Éléments contextuels associés à l'émission de comportements d'agitation verbale présentés par des personnes âgées institutionnalisées atteintes de démence

This research examines the contexts in which verbal agitation (VA) behaviours occur. The study was conducted with 15 participants suffering from dementia who live in an institution and display agitated behaviours. Participants were subject to observation assisted by a hand-held computer. The frequency and duration of agitation episodes were calculated. The time of day, the location, and the activity engaged in, the presence of other persons and use of physical restraint were noted. A total of 180 observation hours were conducted, with each participant being observed for 12 hours, from 8 a.m. to 8 p.m. The results show that the participants are verbally agitated 10% of the time. VA is manifested when participants are in their rooms (94%), not engaged in a specific activity (81%), alone (80%) and physically restrained (78%). VA occurs mainly after 2 p.m. (73%). Certain contextual characteristics rather than others are associated with greater VA concentrations.     

Pharmacologic treatment of schizophrenia: what the future holds

The advent of the newer "atypical" antipsychotics has revolutionized pharmacologic treatment of schizophrenia (SZ) and other psychotic disorders. In contrast to the first-generation conventional neuroleptics, these second-generation antipsychotic agents possess a broader spectrum of efficacy and cause fewer motor side effects such as extrapyramidal symptoms and tardive dyskinesia. Despite their substantial advantages, however, these second-generation agents also have significant limitations in terms of both efficacy and adverse effects. Several strategies to address these shortcomings are currently under study and some of these are likely to become part of our therapeutic armamentarium in the future. Current shortcomings in the pharmacologic treatment of SZ and strategies under investigation to address each of these deficiencies are reviewed. New formulations of existing medications and new antipsychotics under development are discussed. Developing adjunctive treatment strategies to address each of the major psychopathologic domains in SZ are summarized. The potential application of genetic information to treatment-matching in SZ is reviewed and likely refinements in the practice of evidence-based medicine in the pharmacotherapy of SZ are considered.     

齐拉西酮与氯丙嗪对精神分裂症首次发作患者心电图影响的比较研究

为了探讨齐拉西酮与氯丙嗪对首发精神分裂症患者心电图（ECG）的影响,将221例首发精神分裂症患者随机分为两组,齐拉西酮组111例,氯丙嗪组110例,分别给予齐拉西酮和氯丙嗪治疗。于治疗前和治疗后的第2、4、8周末定期进行心电图检查,并对两组患者的心电图结果进行对比分析。服药后两组患者的心电图均有不同程度的改变,以窦性心动过速和ST—T改变为主,齐拉西酮组与氯丙嗪组患者心电图异常发生率分别为24．3％、54．5％,齐拉西酮组所致心电图改变明显低于氯丙嗪组（P〈0．01）。齐拉西酮与氯丙嗪治疗精神分裂症疗效相当,而齐拉西酮对首发精神分裂症患者心电图的影响显著低于氯丙嗪,临床安全性高。     

Toward a tripartite model of intrinsic motivation

Intrinsic motivation (IM) refers to engaging in an activity for the pleasure inherent in the activity. The present article presents a tripartite model of IM consisting of IM to know (i.e., engaging in an activity to experience pleasure while learning and trying to understand something new), IM toward accomplishment (i.e., engaging in an activity for the pleasure experienced when attempting task mastery), and IM to experience stimulation (i.e., engaging in an activity for feelings of sensory pleasure). The tripartite model of IM posits that each type of IM can result from task, situational, and personality determinants and can lead to specific types of cognitive, affective, and behavioral outcomes. The purpose of this research was to test some predictions derived from this model. Across 4 studies (Study 1: N = 331; Study 2: N = 113; Study 3: N = 58; Study 4: N = 135), the 3 types of IM as well as potential determinants and consequences were assessed. Results revealed that experiencing one type of IM over the others depends in part on people's personality styles. Also, each type of IM was found to predict specific outcomes (i.e., affective states and behavioral choices). The implications of the tripartite model of IM for motivation research are discussed.     

