Experience Of Withdrawal Research Articles

Harmful Outcomes in Patients Admitted to Yeovil District Hospital in Acute Alcohol Withdrawal

AimsOur aim was to assess what proportion of patients in Acute Alcohol Withdrawal (AAW) experience harm during their admission to hospital. Our hypothesis was that patients who came to harm were likely to have had sub-optimal withdrawal management. Therefore, we also aimed to identify any underlying issues in the way AAW is currently managed which may be contributing to harmful outcomes.MethodsInclusion criteria for the audit was inpatients at Yeovil District Hospital over a three-month period from May to July 2021, clinically coded under the heading ‘alcohol abuse’, with a minimum two-day admission. Data were gathered from the patients’ medical notes. An outcome was determined as harmful if firstly, it occurred during the withdrawal period, and secondly it was clinically feasible that it had occurred at least in part, as a result of poor AAW management. Notes from 15 patients were qualitatively reviewed, guided by NICE recommendations, to assess both adherence to, and suitability of YDH AWW policy.ResultsAlcohol abuse was identified at the time of medical clerking in all 15 patients. Audit-C scores were completed in 7 patients. All 15 patients had CIWA scoring initiated within 1 hour of clerking, and chlordiazepoxide prescribed as a STAT dose and then a fixed PRN dose according to whether CIWA score was above 10 or not. 10 patients had their CIWA scores monitored for at least 24 hours. 3 out of 15 inpatients had harmful outcomes, including falls, intracerebral haemorrhage, fractured neck of femur, and cardiac arrest.ConclusionOverall, adherence to YDH guidelines was good. Despite this, a high proportion of patients admitted under our care were harmed as a result of inadequate management of alcohol withdrawal. Where issues were identified, these were arguably linked to problems with the YDH AAW policy itself. Unclear guidance over how long to monitor CIWA scores, limitation of chlordiazepoxide doses to 10 mg for even the highest CIWA scores, and omission of Audit-C score in the current hospital guidelines, are suggested as contributors to harm in the three patients identified. Going forward, it will be important to review and make appropriate changes to the YDH policy in these areas according to NICE recommendations, to protect our patients from further harm. These results may well have wider implications in terms of adjustment to AAW policy at other hospitals across the UK.

P024 Real-world experience of Tocilizumab withdrawal in GCA

Abstract Background/Aims Part 2 of the GIACTA trial explored the maintenance of efficacy in giant cell arteritis (GCA) patients. It showed that nearly half the patients treated with weekly tocilizumab (TCZ) maintained remission, though flares did still occur in the remaining half when TCZ was discontinued. Currently, NHS England has approved the use of TCZ in GCA for only 1 year as this duration was agreed upon by clinical experts to be sufficient to sustain remission. However, this remains a point of concern amongst clinicians as to whether data from real-life patients confirms that 1 year of TCZ can achieve sustainable remission. Methods Our objective is to assess the real-world experience of TCZ withdrawal in GCA patients and how different centres are trying to mitigate risk of relapse after its cessation. We are conducting a patient survey across six hospitals in Wessex, United Kingdom. Our aim is to assess the change in clinical features, acute phase reactants and the rate of sustained remission and relapse. Results 53 patients with GCA were included in the survey. Average age of patients was 73.5 years. 36 patients had cranial GCA, five had large vessel vasculitis and no sub-type was mentioned for the 12 remaining patients. Temporal artery biopsy was the most common diagnostic tool used for 21 patients, followed by PET scan for 14 patients. Eight patients had a clinical diagnosis only, while seven were diagnosed with GCA based on findings of Anterior Ischaemic Optic Neuropathy. Only three patients had their diagnosis confirmed via ultrasound temporal arteries. Out of these 53 patients, 45 started Tocilizumab. 15 patients stopped treatment due to side effects. Of the remaining 30 patients, only 17 have completed their 1 year of TCZ so far. Two patients relapsed 6 months after stopping TCZ. One of them was on methotrexate (MTX) and low dose prednisolone, while other was on mycophenolate mofetil only. Of those who are currently stable since completing TCZ, five patients are on MTX with prednisolone, one patient on leflunomide and prednisolone, four patients on prednisolone only and three patients on MTX only. Two patients are on no treatment currently. Conclusion This is an ongoing study. Our figures so far show that most patients are still on treatment with steroids and MTX, either alone or in combination, after completing 1 year of TCZ. This could be due to clinicians trying to mitigate against relapse once TCZ is withdrawn. This study highlights that real-world data on relapse/remission rates following TCZ withdrawal is essential as it will help shape future GCA treatment and guidelines. Disclosure S. Khalid: None. B. Davidson: None. N. Hopkinson: None. A. Mason: None. M. Malik: None. F. Laskou: None. L. Parker: None.

