratton, 2001). Classrooms were randomly assigned to an intervention or control condition that lasted six weeks. We found moderate to large reductions in physical and relational aggression and peer victimization in the intervention classrooms relative to the control classrooms. We also documented moderate increases in prosocial behavior (e.g., inclusion of peers and sharing) in children that received the program compared to those that did not. Thus it appears that when steps are taken to carefully connect social skills or character development lessons with problematic aggressive behavior and coupled with developmentally appropriate reinforcement for engaging in positive behavior, we do not see the unintended effects that were present in our two media effects studies. We have just finished a replication trial of an expanded eight-week program and hope to share our findings soon.


Characteristic Features

Pressured speech differs from ordinary talkativeness and represents a noticeable change in a person's usual manner of speaking. It manifests as a compelling, virtually irresistible desire to talk.

A person experiencing this symptom feels driven to talk, typically for prolonged periods and faster than usual. Other common features include speaking loudly and emphatically, and talking over or interrupting others.

Following the conversation can be challenging for the listener because someone with pressured speech also typically experiences racing thoughts. This leads to jumping rapidly from one topic to another, a sign called flight of ideas.

With a hypomanic episode, the conversation may seem odd but generally logical. Pressured speech during a manic episode, however, usually leaves the listener confused because the conversation is characteristically disjointed, illogical, fantastical, or even scary.


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Keywords : scientific thinking, misconceptions, misunderstandings, terminology, jingle and jangle fallacies

Citation: Lilienfeld SO, Sauvigné KC, Lynn SJ, Cautin RL, Latzman RD and Waldman ID (2015) Fifty psychological and psychiatric terms to avoid: a list of inaccurate, misleading, misused, ambiguous, and logically confused words and phrases. Front. Psychol. 6:1100. doi: 10.3389/fpsyg.2015.01100

Received: 13 April 2015 Accepted: 17 July 2015
Published: 03 August 2015.

Jason W. Osborne, University of Louisville, USA

Kathy Ellen Green, University of Denver, USA
Thomas James Lundy, Independent Researcher, USA

Copyright © 2015 Lilienfeld, Sauvigné, Lynn, Cautin, Latzman and Waldman. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.


Response to outbreaks [ edit | edit source ]

Timothy F. Jones, of the Tennessee Department of Health recommends the following action be taken in the case of an outbreak: Β]

  • Attempt to separate persons with illness associated with the outbreak.
  • Promptly perform physical examination and basic laboratory testing sufficient to exclude serious acute illness.
  • Monitor and provide oxygen as necessary for hyperventilation.
  • Minimize unnecessary exposure to medical procedures, emergency personnel, media or other potential anxiety-stimulating situations.
  • Notify public health authorities of apparent outbreak.
  • Openly communicate with physicians caring for other patients.
  • Promptly communicate results of laboratory and environmental testing to patients.
  • While maintaining confidentiality, explain that other people are experiencing similar symptoms and improving without complications.
  • Remind patients that rumors and reports of "suspected causes" are not equivalent to confirmed results.
  • Acknowledge that symptoms experienced by the patient are real.
  • Explain potential contribution of anxiety to the patient's symptoms.
  • Reassure patient that long-term sequelae from current illness are not expected.
  • As appropriate, reassure patient that thorough clinical, epidemiologic and environmental investigations have identified no toxic cause for the outbreak or reason for further concern.

Some responses by authority to MPI are not appropriate. Intense media coverage seems to exacerbate outbreaks. Α] Β] Ε] Once it is determined that the illness in psychogenic, it should not be given credence by authorities. Ε] For example, in the Singapore factory case study given above, calling in a medicine man to perform an exorcism seemed to perpetuate the outbreak. ⎗]


Understanding Aggression and Violence

Aggression and violence are not the same. While a person who commits an act of violence may be acting with aggression, a person with an aggressive nature will not necessarily engage in violent acts. Although aggression can result in a physical or verbal attack, sometimes the attack may be defensive or impulsive and lack harmful intent. Often considered a physical expression of aggression, violence may be predatory, impulsive, reactive, or defensive in nature. Violence can develop from situational or environmental factors and may result from a mental condition or from personal or cultural beliefs.


Contents

The universal feature of night terrors is inconsolability, very similar to that of a panic attack. [10] During night terror bouts, people are usually described as "bolting upright" with their eyes wide open and a look of fear and panic on their faces. They will often yell, scream, or attempt to speak, though such speech is often incomprehensible. Furthermore, they will usually sweat, exhibit rapid breathing, and have a rapid heart rate (autonomic signs). In some cases, individuals are likely to have even more elaborate motor activity, such as a thrashing of limbs—which may include punching, swinging, or fleeing motions. There is a sense that the individuals are trying to protect themselves and/or escape from a possible threat of bodily injury. [6] Although people may seem to be awake during a night terror, they will appear confused, be inconsolable and/or unresponsive to attempts to communicate with them, and may not recognize others familiar to them. Occasionally, when a person with a night terror is awakened, they will lash out at the one awakening them, which can be dangerous to that individual. Most people who experience this do not remember the incident the next day, [8] although brief dream images or hallucinations may occur and be recalled. [4] Sleepwalking is also common during night-terror bouts, [7] [11] as sleepwalking and night terrors are different manifestations of the same parasomnia. [7] Both children and adults may display behaviour indicative of attempting to escape some may thrash about or get out of bed and begin walking or running around aimlessly while inconsolable, increasing the risk of accidental injury. [12] The risk of injury to others may be exacerbated by inadvertent provocation by nearby people, whose efforts to calm the sufferer may result in a physically violent response from the sufferer as they attempt to escape. [13]

During lab tests, subjects are known to have very high voltages of electroencephalography (EEG) delta activity, an increase in muscle tone, and a doubled or faster heart rate. Brain activities during a typical episode show theta and alpha activity when monitored with an EEG. Episodes can include tachycardia. Night terrors are also associated with intense autonomic discharge of tachypnea, flushing, diaphoresis, and mydriasis [10] —that is, unconscious or involuntary rapid breathing, reddening of the skin, profuse sweating, and dilation of the pupils. Abrupt but calmer arousal from NREM sleep, short of a full night-terror episode, is also common.

In children with night terrors, there is no increased occurrence of psychiatric diagnoses. [14] However, in adults who suffer from night terrors there is a close association with psychopathology and mental disorders. There may be an increased occurrence of night terrors—particularly among those suffering or having suffered from post-traumatic stress disorder (PTSD) and generalized anxiety disorder (GAD). It is also likely that some personality disorders may occur in individuals with night terrors, such as dependent, schizoid, and borderline personality disorders. [14] There have been some symptoms of depression and anxiety that have increased in individuals that have suffered from frequent night terrors. Low blood sugar is associated with both pediatric and adult night terrors. [6] [15] [ self-published source? ] A study of adults with thalamic lesions of the brain and brainstem have been occasionally associated with night terrors. [16] Night terrors are closely linked to sleepwalking and frontal lobe epilepsy. [17]

Children Edit

Night terrors typically occur in children between the ages of three and twelve years, with a peak onset in children aged three and a half years old. [18] An estimated 1–6% of children experience night terrors. Children of both genders and all ethnic backgrounds are affected equally. [18] In children younger than three and a half years old, peak frequency of night terrors is at least one episode per week. Among older children, peak frequency of night terrors is one or two episodes per month. The children will most likely have no recollection of the episode the next day. Pediatric evaluation may be sought to exclude the possibility that the night terrors are caused by seizure disorders or breathing problems. [18] Most children will outgrow sleep terrors. [19]

Adults Edit

Night terrors in adults have been reported in all age ranges. [20] Though the symptoms of night terrors in adolescents and adults are similar, the cause, prognosis and treatment are qualitatively different. These night terrors can occur each night if the sufferer does not eat a proper diet, get the appropriate amount or quality of sleep (e.g. sleep apnea), is enduring stressful events, or if he or she remains untreated. Adult night terrors are much less common, and often respond to treatments to rectify causes of poor quality or quantity of sleep. Night terrors are classified as a mental and behavioral disorder in the ICD. [21] A study done about night terrors in adults showed that other psychiatric symptoms were prevalent in most patients experiencing night terrors hinting at the comorbidity of the two. [10] There is some evidence of a link between night terrors and hypoglycemia. [22]