Patient preferences for medicine administration for acute agitation: results from an internet-based survey of patients diagnosed with bipolar disorder or schizophrenia in two Nordic countries

The objective was to elicit patient preferences for medicine administration method in the management of acute agitation episodes among patients diagnosed with bipolar disorder or schizophrenia. The patients’ experiences of acute agitation episodes and their management of episodes were also explored. Data were collected via an anonymous, internet-based survey of residents in Denmark or Sweden with schizophrenia or bipolar disorder (October 2014 to December 2014). Inclusion criteria were having a diagnosis of schizophrenia or bipolar disorder, and being above 18 years of age. The questionnaire included questions about preferences for medication attributes, experiences with pharmacological treatment for agitation and involvement in treatment plans. A total of 237 diagnosed patients (61 with schizophrenia; 176 with bipolar disorder) completed the questionnaire. Agitation episodes were experienced by 90% of the respondents. In total, 83% of the respondents reported having received treatment with tablets. When patients were presented with the attributes of an inhalation method, respondents stated that the fast onset of action, low risk of adverse reactions and least invasive form of drug delivery were positive attributes of treatment with inhalation. Inhalation is a new delivery route for treatment of acute agitation in patients diagnosed with bipolar disorder or schizophrenia. Inhalation is the preferred treatment method for acute agitation among Danish and Swedish patients with bipolar disorder or schizophrenia.     

Delivering a Brief Insomnia Intervention to Depressed VA Primary Care Patients

Primary care is often the place where patients with depression and comorbid insomnia seek treatment. The experience of comorbid insomnia with depression can have a significant impact on the efficacy of other depression treatments and exacerbate depressive symptoms. Using the empirically based Cognitive-Behavioral Treatment for Insomnia (CBT-I) to target the comorbid experience of insomnia in patients with depression can help improve sleep and potentially modify some depressive symptoms. Additional rationale for such an approach includes that a positive therapeutic experience may enhance engagement with or adherence to other psychotherapeutic interventions. Although other brief CBT-I interventions have been developed for primary care, none of them were actually delivered to depressed patients or implemented in primary care. Therefore, this paper describes a brief CBT-I intervention that was designed to be delivered in 4 sessions lasting from 15 to 45 minutes each within a primary care setting to depressed veterans. A case study is provided along with sample materials used in this intervention. In addition, we share implementation tips based on our experiences and feedback from eight veterans who have completed the intervention to date. Overall, the intervention was generally well received and suggests that the intervention may be feasibly delivered in a primary care setting.     

Comparative effectiveness of CBT interventions for co-morbid chronic pain & insomnia: A pilot study

IntroductionChronic pain is difficult to treat and often precedes or exacerbates sleep disturbances such as insomnia. Insomnia, in turn, can amplify the pain experience. Both conditions are associated with inflammatory processes, which may be involved in the bi-directional relationship between pain and sleep. Cognitive behavioral therapy (CBT) for pain and CBT for insomnia are evidence based interventions for, respectively, chronic pain and insomnia. The study objectives were to determine the feasibility of combining CBT for pain and for insomnia and to assess the effects of the combined intervention and the stand alone interventions on pain, sleep, and mood outcomes compared to a control condition.MethodsTwenty-one adults with co-occurring chronic pain and chronic insomnia were randomized to either CBT for pain, CBT for insomnia, combined CBT for pain and insomnia, or a wait-list control condition.ResultsThe combined CBT intervention was feasible to deliver and produced significant improvements in sleep, disability from pain, depression and fatigue compared to the control condition. Overall, the combined intervention appeared to have a strong advantage over CBT for pain on most outcomes, modest advantage over both CBT for insomnia in reducing insomnia severity in chronic pain patients.DiscussionCBT for pain and CBT for insomnia may be combined with good results for patients with co-occurring chronic pain and insomnia.     