Differential Experience of Interdose Withdrawal During Long-Term Opioid Therapy and its Association With Patient and Treatment Characteristics: A Latent Class Analysis in Chronic Pain Population

Opioid withdrawal is characterized by a set of physical and psychological symptoms that depend on both opioid and patient specific characteristics. The present study aims to identify different latent classes of chronic pain patients according to the type of opioid withdrawal symptoms experienced, and to analyze the relationships between the classes and demographic, opioid therapy, psychological and substance use variables. This cross-sectional descriptive study included 391 chronic pain patients on long-term opioid therapy. A Latent Class Analysis (LCA) identified 3 classes (BIC = 7051.89, entropy = .87, LRTs P < .01). The mild withdrawal class showed low probabilities of presenting physical and psychological symptoms, the moderate withdrawal class was characterized by experiencing psychological symptoms, and the severe withdrawal class stood out for high probabilities of presenting both types of symptoms. The classes differed from each other, with higher rates of moderate-severe POUD, opioid misuse, anxiety, depression, and greater pain intensity and interference in more severe withdrawal classes (P < .05). The multinomial logistic regression showed that moderate-severe POUD and anxiety were the strongest variables related to moderate (ORPOUD = 3.34, ORAnxiety = 2.58) and severe withdrawal classes (ORPOUD = 4.26, ORAnxiety = 5.15). Considering that POUD and anxiety were strongly related to a more severe withdrawal syndrome, the inclusion of psychological interventions in pain management seems critical in this population. PerspectiveAlthough interdose opioid withdrawal is common in chronic pain patients, this study shows 3 different patterns in its experience (mild, moderate, and severe withdrawal). A more severe withdrawal may result in reduced effectiveness of opioids in relieving pain and increased negative consequences, such as higher risk of POUD. Findings that could help improve chronic pain management.

The effects of oxytocin and vasopressin administration on fathers’ neural responses to infant crying: A randomized controlled within-subject study

In a randomized double-blind within-subject control study we investigated the effects of oxytocin and vasopressin administration on neural reactivity to infant cry sounds in 70 first-time fathers in the first year of fatherhood. Additionally, we examined whether effects of oxytocin and vasopressin administration on neural reactivity were moderated by fathers’ early childhood experiences. Neural reactivity to infant cry sounds (versus control sounds) was measured using functional magnetic resonance imaging (fMRI). Furthermore, participants reported on their childhood experiences of parental harsh discipline and parental love withdrawal. Whole brain analyses revealed no significant effect of vasopressin or oxytocin administration on neural activation in response to infant cry sounds. Region of interest analyses showed decreased amygdala activation in both the oxytocin condition and the vasopressin condition as compared to placebo. We found no moderating effects of fathers’ early childhood experiences. Our findings suggest that oxytocin administration may decrease feelings of anxiety or aversion to a crying infant. Whether decreased amygdala activation after vasopressin administration might be explained by contextual factors (e.g., absence of high levels of threat, unfamiliarity of the infant) or represents an affiliative response to infant distress warrants further investigation. Findings of the present study showed that oxytocin and vasopressin are important hormones implicated in neural models of infant cry perception in fatherhood.