When a night terror happens, it is typical for a person to wake up yelling and kicking and to be able to recognize what he or she is saying. The person may even run out of the house (more common among adults) which can then lead to violent actions. [23] It has been found that some adults who have been on a long-term intrathecal clonidine therapy show side effects of night terrors, such as feelings of terror early in the sleep cycle. [24] This is due to the possible alteration of cervical/brain clonidine concentration. [20] In adults, night terrors can be symptomatic of neurological disease and can be further investigated through an MRI procedure. [25]

There is some evidence that a predisposition to night terrors and other parasomnias may be congenital. Individuals frequently report that past family members have had either episodes of sleep terrors or sleepwalking. In some studies, a ten-fold increase in the prevalence of night terrors in first-degree biological relatives has been observed—however, the exact link to inheritance is not known. [6] Familial aggregation has been found suggesting that there is an autosomal mode of inheritance. [10] In addition, some laboratory findings suggest that sleep deprivation and having a fever can increase the likelihood of a night terror episode occurring. [26] Other contributing factors include nocturnal asthma, gastroesophageal reflux, central nervous system medications, [10] and a constricted nasal passage. [27] Special consideration must be used when the subject suffers from narcolepsy, as there may be a link. There have been no findings that show a cultural difference between manifestations of night terrors, though it is thought that the significance and cause of night terrors differ within cultures.

Also, older children and adults provide highly detailed and descriptive images associated with their sleep terrors compared to younger children, who either cannot recall or only vaguely remember. Sleep terrors in children are also more likely to occur in males than females in adults, the ratio between sexes is equal. [6] A longitudinal study examined twins, both identical and fraternal, and found that a significantly higher concordance rate of night terror was found in identical twins than in fraternal. [10] [28]

Though the symptoms of night terrors in adolescents and adults are similar, their causes, prognoses, and treatments are qualitatively different. There is some evidence that suggests that night terrors can occur if the sufferer does not eat a proper diet, does not get the appropriate amount or quality of sleep (e.g., because of sleep apnea), or is enduring stressful events. Adults who have experienced sexual abuse are more likely to receive a diagnosis of sleep disorders, including night terrors. [29] Overall, though, adult night terrors are much less common and often respond best to treatments that rectify causes of poor quality or quantity of sleep.

The DSM-5 diagnostic criteria for sleep terror disorder requires: [2]

  • Recurrent periods where the individual abruptly but not completely wakes from sleep, usually occurring during the first third major period of sleep.
  • The individual experiences intense fear with a panicky scream at the beginning and symptoms of autonomic arousal, such as increased heart rate, heavy breathing, and increased perspiration. The individual cannot be soothed or comforted during the episode.
  • The individual is unable or almost unable to remember images of the dream (only a single visual scene for example).
  • The episode is completely forgotten.
  • The occurrence of the sleep terror episode causes clinically significant distress or impairment in the individual's functioning.
  • The disturbance is not due to the effects of a substance, general medical condition or medication.
  • Coexisting mental or medical disorders do not explain the episodes of sleep terrors.

Differential diagnosis Edit

Night terrors are distinct from nightmares. [30] In fact, in nightmares there are almost never vocalization or agitation, and if there are any, they are less strong in comparison to night terrors. [30] In addition, nightmares appear ordinarily during REM sleep in contrast to night terrors, which occur in NREM sleep. [2] Finally, individuals with nightmares can wake up completely and easily and have clear and detailed memories of their dreams. [2] [30]

A distinction between night terrors and epileptic seizure is required. [30] Indeed, an epileptic seizure could happen during the night but also during the day. [30] To make the difference between both of them, an EEG can be done and if there are some anomalies on it, it would rather be an epileptic seizure. [30]

The assessment of sleep terrors is similar to the assessment of other parasomnias and must include: [31]

  • When the episode occurs during the sleep period
  • Age of onset
  • How often these episodes occur (frequency) and how long they last for (duration)
  • Description of the episode, including behavior, emotions, and thoughts during and after the event
  • How responsive the patient is to external stimuli during the episode
  • How conscious or aware the patient is, when awakened from an episode
  • If the episode is remembered afterwards
  • The triggers or precipitating factors
  • Sleep–wake pattern and sleep environment
  • Daytime sleepiness
  • Other sleep disorders that might be present
  • Family history for NREM parasomnias and other sleep disorders
  • Medical, psychiatric, and neurological history
  • Medication and substance use history

Additionally, a home video might be helpful for a proper diagnosis. A polysomnography in the sleep laboratory is recommended for ruling out other disorders, however, sleep terrors occur less frequently in the sleep laboratory than at home and a polysomnography can therefore be unsuccessful at recording the sleep terror episode. [31]

In most children, night terrors eventually subside and do not need to be treated. It may be helpful to reassure the child and their family that they will outgrow this disorder. [32]

The duration of one episode is mostly brief but it may last longer if parents try to wake up the child. [33] Awakening the child may make their agitation stronger. [33] For all these reasons, it is important to let the sleep terror episode fade away and to just be vigilant in order for them not to fall to the ground. [33]

Considering an episode could be violent, it may be advisable to secure the environment in which the child sleeps. Windows should be closed and potentially dangerous items should be removed from the bedroom, and additionally, alarms can be installed and the child placed in a downstairs bedroom. [34]

Hypnosis could be efficient. Sleepers could become less sensitive to their sleep terrors. [34]

One technique is to wake up just before the sleep terrors begin. When they appear regularly, this method can prevent their appearance. [34]

Psychotherapy or counseling can be helpful in many cases. There is some evidence to suggest that night terrors can result from lack of sleep or poor sleeping habits. In these cases, it can be helpful to improve the amount and quality of sleep which the child is getting. [32] It is also important to have a good sleep hygiene, if a child has night terrors parents could try to change their sleep hygiene. [33] Another option could be to adapt child's naps so that they are not too long or too short. [33] Then, excessive stress or conflicts in a child's life could also have an impact on their sleep too, so to have some strategies to cope with stress combined with psychotherapy could decrease the frequency of the episodes. [35] A polysomnography can be recommended if the child continues to have a lot of night terror episodes. [33]

If all these methods are not enough, benzodiazepines (such as diazepam) or tricyclic antidepressants may be used however, medication is only recommended in extreme cases. [36] Widening the nasal airway by surgical removal of the adenoid was previously considered and demonstrated to be effective [27] nowadays, however, invasive treatments are generally avoided.

A small study of paroxetine found some benefit. [37] Another small trial found benefit with L -5-hydroxytryptophan (L -5-HTP). [38]


Violent behavior in acute psychiatric inpatient facilities: a national survey in Italy

Violence committed by acute psychiatric inpatients represents an important and challenging problem in clinical practice. Sociodemographic, clinical, and treatment information were collected for 1324 patients (677 men and 647 women) admitted to Italian public and private acute psychiatric inpatient facilities during an index period in 2004, and the sample divided into 3 groups: nonhostile patients (no episodes of violent behavior during hospitalization), hostile patients (verbal aggression or violent acts against objects), and violent patients (authors of physical assault). Ten percent (N = 129) of patients showed hostile behavior during hospitalization and 3% (N = 37) physically assaulted other patients or staff members. Variables associated with violent behavior were: male gender, <24 years of age, unmarried status, receiving a disability pension, having a secondary school degree, compulsory admission, hostile attitude at admission, and a diagnosis of schizophrenia, bipolar disorder, personality disorder, mental retardation, organic brain disorder or substance/alcohol abuse. Violent behavior during hospitalization was a predictive factor for higher Brief Psychiatric Rating Scale scores and for lower Personal and Social Performance scale scores at discharge. Despite the low percentage of violent and hostile behavior observed in Italian acute inpatient units, this study shed light on a need for the careful assessment of clinical and treatment variables, and greater effort aimed at improving specific prevention and treatment programs of violent behavior.