Sleep-Related Safety Behaviors and Dysfunctional Beliefs Mediate the Efficacy of Online CBT for Insomnia: A Randomized Controlled Trial

Several trials have demonstrated the efficacy of online cognitive behavioral therapy (CBT) for insomnia. However, few studies have examined putative mechanisms of change based on the cognitive model of insomnia. Identification of modifiable mechanisms by which the treatment works may guide efforts to further improve the efficacy of insomnia treatment. The current study therefore has two aims: (1) to replicate the finding that online CBT is effective for insomnia and (2) to test putative mechanism of change (i.e., safety behaviors and dysfunctional beliefs). Accordingly, we conducted a randomized controlled trial in which individuals with insomnia were randomized to either online CBT for insomnia (n = 36) or a waiting-list control group (n = 27). Baseline and posttest assessments included questionnaires assessing insomnia severity, safety behaviors, dysfunctional beliefs, anxiety and depression, and a sleep diary. Three- and six-month assessments were administered to the CBT group only. Results show moderate to large statistically significant effects of the online treatment compared to the waiting list on insomnia severity, sleep measures, sleep safety behaviors, and dysfunctional beliefs. Furthermore, dysfunctional beliefs and safety behaviors mediated the effects of treatment on insomnia severity and sleep efficiency. Together, these findings corroborate the efficacy of online CBT for insomnia, and suggest that these effects were produced by changing maladaptive beliefs, as well as safety behaviors. Treatment protocols for insomnia may specifically be enhanced by more focused attention on the comprehensive fading of sleep safety behaviors, for instance through behavioral experiments.     

Cognitive-behavioral therapy of insomnia: A clinical case series study of patients with co-morbid disorders and using hypnotic medications

Cognitive-behavioral therapy for insomnia (CBTi) has demonstrated considerable efficacy within randomized clinical trials and case-series designs. This case-series study in a community sleep medicine clinic assessed the effectiveness of an eight-session CBTi protocol chronic insomnia patients who were allowed to continue their use of hypnotics (intent-to-treat n = 48), administered by a clinical psychology doctoral student receiving training and supervision in CBTi by a behavioral sleep medicine certified clinician. Outcome measures included daily sleep diaries, self-report measures on insomnia severity, dysfunctional beliefs and attitudes about sleep, daytime sleepiness, as well as medication usage. Patients showed significant improvements in sleep onset latency, wake time after sleep onset, sleep efficiency, insomnia severity, and dysfunctional sleep beliefs from pre- to post-treatment. No changes were seen in daytime sleepiness - patients were not excessively sleepy either before or after treatment. Use of sleep medication declined significantly from 87.5% pre-treatment to 54% post-treatment, despite no active efforts to encourage patients to withdraw. Results demonstrate that a CBTi conducted in a community sleep medicine clinic with patients not required to discontinue sleep-related medications can have similar effects as therapy delivered among those not on medication.     

The Influence of Applicant and Interviewer Characteristics on the Use of Impression Management1

This study investigated the relationship between characteristics of applicants and interviewers, and type and amount of impression management (IM) used by applicants in the employment interview. Specifically, applicant self-monitoring, self-esteem, locus of control, age, and training, and interviewer communication apprehension, interpersonal communication skill, age, and experience all were expected to influence the type and amount of IM behavior exhibited by applicants in the employment interview. Data from 64 field interviews confirmed that characteristics of the interviewer and, to a lesser extent, characteristics of the applicants were related to the use of IM tactics by applicants.     

Incorporating Principles from Acceptance and Commitment Therapy into Cognitive-Behavioral Therapy for Insomnia: A Case Example

Although traditional cognitive behavioral treatments for insomnia have demonstrated efficacy for many individuals with primary and comorbid insomnia, not all individuals benefit from treatment and some experience a subsequent relapse of insomnia. Furthermore, many individuals experience difficulty in implementing the sleep restriction and stimulus control strategies, especially over the long-term. The current article describes ways in which principles from a newer type of behavior therapy, Acceptance and Commitment Therapy (ACT), can be integrated with traditional behavioral treatment strategies for insomnia. A major goal of ACT is to increase willingness to experience unpleasant thoughts, feelings, and physical sensations, and to promote engagement in personally-valued behaviors while non-judgmentally observing these unpleasant experiences. ACT has the potential to enhance the behavioral treatment of insomnia by fostering willingness to experience short-term discomfort (e.g., fatigue) that occurs while implementing sleep restriction and stimulus control strategies. A case example is presented to illustrate how these principles from ACT can be integrated with behavioral techniques in the treatment of insomnia.     