Reddit discussions about buprenorphine associated precipitated withdrawal in the era of fentanyl

Background Induction of buprenorphine, an evidence-based treatment for opioid use disorder (OUD), has been reported to be difficult for people with heavy use of fentanyl, the most prevalent opioid in many areas of the country. In this population, precipitated opioid withdrawal (POW) may occur even after individuals have completed a period of opioid abstinence prior to induction. Our objective was to study potential associations between fentanyl, buprenorphine induction, and POW, using social media data. Methods This is a mixed methods study of data from seven opioid-related forums (subreddits) on Reddit. We retrieved publicly available data from the subreddits via an application programming interface, and applied natural language processing to identify subsets of posts relevant to buprenorphine induction, POW, and fentanyl and analogs (F&A). We computed mention frequencies for keywords/phrases of interest specified by our medical toxicology experts. We further conducted manual, qualitative, and thematic analyses of automatically identified posts to characterize the information presented. Results: In 267,136 retrieved posts, substantial increases in mentions of F&A (3 in 2013 to 3870 in 2020) and POW (2 in 2012 to 332 in 2020) were observed. F&A mentions from 2013 to 2021 were strongly correlated with mentions of POW (Spearman’s ρ: 0.882; p = .0016), and mentions of the Bernese method (BM), a microdosing induction strategy (Spearman’s ρ: 0.917; p = .0005). Manual review of 384 POW- and 106 BM-mentioning posts revealed that common discussion themes included “specific triggers of POW” (55.1%), “buprenorphine dosing strategies” (38.2%) and “experiences of OUD” (36.1%). Many reported experiencing POW despite prolonged opioid abstinence periods, and recommended induction via microdosing, including specifically via the BM. Conclusions Reddit subscribers often associate POW with F&A use and describe self-managed buprenorphine induction strategies involving microdosing to avoid POW. Further objective studies in patients with fentanyl use and OUD initiating buprenorphine are needed to corroborate these findings. HIGHLIGHTS Increase in mentions of precipitated opioid withdrawal (POW) on Reddit from 2012 to 2021 was associated with the increase in fentanyl and analog mentions. Experiences of precipitated opioid withdrawal (POW) were described by individuals despite reporting prolonged periods of abstinence compared to standard buprenorphine induction protocols. People with Opioid Use Disorder (OUD) on Reddit are using and recommending microdosing strategies with buprenorphine to avoid POW. People who used fentanyl report experiencing POW following statistically longer periods of abstinence than people who use heroin.

Identifying Clusters of Adolescents Based on Their Daily-Life Social Withdrawal Experience.

Social withdrawal is often presented as overall negative, with a focus on loneliness and peer exclusion. However, social withdrawal is also a part of normative adolescent development, which indicates that groups of adolescents potentially experience social withdrawal differently from one another. This study investigated whether different groups of adolescents experienced social withdrawal in daily life as positive versus negative, using experience sampling data from a large-scale study on mental health in general population adolescents aged 11 to 20 (n = 1913, MAge = 13.8, SDAge = 1.9, 63% female) from the Flemish region in Belgium. Two social withdrawal clusters were identified using model-based cluster analysis: one cluster characterized by high levels of positive affect and one cluster characterized by high levels of negative affect, loneliness and exclusion. Logistic regression showed that boys had 66% decreased odds of belonging to the negative cluster. These results show that daily-life social withdrawal experiences are heterogeneous in adolescence, which strengthens the view that, both in research and clinical practice, social withdrawal should not be seen as necessarily maladaptive.

Free Papers Compiled

Background:Alcohol withdrawal syndrome occurs in patients who have decreased or discontinued taking alcohol most patients who undergo withdrawal experience mild to moderate symptoms including nausea vomiting agitation however delirium tremens occurs in very few individuals and is associated with significant mortality and morbidityAim:To assess Prevalence end correlate of delirium tremens in male Alcoholics.Materials and Methods:All adult patients admitted above the age of 18 years Who did not have early manifestation of DT at zero time they were at risk for alcohol withdrawal syndrome at zero time and they were admitted primarily for detoxification from alcohol. the patients who were already in delirium or had very low chances of going into delirium were excluded. They were assessed with a self made Socio demographic proforma,Severity of alcohol dependence questionnaire, clinical institute withdrawal assessment of alcohol scale revised.Results:30 % males with alcohol dependence went into delirium tremens. Net income ,education ,years since consuming, amount and type of alcohol had an impact on prevalence of delirium tremens.Conclusion:Chances of delirium tremens increases with factors like age , net income, employment and also time since consuming , type and amount of alcohol.