Aggression and Impulsivity in Schizophrenia

Although the prevalence of violence is similar in psychiatric patients and in the general population, patients suffering from schizophrenia are often portrayed in the media as being unpredictably aggressive and impulsive. The result is increased stigmatization and poorer treatment outcomes. Multiple factors, including insufficient social support, substance abuse, and symptom exacerbations, can precipitate aggressive behavior. Moreover, failure to treat schizophrenic patients adequately is a major risk factor for aggression. 1

Aggressive behavior and impulsivity are often found in paranoid schizophrenia and can occur during both acute and chronic phases of the illness. Impulsivity is defined as action without planning or reflection, and it seems to be related to a failure of behavioral filtering outside of consciousness.

Patients with schizophrenia may show dysfunctional impulsivity and impulsive aggression. Although the neurobiological aspects of aggression in patients with schizophrenia are still not well understood, impulsivity and aggression may correlate with frontal and temporal brain abnormalities. 2 Psychotic symptoms, such as delusions and hallucinations, with subsequent suspiciousness and hostility, may result in aggressive behavior. Or, aggression may be impulsive and caused by an environmental frustrating event. Patients may be more aggressive and violent during acute episodes. 3

Schizophrenic patients have less insight, experience greater thought disorder, and have poorer control of their aggressive impulses. Comorbidity with alcohol or other substances of abuse is frequent and complicates the agitation and the impulsivity. Among patients with schizophrenia, MDD, and bipolar disorder, the risk for homicide was found to be increased with comorbid alcohol abuse or dependence. 4

Assessment of impulsivity and aggression

McNiel and Binder 5 categorized the risk factors for aggression into 4 sets of variables:

Demographic or personal: history of violence, violent threats or fantasies, age, sex, history of child abuse

Clinical: diagnosis, relevant symptoms, treatment adherence

Situational: social support, availability of weapons

Physician: the nature of the alliance with the patient, the potential cognitive bias of the evaluator

Assessment through clinical history still remains the most important way to gauge potential violent behavior in patients with schizophrenia, although it is still impossible to predict with any certainty whether a patient will become aggressive. Dysfunctional impulsivity can be assessed with many self-report questionnaires and several tests of cognitive ability (Table).

Clinical management of aggression

Because of the multidimensional etiology of aggression, making treatment decisions can be difficult. The underlying psychosis, poor impulse control, and comorbid substance use all need to be managed. In addition, the personality traits that may have contributed to the violent behavior need to be recognized. Hostility and aggressive behavior during psychosis can result when patients with a thought disorder or persecutory delusion perceive themselves as threatened. Patients with paranoid schizophrenic manifestations of suspiciousness, mistrust, and anger may be particularly challenging for clinicians who need to abstain from questioning the patient’s delusions.

Clinicians need to ensure that a safe place-for themselves and for the patient-is available where they can meet with the patient. In the emergency department, this can be particularly challenging if no dedicated space is available. A crowded place with many other somatic emergencies can impair proper management of aggressive and impulsive behavior. In such settings, administration of sedative agents is often the first-line approach, whereas when quiet rooms are available, there may be more space for collaboration between physicians and patients, leading to less invasive interventions.

Collaboration with the patient is crucial as is an experienced staff capable of handling difficult situations. Staff should respect protocols and avoid any personal reaction to things that the agitated patient may do or say in addition, the fewer the stimuli the better. When possible, the clinician should ascertain whether there is any substance and/or alcohol abuse.

Violence by schizophrenic patients can be prevented if the patient is carefully monitored-before, during, and after hospitalization. More than 50% of patients hospitalized for a first episode of schizophrenia who had threatened others had displayed overt signs of illness for over a year. 6 After discharge, there is an increase of violence risk: aggressions committed by persons with schizophrenia often occur within the first few months of hospital discharge. 7 Once a patient with schizophrenia is discharged, he or she may become medication-nonadherent, resulting in symptom recurrence and an increased risk of agitation, impulse discontrol, and possible aggression.

Treatment approaches

In an acute setting, pharmacological interventions may be necessary, and the clinician may be challenged by the need to administer the maximum dose and at the same time not harm the patient. It is important to monitor vital signs, provide close observation, and assess agitation for at least 24 hours. Adverse events from otherwise good sedative agents can occur because different compounds are administered simultaneously or in addition to previously administered medications.

In the long-term management of aggressive behavior, ascertain whether the potential for violence can be managed with psychotherapy before proceeding with medications. It is important to convey empathy and authenticity: if the agitated patient feels that he is understood and a good therapeutic relationship is in process, he may be less suspicious and defensive.

Although pharmacological treatment may help manage aggressive behavior in schizophrenic patients, it may be difficult to establish the direct effect of each medicine. Drugs are usually used to maintain impulse control and reduce aggressive behavior. Although they may induce paradoxic disinhibition, benzodiazepines, especially lorazepam, are well tolerated and not associated with the extrapyramidal adverse effects typically associated with antipsychotics. Benzodiazepines are very useful in combination therapy with typical or atypical antipsychotics. 8

In patients with acute psychosis, the use of typical antipsychotics, especially haloperidol, is supported by their strong evidence base and the long and safe history of their intramuscular formulation. Atypical antipsychotics may decrease hostility over the long term. They also are associated with a lower risk of acute extrapyramidal adverse effects, such as dystonia and akathisia, as well as a lower risk of cardiovascular adverse effects, such as QTc prolongation.

Clozapine, olanzapine, risperidone, aripiprazole, ziprasidone, and asenapine are the atypical antipsychotics most often used in the long-term treatment of hostility, impulsivity, and aggression in patients with schizophrenia. Those available in oral dissolving form are particularly useful for ease of administration (avoiding swallowing). Intramuscular formulations of atypical antipsychotics are also beneficial for treating aggressive and impulsive behavior in schizophrenic patients. Long-acting injectable formulations of antipsychotics are available for long-term treatment of patients with schizophrenia and schizoaffective disorder. 9 These formulations are particularly beneficial for patients who might have trouble with medication adherence.

Clozapine decreases hostile, aggressive, and violent behavior in the treatment of persistent aggression in patients with schizophrenia. It represents the best long-term medication choice. In one study, after treatment with clozapine, the scores on the hostility item of the Positive and Negative Syndrome Scale were reduced in 157 patients with treatment-resistant schizophrenia. 10 However, clozapine is not used for acute episodes because the dose must be titrated slowly during the first 3 weeks of treatment and it is likely that its anti-aggressive effect is not related to its antipsychotic effects.

Mood stabilizers-anticonvulsants and lithium-are often also prescribed in combination with antipsychotics. Substance abuse comorbidity increases the risk of violent behavior. Atypical antipsychotics and benzodiazepines are recommended for schizophrenic patients with substance abuse comorbidity. (Benzodiazepines are safe and effective sedative agents that do not create problems with addiction in the acute phase, especially when the patient is closely monitored.) Of note is loxapine, a typical antipsychotic, now available to treat agitation in inhalation form. According to preliminary evidence, agitation is reduced within 2 minutes of administration and the effects of a single dose last up to 24 hours. 11

Aggressive and impulsive behaviors in schizophrenia pose many clinical challenges. The best way to reduce the risk of aggression is with adequate treatment of schizophrenia. 1 Using one of the many tools (Table) to assess a patient’s agitation/hostility can help psychiatrists make treatment decisions that will reduce the risk of aggression. Proper training of staff and a structured, calming environment can easily reduce the risk of violence and improve outcomes, ensuring safety for both staff and patients. Understanding treatment protocols provides clinicians with the knowledge for proper management and gives patients better solutions with possibly less invasive interventions.

Disclosures:

Dr Pompili is Professor of Suicidology in the department of neurosciences, mental health, and sensory organs at Sapienza University of Rome, and Director of the Suicide Prevention Center at Sant’Andrea Hospital in Rome. Dr Fiorillo is Associate Professor in the department of psychiatry at the University of Naples SUN, Naples, Italy. The authors report no conflicts of interest concerning the subject matter of this article.