氟哌啶醇与丙咪嗪交互作用对成本效益决策的影响

本实验采用T迷宫延迟奖赏模型研究多巴胺D2受体拮抗剂氟哌啶醇和5-羟色胺重摄取抑制剂丙咪嗪的交互作用对成本效益决策的影响, 同时探讨了延迟时间对决策的影响。T迷宫两臂分别设置为低成本-低奖赏端和高成本-高奖赏端。实验结果发现：氟哌啶醇能够降低大鼠选择高成本-高奖赏端的次数, 丙咪嗪则能够增加大鼠选择高成本-高奖赏端的次数; 在同时注射这两种药物情况下, 丙咪嗪能够抑制由氟哌啶醇引起的对低成本-低奖赏端的选择倾向。另外, 实验发现, 随延迟时间的增加大鼠选择高成本-高奖赏端的次数相对减少。由此可见, 丙咪嗪能够反转由氟哌啶醇导致的对低成本-低奖赏端的选择倾向, 这可能是由于细胞间5-羟色胺含量的升高部分反转了由多巴胺系统受损导致的行为倾向; 延迟时间的改变可对决策倾向产生逆转, 因此成本的支出即延迟时间也是影响成本效益决策的重要因素。     

Comparative meta-analysis of behavioral interventions for insomnia and their efficacy in middle-aged adults and in older adults 55+ years of age.

Meta-analyses support the effectiveness of behavioral interventions for the treatment of insomnia, although few have systematically evaluated the relative efficacy of different treatment modalities or the relation of old age to sleep outcomes. In this meta-analysis of randomized controlled trials (k = 23), moderate to large effects of behavioral treatments on subjective sleep outcomes were found. Evaluation of the moderating effects of behavioral intervention type (i.e., cognitive-behavioral treatment, relaxation, behavioral only) revealed similar effects for the 3 treatment modalities. Both middle-aged adults and persons older than 55 years of age showed similar robust improvements in sleep quality, sleep latency, and wakening after sleep onset. A research agenda is recommended to examine the mechanisms of action of behavioral treatments on sleep with increased attention to the high prevalence of insomnia in older individuals.     

Quantitative criteria for insomnia

Formal diagnostic systems (DSM-IV, ICSD, and ICD-10) do not provide adequate quantitative criteria to diagnose insomnia. This may not present a serious problem in clinical settings where extensive interviews determine the need for clinical management. However, lack of standard criteria introduce disruptive variability into the insomnia research domain. The present study reviewed two decades of psychology clinical trials for insomnia to determine common practice with regard to frequency, severity, and duration criteria for insomnia. Modal patterns established frequency (> or =3 nights a week) and duration (> or =6 months) standard criteria. We then applied four versions of severity criteria to a random sample and used sensitivity-specificity analyses to identify the most valid criterion. We found that severity of sleep onset latency or wake time after sleep onset of: (a) > or =31 min; (b) occurring > or =3 nights a week; (c) for > or =6 months are the most defensible quantitative criteria for insomnia.     