Unbinding Isaac: The Significance of the Akedah for Modern Jewish Thought

Unbinding Isaac: The Significance of the Akedah for Modern Jewish Thought

Patterns of withdrawal in patients with opioid use disorder (OUD) transitioning from untreated OUD or buprenorphine treatment to extended-release naltrexone

ABSTRACT Background Pharmacologic treatment is recommended for many individuals with opioid use disorder (OUD). For patients who select opioid antagonist treatment, effective management of opioid withdrawal symptoms during transition to antagonist treatment requires consideration of the patient experience. Objectives To compare patterns of opioid withdrawal between those withdrawing from untreated opioid use and those withdrawing from buprenorphine. Methods We performed a post hoc, cross-study comparison of the temporal pattern of opioid withdrawal during 1-week induction onto extended-release naltrexone by similar protocols enrolling two participant populations: participants with OUD entering a study with untreated opioid use (N = 378, NCT02537574) or on stable buprenorphine (BUP) treatment (N = 101, NCT02696434). Results The temporal pattern of withdrawal from induction day 1 through day 7 differed between the two participant populations for Clinical Opiate Withdrawal Score (COWS) and Subjective Opiate Withdrawal Score (SOWS): participants with untreated OUD prior to study entry were more likely to experience an earlier relative peak in opioid withdrawal followed by a gradual decline, whereas participants on stable BUP treatment prior to study entry were more likely to experience a relatively later, though still mild, peak opioid withdrawal. The peak COWS was reached at a mean (standard deviation) of 1.9 (1.5) days for participants with untreated OUD and 5.0 (1.5) days for participants on stable BUP. Daily peak cravings were generally higher for participants with untreated OUD than participants on stable BUP. Conclusion Awareness of population-specific variations in the patient experience of opioid withdrawal may help clinicians anticipate the expected course of withdrawal.

Experts in Self-Isolation? Monastic Outreach during Lockdown

This paper draws on digital ethnography to examine the experience of a Catholic English Benedictine monastery in the context of restrictions on religious gatherings during the global COVID-19 pandemic. As the monks expand their digital presence and social media involvement, it is their experience of social withdrawal and apparent expertise in self-isolation that provides the grounding for their public engagement. While Max Weber depicts the monk as a world-transcending “virtuoso”, in a time of lockdown, this separation from the world provides a point of connection with the experience of wider society.

Psychological Factors Associated with Social Withdrawal (Hikikomori).

ObjectiveCases of prolonged social withdrawal (hikikomori) have recently been reported in several countries. This study examined the impact of cognitive-behavioral and emotional factors on hikikomori behavior to identify intervention targets. Identifying such targets could facilitate the development of techniques to address hikikomori characteristics. MethodsTwo hundred Japanese individuals (mean age=38.73, SD=6.85) completed the Adaptive Behaviors Scale for Hikikomori and Stress Response Scale-18, along with the Japanese versions of the Self-Compassion Scale (Short Form), Acceptance and Action Questionnaire-II, and Brief Coping Orientation to Problems Experienced Inventory. Participants were divided into two groups: individuals with no experience of social withdrawal, and those with experience of social withdrawal. Results Hierarchical multiple regression analysis showed that the use of instrumental support, behavioral disengagement stress coping skills, self-compassion, and psychological stress were associated with hikikomori behaviors. Furthermore, higher instrumental support levels, associated with a decrease in hikikomori behaviors, were found in the hikikomori group. Conclusion The use of instrumental support, behavioral disengagement stress coping skills, self-compassion, and psychological stress should be targeted in hikikomori prevention interventions. Moreover, encouragement for the use of instrumental support is needed for improving hikikomori.