References:

1. Torrey EF. Stigma and violence: isn’t it time to connect the dots? Schizophr Bull. 201137:892-896.

2. Hoptman MJ, Antonius D. Neuroimaging correlates of aggression in schizophrenia: an update. Curr Opin Psychiatry. 201124:100-106.

3. Soyka M, Graz C, Bottlender R, et al. Clinical correlates of later violence and criminal offences in schizophrenia. Schizophr Res. 200794:89-98.

4. Schanda H, Knecht G, Schreinzer D, et al. Homicide and major mental disorders: a 25-year study. Acta Psychiatr Scand. 2004110:98-107.

5. McNiel DE, Binder RL. The relationship between acute psychiatric symptoms, diagnosis, and short-term risk of violence. Hosp Community Psychiatry. 199445:133-137.

6. Humphreys MS, Johnstone EC, MacMillan JF, Taylor PJ. Dangerous behavior preceding first admissions for schizophrenia. Br J Psychiatry. 1992 161:501-505.

7. Link BG, Andrews H, Cullen FT. The violent and illegal behavior of mental patients reconsidered. Am Sociol Rev. 199257:275-292.

8. Hughes DH, Kleespies PM. Treating aggression in the psychiatric emergency service. J Clin Psychiatry. 200364(suppl 4):10-15.

9. Girardi P, Serafini G, Pompili M, et al. Prospective, open study of long-acting injected risperidone versus oral antipsychotics in 88 chronically psychotic patients. Pharmacopsychiatry. 201043:66-72.

10. Citrome L, Volavka J, Czobor P, et al. Effects of clozapine, olanzapine, risperidone, and haloperidol on hostility among patients with schizophrenia. Psychiatr Serv. 200152:1510-1514.

11. Kwentus J, Riesenberg RA, Marandi M, et al. Rapid acute treatment of agitation in patients with bipolar I disorder: a multicenter, randomized, placebo-controlled clinical trial with inhaled loxapine. Bipolar Disord. 201214:31-40.

12. Cook WW, Medley DM. Proposed hostility and pharisaic-virtue scales for the MMPI. J Appl Psychol. 195438:414-418.

13. Buss AH, Durkee A. An inventory for assessing different kinds of hostility. J Consult Psychol. 195721:343-349.

14. Caine TM, Foulds GA, Hope K. Manual of the Hostility and Direction of Hostility Questionnaire (HDHQ). 3rd ed. London: University of London Press 1967.

15. Novaco RW. Anger violence and mental disorder: the development and validation of an assessment procedure. Presented at: Meeting on Risk Special Studies September 1975 Pittsburgh.

16. Bunney WE Jr, Hamburg DA. Methods for reliable longitudinal observation of behavior. Arch Gen Psychiatry. 19639:280-294.

17. Hargreaves WA. Systematic nursing observations of psychopathology. Arch Gen Psychiatry. 196818:518-531.

18. Green RA, Bigelow L, O’Brien P, et al. The Inpatient Behavioral Rating Scale: a 26-item scale for recording nursing observations of patients’ mood and behavior. Psychol Rep. 197740:543-549.

19. Squier RW. An acute psychiatric rating scale for the clinical assessment of functionally disturbed inpatients. Acta Psychiat Scand. 199591:402-409.

20. Kay SR, Wolkenfeld F, Murrill LM. Profiles of aggression among psychiatric patients. II. Covariates and predictors. J Nerv Ment Dis. 1988176:547-557.

21. Plutchik R, van Praag HM. A self-report measure of violence risk, II. Compr Psychiatry. 199031:450-456.

22. Korn ML, Botsis AJ, Kotler M, et al. The Suicide and Aggression Survey: a semistructured instrument for the measurement of suicidality and aggression. Compr Psychiatry. 199233:359-365.


Violent behavior in acute psychiatric inpatient facilities: a national survey in Italy

Violence committed by acute psychiatric inpatients represents an important and challenging problem in clinical practice. Sociodemographic, clinical, and treatment information were collected for 1324 patients (677 men and 647 women) admitted to Italian public and private acute psychiatric inpatient facilities during an index period in 2004, and the sample divided into 3 groups: nonhostile patients (no episodes of violent behavior during hospitalization), hostile patients (verbal aggression or violent acts against objects), and violent patients (authors of physical assault). Ten percent (N = 129) of patients showed hostile behavior during hospitalization and 3% (N = 37) physically assaulted other patients or staff members. Variables associated with violent behavior were: male gender, <24 years of age, unmarried status, receiving a disability pension, having a secondary school degree, compulsory admission, hostile attitude at admission, and a diagnosis of schizophrenia, bipolar disorder, personality disorder, mental retardation, organic brain disorder or substance/alcohol abuse. Violent behavior during hospitalization was a predictive factor for higher Brief Psychiatric Rating Scale scores and for lower Personal and Social Performance scale scores at discharge. Despite the low percentage of violent and hostile behavior observed in Italian acute inpatient units, this study shed light on a need for the careful assessment of clinical and treatment variables, and greater effort aimed at improving specific prevention and treatment programs of violent behavior.


Understanding Aggression and Violence

Aggression and violence are not the same. While a person who commits an act of violence may be acting with aggression, a person with an aggressive nature will not necessarily engage in violent acts. Although aggression can result in a physical or verbal attack, sometimes the attack may be defensive or impulsive and lack harmful intent. Often considered a physical expression of aggression, violence may be predatory, impulsive, reactive, or defensive in nature. Violence can develop from situational or environmental factors and may result from a mental condition or from personal or cultural beliefs.


Aggression: Prevention, Control and Management of Aggression

The Frustration – Aggression hypothesis formulated by Miller Dollard and associates hailed that aggression accumulates in an individual as a result of his frustrating experiences and out bursts of a particular point where it becomes severe. In order to avoid aggressive out bursts accumulation of frustrating experience should be discouraged.

This can be done by allowing the individual to express his tension and pent up emotions in between. If the anger, hostility and tension etc. are not released and suppressed aggressive act and violence becomes unmanageable.

i. Catharses:

That is why, Freud has recommended catharsis or out let of pent up emotions as the most suitable way of releasing tension. In psychotherapy this principle of catharsis is very much used even now a day. It is every body’s experience that the principles of catharsis minimizes aggressive experience. Everyone in day to day life must have found that when mild anger and feelings of anguish are expressed one feels relieved, otherwise there is anxiety.

ii. Talking Therapy:

When one feels hostility or annoyance against someone, if he tells this to some one of confidence like a good friend, a spouse, son or daughter or any well wisher his aggression is released without harming the enemy or target of aggression.

By talking out ones suppressed and repressed urges the expression of aggression can be managed aggressiveness will be expressed without doing otherwise continuous but unexpressed aggressive anxiety and mental illness. When others experiences of the victim the victim gets relaxed.

iii. Writing Therapy:

When a less dominant person is insulted = dominant person, the less powerful person will aggression towards the aggressor. Take the examples wife in Indian society. If the husband maltreats the wife or frustrates her she cannot express her aggression towards her- society does not appreciate it.

In such a situation the wife can write down her aggressive feelings towards her husband in can be released and give her peace of mind. Otherwise this may lead to depression, anxiety and neurosis. Management and control of aggressive tendencies can thus be possible through writing therapy.

Daily diary writing is a kind of writing therapy. That is why o said diary writing is maintained by mentally ill persons. By this technique hostile feeling can be relieved without target of aggression.

iv. Displacement:

Aggression of children can be relieved through displacement or transfer of aggression to some objects like toy, doll or any non living object. So children are given toys and big dolls to express their aggression on these objects, instead of expressing, suppressing and repressing it.

Various observations and experimental studies do indicate that when children are given the chance to express their anger and aggression in course of their growth, they become less hostile afterwards.