Differential antagonism of cocaine self-administration and cocaine-induced disruptions of learning by haloperidol in rhesus monkeys

Six rhesus monkeys responding under a three-component multiple schedule were administered haloperidol to determine its effects on cocaine self-administration and on cocaine's disruptive effects on the repeated acquisition and performance of response chains. In the absence of haloperidol, 0.0032-0.032 mg/kg/infusion of cocaine increased response rate and the number of infusions in the self-administration component when compared to saline administration, whereas 0.1-0.32 mg/kg/infusion decreased response rate and the number of infusions. When compared to saline administration, the two lowest infusion doses of cocaine had little or no effect on responding in the acquisition and performance components; however, higher infusion doses of cocaine dose-dependently decreased response rate in these components. In addition, the higher doses of cocaine also increased the percentage of errors in the acquisition and performance components. Pretreatment with haloperidol (0.0032 or 0.01 mg/kg, i.m.) antagonized the effects of low doses of cocaine on the number of infusions in the self-administration component, whereas only the 0.01-mg/kg dose antagonized the effects of high doses of cocaine on the number of infusions. Neither dose of haloperidol antagonized the rate-decreasing effects of cocaine on responding in the acquisition and performance components significantly; the highest dose of haloperidol alone decreased rates of responding in each component. Antagonism of cocaine's error-increasing effects by haloperidol was only evident at one dose of cocaine (0.032 mg/kg/infusion), and was more complete in the performance components than in the acquisition components. Together, these data show the limited suitability of haloperidol for selectively antagonizing cocaine self-administration in the context of a multiple schedule involving transition behavior, and show the lack of uniform antagonism across operant behaviors.     

Required relaxation: a method of inhibiting agitative-disruptive behavior of retardates

Institutionalized retardates frequently exhibit agitative-disruptive behavior. Recent experiments have shown that overcorrective training in specific types of behavior can inhibit inappropriate behavior. A procedure was developed in which overcorrective practice in relaxation was given to each of eight adult retardates for their disruptions. The agitated resident was required to spend a fixed period of time in relaxation in his own bed upon each occurrence of agitation. This overcorrective relaxation resulted in a rapid, enduring and almost complete reduction in such behavior as self-injury, threats, physical aggression, screaming, crying, cursing and tantrums. Ward attendants strongly preferred the required relaxation procedure to the time-out technique and other inhibition procedures they had used. The procedure appears to be about as effective as alternative techniques and to have the advantages of ease of implementation and acceptability by ward staff and retardates as a ‘reasonable’ reaction to agitation.     

Studies of open-loop pointing in the presence of induced motion

In the present research, we examined the influence of induced motion (IM) on open-loop pointing responses and the possibility that IM alters the registration of either eye or trunk position. In two experiments, subjects tracked a dot that oscillated vertically while a rectangular stimulus oscillated horizontally. The pairing of frame and dot motion caused the dot to appear to move on a slant, due to IM. In the first experiment, the subjects made judgments of the apparent slant of the dot's motion and, on separate trials, pointed open loop at the apparent location of the dot at the endpoints of its motion. Both responses were influenced by IM, although the effect on dot localization was less than the amount predicted by the IM, as indicated by the slant responses. Results were similar immediately following IM and after a 5-sec delay. In the second experiment, the subjects pointed open loop either at the apparent location of the endpoints of the tracked dot's motion or at the apparent location of one of three other briefly flashed stationary dots. The pointing responses directed toward the fixated IM target were influenced by IM to a greater extent than the responses directed toward the stationary dots. The results of the two experiments are inconsistent with the hypothesis that the effect of IM on open-loop pointing at the IM target results completely from altered perception of either eye or trunk position, since misregistration of either would be expected to influence, in a similar fashion, pointing at both the tracked dot and the briefly flashed, stationary targets.     

Psychological treatment of secondary insomnia

Psychological treatment of insomnia has focused on primary insomnia (i.e., having a psychological origin). Secondary insomnia, sleep disturbance caused by a psychiatric or medical disorder, although it is more common than primary insomnia, has received very little attention as a result of the belief that it would be refractory to treatment. The present study randomly assigned older adults with secondary insomnia to a treatment group, 4 sessions composed of relaxation and stimulus control, or a no-treatment control group. Self-report assessments conducted at pretreatment, posttreatment, and a 3-month follow-up revealed that treated participants showed significantly greater improvement on wake time during the night, sleep efficiency percentage, and sleep quality rating. The authors hypothesize that treatment success was probably due in part to difficulty in diagnostic discrimination between primary and secondary insomnia.