Drug and sexual HIV-risk behaviors among adolescents and young adults with opioid use disorder

Opioid use disorder (OUD) among adolescents and young adults (youth) is associated with drug use and sexual HIV-related risk behaviors and opioid overdose. This mixed methods analysis assesses risk behaviors among a sample of 15–21-year-olds (N = 288) who were being treated for OUD in a residential drug treatment program in Baltimore, Maryland. Participants were enrolled in a parent study in which they received either extended-release naltrexone (XR-NTX) or Treatment as Usual (TAU), consisting of outpatient counseling with or without buprenorphine, prior to discharge. At baseline, participants were administered the HIV-Risk Assessment Battery (RAB), and clinical intake records were reviewed to determine participants' history of sexual, physical, or other abuse, as well as parental and partner substance use. A sub-sample of study participants completed semi-structured qualitative interviews (N = 35) at baseline, three-, and six-month follow-up periods. This analysis identified gender (e.g., female IRR = 1.63, CI 1.10–2.42, p = .014), the experience of dependence (e.g., previous detoxification IRR = 1.08, CI 1.01–1.15, p = .033) and withdrawal (e.g., severe withdrawal symptoms IRR = 1.41, CI 1.08–1.84, p = .012), and the role of relationships (e.g., using with partner IRR = 2.45, CI 1.15–5.22, p = .021) as influencing high-risk substance use behaviors. Similarly, high-risk sex was influenced by gender (e.g., female IRR = 1.43, CI 1.28–1.59, p < .001), and the role of relationships (e.g., using with partner IRR = 0.78, CI 0.62–0.98, p = .036). These are key targets for future prevention, treatment, and intervention.

Learning from the experiences of Black, Asian and Minority Ethnic (BAME) university students who withdraw from their undergraduate degree

Students from a Black, Asian and Minority Ethnic (BAME) background are more likely to withdraw from their undergraduate degree in the United Kingdom (UK). It is therefore important to explore withdrawal experiences and perspectives that relate to this population of students to increase both student retention and success. Thirteen UK-domiciled, full-time undergraduate, first-degree entrants from a BAME background, who had withdrawn from a post-1992 university in the West Midlands, took part in a semi-structured interview. The present study explored BAME student experiences of withdrawal which covered personal, academic and social concerns. Using a thematic analysis approach, five themes were developed: (a) academic issues, (b) does anybody even care? (c) balancing part-time employment alongside HE, (d) family perception and pressure and (e) the importance of social integration. Participants often discussed withdrawal as a holistic experience whereby although certain aspects were more prominently spoken about, generally withdrawal was a materialisation of more than one problematic area. There is a need for institutions to further understand the challenges faced by BAME students in order to provide more localised support and intervention to improve BAME retention, success and experiences within higher education (HE).

Successful use of tapering strips for hyperbolic reduction of antidepressant dose: a cohort study.

Background:Tapering strips facilitate antidepressant discontinuation, allowing for personalised titration of discontinuation to the intensity of withdrawal. A tapering strip consists of antidepressant or other medication, packaged in a 28-day roll of daily pouches, each with the same or slightly lower dose than the one before. Previous studies demonstrated 70% real-world effectiveness of tapering strips. Here, we present a third, questionnaire-based retrospective cohort study in a large sample.Methods:Patients whose doctor had prescribed tapering strips between October 2015 and December 2018 were sent a questionnaire for participation after completion of tapering between December 2015 and January 2020. Of 1240 individuals who returned a questionnaire (response rate: 59%), 987 (80%) used an antidepressant, of whom 824 (83%) had wished to discontinue their antidepressant.Results:The sample was demographically representative of antidepressant users in the Netherlands. Less than 40% of participants had heard of tapering strips through their clinicians – Internet was the most frequent source. Of the 824 individuals, 341 (41%) had used strips for tapering venlafaxine, 206 (25%) for paroxetine and 277 (34%) for other antidepressants. Median duration of antidepressant use was 5–10 years, and most (71%) had tried to come off without tapering strips at least once. Most patients (72%) were able to discontinue their antidepressant, using a median of two strips to taper over a median period of 56 days. Females and individuals with (1) more severe experience of withdrawal during the use of tapering strips, (2) more years of use of antidepressant medication and (3) more previous attempts at discontinuation were less likely to be able to discontinue their antidepressant medication with tapering strips.Conclusion:The results of this study validate, for the third time, the observation that tapering strips can address the problem of antidepressant withdrawal symptoms in individuals attempting to discontinue antidepressants.