Hence, in order to control one’s aggression which is dangerous for the society, one has to learn to express the pent up emotions in small degrees as and when the occasion so demands. Non aggression can be possible through displacement of anger.

v. Catherses:

Fishback conducted an experiment on some college student who was subjected to derogatory remarks and insults. Among them one group was allowed to express his pent up emotions through T.A.T cards and the second group through writing stories on some T.A.T. cards.

These subjects showed less hostility and aggression compared to the third group which was administered with an aptitude test and hence did not get the chance to release his aggressive feeling. Similar evidences are found in many other studies which indicate that catharsis can be very useful in reducing and controlling the feelings of hostility and control.

vi. Judicious Early Childhood Training:

Aggressive behaviour can be prevented to some extent by judicious early childhood training, proper parental care, and adequate parenting style. By trying to fulfill the basic needs of the child, the child can be exposed to less frustration inducing situations.

The child should not be harashed on allowed to cry for a continuous period. He should be given the training from the early child to face frustration in an adoptive instead of mal adoptive manner. His training should be flexible rather than rigid.

vii. Good Parental Model:

The child should be exposed to good and normal models. Parents should try their best not to quarrel in the presence of a child. They should try to be beet models for the child to imitate. They should do what they preach. There should not be any gaff between preaching and actual practice.

viii. Training to Tolerate Frustration:

Instead of fulfilling all the required and unnecessary wishes of the child — under certain cases, he should be trained to tolerate frustration. Frustration tolerance can be generated in the child by not fulfilling what-ever he wishes. The genuine needs should be no doubt fulfilled.

But certain wishes which are undesirable should not be fulfilled and he should be trained gradually to tolerate the frustration of certain needs. Because of the difference in frustration tolerance capacity people differ in their aggressive reactions. In this case imitation of models tolerating frustration also helps a lot in the management and control of aggression.

Control of Television, Video Shows and Films showing Aggressive Models:

By controlling the child’s viewing of aggressive and violent models in T.V., Pictures and video a lot of aggressive behaviour can be controlled. This will be discussed in detail separate in a subsequent chapter.

i. Non Reinforcive Action:

If aggressive behaviour is encouraged it is reinforced. But through non reinforcive action arousal of anger and hostility can be reduced. If the too much aggressive behaviour of the child is discouraged through social learning and socialization process, the child will learn to reduce his hostile actions. If aggressive behaviour is mildly penalized it will be non reinforcive.

ii. Loss of Love:

When the child is involved in various hostile and violent activities he should be told by his parents, particularly the mother that she would not love him or take care of him if he is engaged in hostile activities. The child who never wants to loose the love of his mother would definitely try to do so. This I have experimented with my grand son Anuraag.

iii. Observation of Non Aggressive Models:

Aggression can be reduced effectively in highly aggressive boys by allowing them to observe models who behave in a restrained and non-aggressive manner in the face of provocation. This can be effectively done by the television and movie industries. Nonviolent movies and serials should be produced more and more and telecast in the television.

During the formative period of one’s personality imitation is maximum, and very quick. It is said by social psychologists that if the aggressive behaviour of children go unchecked or unrestricted in the early formative years, they are more probable to be reinforced and continue in his adult life which is dangerous for the society and nation.

iv. Teaching of Discipline and Morality:

By training the child to be, disciplined and develop positive values and morality a lot of aggressive behaviour can be controlled. Parents and teachers have to play an active role in this regard. A disciplined and socialized individual with moral values will not try to show frequent violence which is harmful for the family and the society.

v. Flexibility in Punishment during Childhood and No Rigid Training:

The life history of several convicts and criminals in jails has shown that those who have been jailed for their aggressive acts most of them were severely punished during childhood and punished repeatedly. That is why there is a saying that a woman who has been severely punished by his mother in law she also punishes her daughter in law severely when she becomes a mother in law.

vi. Control of Parental Aggression:

It is very often said that angry parents have angry children. So parents must try to control their frequent anger, irritation and hostility. Children should be taught that there are other non aggressive or mildly aggressive reactions to frustration which can be used while reacting to a frustrating situation. Parents must try to be an ideal model for their children.

Finally every parent must try to develop a socially acceptable personality of their children so that their aggressiveness can be controlled to a remarkable degree for ensuring peace and happiness in the society. Extreme form of aggression becomes pathological.

It undoubtedly ruins the personality of the individual. When aggression becomes a trait in the personality of such people, it becomes a sort of character disorder and stands on the way of normal and integrated personality development.

Therefore it is essential that aggressive behaviour should be prevented from early childhood by basically preventing exposure to frustration. It should also be controlled and managed for the development of normal personality and society friendly personality.

Though nonaggression is helpful for a healthy and happy society, too much of non aggression is not desirable. Aggression to some degree is essential for self protection and security, for managing one’s self in the society, for release of tension and hostility.

Aggression therefore, should be expressed in a limited degree as and when required. Aggression can be turned to non aggression through various defence mechanisms like sublimation, rationalization, projection and socially accepted behaviour like sports, mountaineering, athletics and other acts of courage and adventure.


Contents

The universal feature of night terrors is inconsolability, very similar to that of a panic attack. [10] During night terror bouts, people are usually described as "bolting upright" with their eyes wide open and a look of fear and panic on their faces. They will often yell, scream, or attempt to speak, though such speech is often incomprehensible. Furthermore, they will usually sweat, exhibit rapid breathing, and have a rapid heart rate (autonomic signs). In some cases, individuals are likely to have even more elaborate motor activity, such as a thrashing of limbs—which may include punching, swinging, or fleeing motions. There is a sense that the individuals are trying to protect themselves and/or escape from a possible threat of bodily injury. [6] Although people may seem to be awake during a night terror, they will appear confused, be inconsolable and/or unresponsive to attempts to communicate with them, and may not recognize others familiar to them. Occasionally, when a person with a night terror is awakened, they will lash out at the one awakening them, which can be dangerous to that individual. Most people who experience this do not remember the incident the next day, [8] although brief dream images or hallucinations may occur and be recalled. [4] Sleepwalking is also common during night-terror bouts, [7] [11] as sleepwalking and night terrors are different manifestations of the same parasomnia. [7] Both children and adults may display behaviour indicative of attempting to escape some may thrash about or get out of bed and begin walking or running around aimlessly while inconsolable, increasing the risk of accidental injury. [12] The risk of injury to others may be exacerbated by inadvertent provocation by nearby people, whose efforts to calm the sufferer may result in a physically violent response from the sufferer as they attempt to escape. [13]

During lab tests, subjects are known to have very high voltages of electroencephalography (EEG) delta activity, an increase in muscle tone, and a doubled or faster heart rate. Brain activities during a typical episode show theta and alpha activity when monitored with an EEG. Episodes can include tachycardia. Night terrors are also associated with intense autonomic discharge of tachypnea, flushing, diaphoresis, and mydriasis [10] —that is, unconscious or involuntary rapid breathing, reddening of the skin, profuse sweating, and dilation of the pupils. Abrupt but calmer arousal from NREM sleep, short of a full night-terror episode, is also common.