Experiences of Social Withdrawal: Why Aging Matters Among Individuals With Hemophilia Facing Unexpected Longevity

For the first time, individuals with hemophilia are living beyond their 30s and 40s. This cohort, many of whom had been dependent on donated blood and contracted HIV and hepatitis, face unique challenges as they age with hemophilia and other conditions. Little is known about the experiences and health needs of these adults over the age of 40. Scientific advances have changed the life course of individuals who received earlier treatment modalities. Today, a person with hemophilia who has received preventative synthetic treatment can look forward to a long, healthy and active life. Semi-structured telephone interviews (n=32) were conducted with long-term survivors, family members, and professionals who supported these families. Findings include shame, fear and coping through social withdrawal in order to hide their hemophilia to avoid assumptions of HIV status. Analyzing unexpected longevity and why age matters for this historically isolated cohort, we explore appropriate care models.

Issue of Accumulation and Redistribution of Oil and Gas Rental Income in the Context of Exhaustible Natural Resources in Arctic Zone of Russian Federation

The significant resource potential of the Arctic has attracted the attention of its adjacent countries and extra-regional states. The mineral and raw material base of the Arctic Zone of the Russian Federation (AZRF) comprises a wide range of minerals. However, due to its hydrocarbon reserves, the Arctic is considered to be the most important geopolitical and geo-economic macro-region for Russia. A significant portion of the Arctic hydrocarbons (about 19%) is concentrated in the territory of Russia’s shelf. The extraction of Arctic marine oil and gas resources and ensuring the sustainability of the Russian energy complex depend significantly on the level of Arctic development. Thus, the pace and quality of the development of AZRF are strategically important to ensure the national interests of the country. It has been proven that the implementation of the state program for AZRF development and strategic plans of the largest companies operating in the region consolidate the raw material nature of AZRF development. Rent becomes the main form of income. This article addresses the main directions of the region’s development and the factors that prevent a high level of industrialization, which increase attention to the withdrawal and redistribution of rental income. The article considers the Russian and foreign experiences of withdrawal and redistribution of oil and gas rental income, and analyzes the level of socio-economic development of AZRF. The authors suggest a methodology for assessing the impact of a country’s area and population size on the ability to achieve a high income due to hydrocarbons. The authors also explain the principles of rental income redistribution in the region as a basis for improving the level of AZRF’s socio-economic development and as a condition for transition from the “colonial model” of development to the “sustainable development” model. The study results can be used to elaborate a mechanism for rental income redistribution in AZRF and state programs for the region’s development.

Schizophrénie et rétablissement : analyse phénoménologique d’un cas de retrait positif