In children with night terrors, there is no increased occurrence of psychiatric diagnoses. [14] However, in adults who suffer from night terrors there is a close association with psychopathology and mental disorders. There may be an increased occurrence of night terrors—particularly among those suffering or having suffered from post-traumatic stress disorder (PTSD) and generalized anxiety disorder (GAD). It is also likely that some personality disorders may occur in individuals with night terrors, such as dependent, schizoid, and borderline personality disorders. [14] There have been some symptoms of depression and anxiety that have increased in individuals that have suffered from frequent night terrors. Low blood sugar is associated with both pediatric and adult night terrors. [6] [15] [ self-published source? ] A study of adults with thalamic lesions of the brain and brainstem have been occasionally associated with night terrors. [16] Night terrors are closely linked to sleepwalking and frontal lobe epilepsy. [17]

Children Edit

Night terrors typically occur in children between the ages of three and twelve years, with a peak onset in children aged three and a half years old. [18] An estimated 1–6% of children experience night terrors. Children of both genders and all ethnic backgrounds are affected equally. [18] In children younger than three and a half years old, peak frequency of night terrors is at least one episode per week. Among older children, peak frequency of night terrors is one or two episodes per month. The children will most likely have no recollection of the episode the next day. Pediatric evaluation may be sought to exclude the possibility that the night terrors are caused by seizure disorders or breathing problems. [18] Most children will outgrow sleep terrors. [19]

Adults Edit

Night terrors in adults have been reported in all age ranges. [20] Though the symptoms of night terrors in adolescents and adults are similar, the cause, prognosis and treatment are qualitatively different. These night terrors can occur each night if the sufferer does not eat a proper diet, get the appropriate amount or quality of sleep (e.g. sleep apnea), is enduring stressful events, or if he or she remains untreated. Adult night terrors are much less common, and often respond to treatments to rectify causes of poor quality or quantity of sleep. Night terrors are classified as a mental and behavioral disorder in the ICD. [21] A study done about night terrors in adults showed that other psychiatric symptoms were prevalent in most patients experiencing night terrors hinting at the comorbidity of the two. [10] There is some evidence of a link between night terrors and hypoglycemia. [22]

When a night terror happens, it is typical for a person to wake up yelling and kicking and to be able to recognize what he or she is saying. The person may even run out of the house (more common among adults) which can then lead to violent actions. [23] It has been found that some adults who have been on a long-term intrathecal clonidine therapy show side effects of night terrors, such as feelings of terror early in the sleep cycle. [24] This is due to the possible alteration of cervical/brain clonidine concentration. [20] In adults, night terrors can be symptomatic of neurological disease and can be further investigated through an MRI procedure. [25]

There is some evidence that a predisposition to night terrors and other parasomnias may be congenital. Individuals frequently report that past family members have had either episodes of sleep terrors or sleepwalking. In some studies, a ten-fold increase in the prevalence of night terrors in first-degree biological relatives has been observed—however, the exact link to inheritance is not known. [6] Familial aggregation has been found suggesting that there is an autosomal mode of inheritance. [10] In addition, some laboratory findings suggest that sleep deprivation and having a fever can increase the likelihood of a night terror episode occurring. [26] Other contributing factors include nocturnal asthma, gastroesophageal reflux, central nervous system medications, [10] and a constricted nasal passage. [27] Special consideration must be used when the subject suffers from narcolepsy, as there may be a link. There have been no findings that show a cultural difference between manifestations of night terrors, though it is thought that the significance and cause of night terrors differ within cultures.

Also, older children and adults provide highly detailed and descriptive images associated with their sleep terrors compared to younger children, who either cannot recall or only vaguely remember. Sleep terrors in children are also more likely to occur in males than females in adults, the ratio between sexes is equal. [6] A longitudinal study examined twins, both identical and fraternal, and found that a significantly higher concordance rate of night terror was found in identical twins than in fraternal. [10] [28]

Though the symptoms of night terrors in adolescents and adults are similar, their causes, prognoses, and treatments are qualitatively different. There is some evidence that suggests that night terrors can occur if the sufferer does not eat a proper diet, does not get the appropriate amount or quality of sleep (e.g., because of sleep apnea), or is enduring stressful events. Adults who have experienced sexual abuse are more likely to receive a diagnosis of sleep disorders, including night terrors. [29] Overall, though, adult night terrors are much less common and often respond best to treatments that rectify causes of poor quality or quantity of sleep.

The DSM-5 diagnostic criteria for sleep terror disorder requires: [2]

  • Recurrent periods where the individual abruptly but not completely wakes from sleep, usually occurring during the first third major period of sleep.
  • The individual experiences intense fear with a panicky scream at the beginning and symptoms of autonomic arousal, such as increased heart rate, heavy breathing, and increased perspiration. The individual cannot be soothed or comforted during the episode.
  • The individual is unable or almost unable to remember images of the dream (only a single visual scene for example).
  • The episode is completely forgotten.
  • The occurrence of the sleep terror episode causes clinically significant distress or impairment in the individual's functioning.
  • The disturbance is not due to the effects of a substance, general medical condition or medication.
  • Coexisting mental or medical disorders do not explain the episodes of sleep terrors.

Differential diagnosis Edit

Night terrors are distinct from nightmares. [30] In fact, in nightmares there are almost never vocalization or agitation, and if there are any, they are less strong in comparison to night terrors. [30] In addition, nightmares appear ordinarily during REM sleep in contrast to night terrors, which occur in NREM sleep. [2] Finally, individuals with nightmares can wake up completely and easily and have clear and detailed memories of their dreams. [2] [30]

A distinction between night terrors and epileptic seizure is required. [30] Indeed, an epileptic seizure could happen during the night but also during the day. [30] To make the difference between both of them, an EEG can be done and if there are some anomalies on it, it would rather be an epileptic seizure. [30]

The assessment of sleep terrors is similar to the assessment of other parasomnias and must include: [31]

  • When the episode occurs during the sleep period
  • Age of onset
  • How often these episodes occur (frequency) and how long they last for (duration)
  • Description of the episode, including behavior, emotions, and thoughts during and after the event
  • How responsive the patient is to external stimuli during the episode
  • How conscious or aware the patient is, when awakened from an episode
  • If the episode is remembered afterwards
  • The triggers or precipitating factors
  • Sleep–wake pattern and sleep environment
  • Daytime sleepiness
  • Other sleep disorders that might be present
  • Family history for NREM parasomnias and other sleep disorders
  • Medical, psychiatric, and neurological history
  • Medication and substance use history

Additionally, a home video might be helpful for a proper diagnosis. A polysomnography in the sleep laboratory is recommended for ruling out other disorders, however, sleep terrors occur less frequently in the sleep laboratory than at home and a polysomnography can therefore be unsuccessful at recording the sleep terror episode. [31]

In most children, night terrors eventually subside and do not need to be treated. It may be helpful to reassure the child and their family that they will outgrow this disorder. [32]

The duration of one episode is mostly brief but it may last longer if parents try to wake up the child. [33] Awakening the child may make their agitation stronger. [33] For all these reasons, it is important to let the sleep terror episode fade away and to just be vigilant in order for them not to fall to the ground. [33]

Considering an episode could be violent, it may be advisable to secure the environment in which the child sleeps. Windows should be closed and potentially dangerous items should be removed from the bedroom, and additionally, alarms can be installed and the child placed in a downstairs bedroom. [34]

Hypnosis could be efficient. Sleepers could become less sensitive to their sleep terrors. [34]

One technique is to wake up just before the sleep terrors begin. When they appear regularly, this method can prevent their appearance. [34]

Psychotherapy or counseling can be helpful in many cases. There is some evidence to suggest that night terrors can result from lack of sleep or poor sleeping habits. In these cases, it can be helpful to improve the amount and quality of sleep which the child is getting. [32] It is also important to have a good sleep hygiene, if a child has night terrors parents could try to change their sleep hygiene. [33] Another option could be to adapt child's naps so that they are not too long or too short. [33] Then, excessive stress or conflicts in a child's life could also have an impact on their sleep too, so to have some strategies to cope with stress combined with psychotherapy could decrease the frequency of the episodes. [35] A polysomnography can be recommended if the child continues to have a lot of night terror episodes. [33]

If all these methods are not enough, benzodiazepines (such as diazepam) or tricyclic antidepressants may be used however, medication is only recommended in extreme cases. [36] Widening the nasal airway by surgical removal of the adenoid was previously considered and demonstrated to be effective [27] nowadays, however, invasive treatments are generally avoided.

A small study of paroxetine found some benefit. [37] Another small trial found benefit with L -5-hydroxytryptophan (L -5-HTP). [38]


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Keywords : scientific thinking, misconceptions, misunderstandings, terminology, jingle and jangle fallacies

Citation: Lilienfeld SO, Sauvigné KC, Lynn SJ, Cautin RL, Latzman RD and Waldman ID (2015) Fifty psychological and psychiatric terms to avoid: a list of inaccurate, misleading, misused, ambiguous, and logically confused words and phrases. Front. Psychol. 6:1100. doi: 10.3389/fpsyg.2015.01100

Received: 13 April 2015 Accepted: 17 July 2015
Published: 03 August 2015.

Jason W. Osborne, University of Louisville, USA

Kathy Ellen Green, University of Denver, USA
Thomas James Lundy, Independent Researcher, USA

Copyright © 2015 Lilienfeld, Sauvigné, Lynn, Cautin, Latzman and Waldman. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.


Characteristic Features

Pressured speech differs from ordinary talkativeness and represents a noticeable change in a person's usual manner of speaking. It manifests as a compelling, virtually irresistible desire to talk.

A person experiencing this symptom feels driven to talk, typically for prolonged periods and faster than usual. Other common features include speaking loudly and emphatically, and talking over or interrupting others.

Following the conversation can be challenging for the listener because someone with pressured speech also typically experiences racing thoughts. This leads to jumping rapidly from one topic to another, a sign called flight of ideas.

With a hypomanic episode, the conversation may seem odd but generally logical. Pressured speech during a manic episode, however, usually leaves the listener confused because the conversation is characteristically disjointed, illogical, fantastical, or even scary.


Aggression and Impulsivity in Schizophrenia

Although the prevalence of violence is similar in psychiatric patients and in the general population, patients suffering from schizophrenia are often portrayed in the media as being unpredictably aggressive and impulsive. The result is increased stigmatization and poorer treatment outcomes. Multiple factors, including insufficient social support, substance abuse, and symptom exacerbations, can precipitate aggressive behavior. Moreover, failure to treat schizophrenic patients adequately is a major risk factor for aggression. 1

Aggressive behavior and impulsivity are often found in paranoid schizophrenia and can occur during both acute and chronic phases of the illness. Impulsivity is defined as action without planning or reflection, and it seems to be related to a failure of behavioral filtering outside of consciousness.

Patients with schizophrenia may show dysfunctional impulsivity and impulsive aggression. Although the neurobiological aspects of aggression in patients with schizophrenia are still not well understood, impulsivity and aggression may correlate with frontal and temporal brain abnormalities. 2 Psychotic symptoms, such as delusions and hallucinations, with subsequent suspiciousness and hostility, may result in aggressive behavior. Or, aggression may be impulsive and caused by an environmental frustrating event. Patients may be more aggressive and violent during acute episodes. 3

Schizophrenic patients have less insight, experience greater thought disorder, and have poorer control of their aggressive impulses. Comorbidity with alcohol or other substances of abuse is frequent and complicates the agitation and the impulsivity. Among patients with schizophrenia, MDD, and bipolar disorder, the risk for homicide was found to be increased with comorbid alcohol abuse or dependence. 4

Assessment of impulsivity and aggression

McNiel and Binder 5 categorized the risk factors for aggression into 4 sets of variables:

Demographic or personal: history of violence, violent threats or fantasies, age, sex, history of child abuse

Clinical: diagnosis, relevant symptoms, treatment adherence

Situational: social support, availability of weapons

Physician: the nature of the alliance with the patient, the potential cognitive bias of the evaluator

Assessment through clinical history still remains the most important way to gauge potential violent behavior in patients with schizophrenia, although it is still impossible to predict with any certainty whether a patient will become aggressive. Dysfunctional impulsivity can be assessed with many self-report questionnaires and several tests of cognitive ability (Table).

Clinical management of aggression

Because of the multidimensional etiology of aggression, making treatment decisions can be difficult. The underlying psychosis, poor impulse control, and comorbid substance use all need to be managed. In addition, the personality traits that may have contributed to the violent behavior need to be recognized. Hostility and aggressive behavior during psychosis can result when patients with a thought disorder or persecutory delusion perceive themselves as threatened. Patients with paranoid schizophrenic manifestations of suspiciousness, mistrust, and anger may be particularly challenging for clinicians who need to abstain from questioning the patient’s delusions.

Clinicians need to ensure that a safe place-for themselves and for the patient-is available where they can meet with the patient. In the emergency department, this can be particularly challenging if no dedicated space is available. A crowded place with many other somatic emergencies can impair proper management of aggressive and impulsive behavior. In such settings, administration of sedative agents is often the first-line approach, whereas when quiet rooms are available, there may be more space for collaboration between physicians and patients, leading to less invasive interventions.

Collaboration with the patient is crucial as is an experienced staff capable of handling difficult situations. Staff should respect protocols and avoid any personal reaction to things that the agitated patient may do or say in addition, the fewer the stimuli the better. When possible, the clinician should ascertain whether there is any substance and/or alcohol abuse.

Violence by schizophrenic patients can be prevented if the patient is carefully monitored-before, during, and after hospitalization. More than 50% of patients hospitalized for a first episode of schizophrenia who had threatened others had displayed overt signs of illness for over a year. 6 After discharge, there is an increase of violence risk: aggressions committed by persons with schizophrenia often occur within the first few months of hospital discharge. 7 Once a patient with schizophrenia is discharged, he or she may become medication-nonadherent, resulting in symptom recurrence and an increased risk of agitation, impulse discontrol, and possible aggression.

Treatment approaches

In an acute setting, pharmacological interventions may be necessary, and the clinician may be challenged by the need to administer the maximum dose and at the same time not harm the patient. It is important to monitor vital signs, provide close observation, and assess agitation for at least 24 hours. Adverse events from otherwise good sedative agents can occur because different compounds are administered simultaneously or in addition to previously administered medications.

In the long-term management of aggressive behavior, ascertain whether the potential for violence can be managed with psychotherapy before proceeding with medications. It is important to convey empathy and authenticity: if the agitated patient feels that he is understood and a good therapeutic relationship is in process, he may be less suspicious and defensive.

Although pharmacological treatment may help manage aggressive behavior in schizophrenic patients, it may be difficult to establish the direct effect of each medicine. Drugs are usually used to maintain impulse control and reduce aggressive behavior. Although they may induce paradoxic disinhibition, benzodiazepines, especially lorazepam, are well tolerated and not associated with the extrapyramidal adverse effects typically associated with antipsychotics. Benzodiazepines are very useful in combination therapy with typical or atypical antipsychotics. 8

In patients with acute psychosis, the use of typical antipsychotics, especially haloperidol, is supported by their strong evidence base and the long and safe history of their intramuscular formulation. Atypical antipsychotics may decrease hostility over the long term. They also are associated with a lower risk of acute extrapyramidal adverse effects, such as dystonia and akathisia, as well as a lower risk of cardiovascular adverse effects, such as QTc prolongation.

Clozapine, olanzapine, risperidone, aripiprazole, ziprasidone, and asenapine are the atypical antipsychotics most often used in the long-term treatment of hostility, impulsivity, and aggression in patients with schizophrenia. Those available in oral dissolving form are particularly useful for ease of administration (avoiding swallowing). Intramuscular formulations of atypical antipsychotics are also beneficial for treating aggressive and impulsive behavior in schizophrenic patients. Long-acting injectable formulations of antipsychotics are available for long-term treatment of patients with schizophrenia and schizoaffective disorder. 9 These formulations are particularly beneficial for patients who might have trouble with medication adherence.

Clozapine decreases hostile, aggressive, and violent behavior in the treatment of persistent aggression in patients with schizophrenia. It represents the best long-term medication choice. In one study, after treatment with clozapine, the scores on the hostility item of the Positive and Negative Syndrome Scale were reduced in 157 patients with treatment-resistant schizophrenia. 10 However, clozapine is not used for acute episodes because the dose must be titrated slowly during the first 3 weeks of treatment and it is likely that its anti-aggressive effect is not related to its antipsychotic effects.

Mood stabilizers-anticonvulsants and lithium-are often also prescribed in combination with antipsychotics. Substance abuse comorbidity increases the risk of violent behavior. Atypical antipsychotics and benzodiazepines are recommended for schizophrenic patients with substance abuse comorbidity. (Benzodiazepines are safe and effective sedative agents that do not create problems with addiction in the acute phase, especially when the patient is closely monitored.) Of note is loxapine, a typical antipsychotic, now available to treat agitation in inhalation form. According to preliminary evidence, agitation is reduced within 2 minutes of administration and the effects of a single dose last up to 24 hours. 11

Aggressive and impulsive behaviors in schizophrenia pose many clinical challenges. The best way to reduce the risk of aggression is with adequate treatment of schizophrenia. 1 Using one of the many tools (Table) to assess a patient’s agitation/hostility can help psychiatrists make treatment decisions that will reduce the risk of aggression. Proper training of staff and a structured, calming environment can easily reduce the risk of violence and improve outcomes, ensuring safety for both staff and patients. Understanding treatment protocols provides clinicians with the knowledge for proper management and gives patients better solutions with possibly less invasive interventions.

Disclosures:

Dr Pompili is Professor of Suicidology in the department of neurosciences, mental health, and sensory organs at Sapienza University of Rome, and Director of the Suicide Prevention Center at Sant’Andrea Hospital in Rome. Dr Fiorillo is Associate Professor in the department of psychiatry at the University of Naples SUN, Naples, Italy. The authors report no conflicts of interest concerning the subject matter of this article.

References:

1. Torrey EF. Stigma and violence: isn’t it time to connect the dots? Schizophr Bull. 201137:892-896.

2. Hoptman MJ, Antonius D. Neuroimaging correlates of aggression in schizophrenia: an update. Curr Opin Psychiatry. 201124:100-106.

3. Soyka M, Graz C, Bottlender R, et al. Clinical correlates of later violence and criminal offences in schizophrenia. Schizophr Res. 200794:89-98.

4. Schanda H, Knecht G, Schreinzer D, et al. Homicide and major mental disorders: a 25-year study. Acta Psychiatr Scand. 2004110:98-107.

5. McNiel DE, Binder RL. The relationship between acute psychiatric symptoms, diagnosis, and short-term risk of violence. Hosp Community Psychiatry. 199445:133-137.

6. Humphreys MS, Johnstone EC, MacMillan JF, Taylor PJ. Dangerous behavior preceding first admissions for schizophrenia. Br J Psychiatry. 1992 161:501-505.

7. Link BG, Andrews H, Cullen FT. The violent and illegal behavior of mental patients reconsidered. Am Sociol Rev. 199257:275-292.

8. Hughes DH, Kleespies PM. Treating aggression in the psychiatric emergency service. J Clin Psychiatry. 200364(suppl 4):10-15.

9. Girardi P, Serafini G, Pompili M, et al. Prospective, open study of long-acting injected risperidone versus oral antipsychotics in 88 chronically psychotic patients. Pharmacopsychiatry. 201043:66-72.

10. Citrome L, Volavka J, Czobor P, et al. Effects of clozapine, olanzapine, risperidone, and haloperidol on hostility among patients with schizophrenia. Psychiatr Serv. 200152:1510-1514.

11. Kwentus J, Riesenberg RA, Marandi M, et al. Rapid acute treatment of agitation in patients with bipolar I disorder: a multicenter, randomized, placebo-controlled clinical trial with inhaled loxapine. Bipolar Disord. 201214:31-40.

12. Cook WW, Medley DM. Proposed hostility and pharisaic-virtue scales for the MMPI. J Appl Psychol. 195438:414-418.

13. Buss AH, Durkee A. An inventory for assessing different kinds of hostility. J Consult Psychol. 195721:343-349.

14. Caine TM, Foulds GA, Hope K. Manual of the Hostility and Direction of Hostility Questionnaire (HDHQ). 3rd ed. London: University of London Press 1967.

15. Novaco RW. Anger violence and mental disorder: the development and validation of an assessment procedure. Presented at: Meeting on Risk Special Studies September 1975 Pittsburgh.

16. Bunney WE Jr, Hamburg DA. Methods for reliable longitudinal observation of behavior. Arch Gen Psychiatry. 19639:280-294.

17. Hargreaves WA. Systematic nursing observations of psychopathology. Arch Gen Psychiatry. 196818:518-531.

18. Green RA, Bigelow L, O’Brien P, et al. The Inpatient Behavioral Rating Scale: a 26-item scale for recording nursing observations of patients’ mood and behavior. Psychol Rep. 197740:543-549.

19. Squier RW. An acute psychiatric rating scale for the clinical assessment of functionally disturbed inpatients. Acta Psychiat Scand. 199591:402-409.

20. Kay SR, Wolkenfeld F, Murrill LM. Profiles of aggression among psychiatric patients. II. Covariates and predictors. J Nerv Ment Dis. 1988176:547-557.

21. Plutchik R, van Praag HM. A self-report measure of violence risk, II. Compr Psychiatry. 199031:450-456.

22. Korn ML, Botsis AJ, Kotler M, et al. The Suicide and Aggression Survey: a semistructured instrument for the measurement of suicidality and aggression. Compr Psychiatry. 199233:359-365.


Intervention research

There are implications of these media effects studies for intervention work with young children. My colleagues Greta Massetti, PhD (now at the Centers for Disease Control and Prevention) and former graduate student Kirstin Gros, PhD (now at the Medical University of South Carolina) and I have developed an intervention program called the Early Childhood Friendship Project. In designing this intervention, we were mindful that any “friendship problems” or aggressive behavior that we depicted via puppet shows or stories would need to be connected to a resolution in close temporal proximity. We also made sure to keep our program developmentally appropriate and use behavioral reinforcement or developmentally appropriate labeled praise to encourage children to adopt our social skills and lessons rather than aggressive behavior.

Our first intervention study (Ostrov et al., 2009) was designed using available best practices and evidence-based models to reduce aggression and peer victimization and increase social skills, prosocial behavior and friendship formation skills (e.g., Reid & Webster-Stratton, 2001). Classrooms were randomly assigned to an intervention or control condition that lasted six weeks. We found moderate to large reductions in physical and relational aggression and peer victimization in the intervention classrooms relative to the control classrooms. We also documented moderate increases in prosocial behavior (e.g., inclusion of peers and sharing) in children that received the program compared to those that did not. Thus it appears that when steps are taken to carefully connect social skills or character development lessons with problematic aggressive behavior and coupled with developmentally appropriate reinforcement for engaging in positive behavior, we do not see the unintended effects that were present in our two media effects studies. We have just finished a replication trial of an expanded eight-week program and hope to share our findings soon.


Response to outbreaks [ edit | edit source ]

Timothy F. Jones, of the Tennessee Department of Health recommends the following action be taken in the case of an outbreak: Β]

  • Attempt to separate persons with illness associated with the outbreak.
  • Promptly perform physical examination and basic laboratory testing sufficient to exclude serious acute illness.
  • Monitor and provide oxygen as necessary for hyperventilation.
  • Minimize unnecessary exposure to medical procedures, emergency personnel, media or other potential anxiety-stimulating situations.
  • Notify public health authorities of apparent outbreak.
  • Openly communicate with physicians caring for other patients.
  • Promptly communicate results of laboratory and environmental testing to patients.
  • While maintaining confidentiality, explain that other people are experiencing similar symptoms and improving without complications.
  • Remind patients that rumors and reports of "suspected causes" are not equivalent to confirmed results.
  • Acknowledge that symptoms experienced by the patient are real.
  • Explain potential contribution of anxiety to the patient's symptoms.
  • Reassure patient that long-term sequelae from current illness are not expected.
  • As appropriate, reassure patient that thorough clinical, epidemiologic and environmental investigations have identified no toxic cause for the outbreak or reason for further concern.

Some responses by authority to MPI are not appropriate. Intense media coverage seems to exacerbate outbreaks. Α] Β] Ε] Once it is determined that the illness in psychogenic, it should not be given credence by authorities. Ε] For example, in the Singapore factory case study given above, calling in a medicine man to perform an exorcism seemed to perpetuate the outbreak. ⎗]


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Comments:

  1. Mac An Bharain

    I'm sorry, of course, but I think it's obvious.

  2. Powell

    Won't go that way.

  3. Molmaran

    Excuse, it is removed

  4. Grantland

    Everything, I'm getting married on November 15. Congratulate me! Now I will rarely come to you.

  5. Kirkley

    What a fascinating question



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