ObjectivesThe recovery paradigm has emerged in mental health over the last thirty years, referring to the subjective and dynamic process by which a person achieves a satisfying life, relying on his/her strengths, his/her values, and the very experience of his/her psychiatric illness. The understanding of the experience of people living with schizophrenia and engaged in a path of recovery is undermined by an objective and categorical psychiatric approach, targeting symptoms and deficits to be compensated. We propose a phenomenological approach to a clinical situation of positive withdrawal, as developed by Corin and Lauzon, as a form of recovery for the schizophrenic subject, in order to shed light on the first-person experience of what psychiatric semiology refers to as negative symptoms, apragmatism and social withdrawal. MethodWe develop the single case of Sam, 39 years old man who has been treated for schizophrenia for about 10 years. He talks about his “spiritual schizophrenia”, which has in the past generated a demon above his head guiding his aggressive behaviors. Since he was discharged from hospital three years ago, Sam has become an “ordinary person” again, according to him. His daily routine is ritualized by a weekly activity at the day hospital, daily nursing visits at home, television, and visits from two friends on weekends. He explains that he needs peace and quiet around him and like to be aware of his neighbourhood and village lives and events. He listens to his spiritual guides and his gift of clairvoyance, which predicted him, more happiness from his forties onwards by getting a job and by a love encounter. We propose a phenomenological analysis of his experience of recovery and positive withdrawal. ResultsSam's embodied experience was previously characterized by a confusion between the intentional and sensitive flesh (Leib) and the objectified body (Körper), disembodied and materialized as if on the outside by a demon on top of his head. Today, it seems to be re-articulated in a dialectic harmony between Leib and Körper. Sam inhabits his body in an embodied life, as an interface between himself, his history and the world. His relationship to space is characterized by the paradox of an opening to the shared world by keeping a distance from others. Sam gets punctually and cyclically involved in selected spaces that do not require any intimate social commitment, and stays on the lookout, from his home, for events in his neighborhood, his village, and world news. The Others participate in his distant integration into the community: his link with the mayor of the village validates his identity as a fully-fledged citizen, his family regularly invoked in his self-narrative is kept at a distance by monthly digital contacts, the neighbor's daily life must not be disturbed under penalty of divine punishment, etc. Sam claims a necessity of calm both inside and outside, as a support for a controlled intersubjectivity allowing the reconstruction of the self. Finally, the patient's temporality is structured by patience. À slow-now allows him to synchronize private and public paces. His esoteric beliefs give meaning to the cyclical repetition of events; his spiritual guides direct his life trajectory, promising him professional and relational dynamism from the age of forty. ConclusionÀ phenomenological approach as close as possible to the subjective experience of the person living with schizophrenia has made it possible to break loose from the social withdrawal symptom pointed out by psychiatric semiology. Positive withdrawal, as an active positioning of the subject both inside and outside the society, illustrates a process of recovery from the illness. By supporting an identity reconstruction through a dialectical tension between proximity and distance with the Other and the world, positive withdrawal reveals the importance of considering the paradoxical shape of recovery processes. It invites clinicians to free oneself from normative interventions motivated by a restrictive psychiatric empiricism.

The Relationship Between Life Attitude and Death Coping Self-Efficacy in Intensive Care Nurses

Critical care nurses must often care for patients who are dying and their families. Thus, understanding the self-efficacy and life attitudes of nursing staff in the ICU in response to death is important to the development and provision of relevant education and training. This study was designed to explore the self-efficacy of ICU nurses in response to death and related predictive factors. This was a cross-sectional research study. The subjects were 216 nurses in the adult ICU of a medical center in northern Taiwan. The research tools used included the death coping self-efficacy scale and the life attitude scale. Data were analyzed using Pearson's correlation, t-test, one-way ANOVA, and multiple regression. The results showed: 1. In terms of death coping self-efficacy, the mean score was 112.0 ± 14.3, with the highest scoring subscale, hospice care, earning a mean score of 51.1 ± 6.3. In terms of life attitude, the mean score was 128.9 ± 13.8, with the highest scoring subscale, life autonomy, earning a mean score of 24.0 ± 3.2. 2. Nurses with experiences of withdrawal of life support had better coping efficacy (t = 1.94, p = .05) and those with a graduate degree or above earned a better average life attitude score than those educated to the university / junior college level. 3. Age and ICU seniority were found to correlate positively with grief-related coping skills (r = .241- .315), with the life-attitude subscales of aspiring, life-autonomy, love, and caring showing positive correlations with death coping self-efficacy (r = .138- .482). 4. The predictors found in this study for death coping self-efficacy were age, aspiring, life-autonomy, love, and caring, with a total explained variance of 30.1% (F = 12.78, p < .001). The results of this study indicate that education level and having hospice care experience are both significant predictors of life attitude in ICU nurses, which is a factor that is known to affect self-efficacy in response to death. Life attitude and hospice care training programs for ICU nurses should be promoted to foster positive life attitudes and thereby enhance self-efficacy in response to death to improve the quality of intensive clinical care.

UK psychiatrists' experience of withdrawal of antipsychotics prescribed for challenging behaviours in adults with intellectual disabilities and/or autism.

A high proportion of adults with intellectual disabilities are prescribed off-licence antipsychotics in the absence of a psychiatric illness. The National Health Service in England launched an initiative in 2016, 'Stopping over-medication of people with a learning disability [intellectual disability], autism or both' (STOMP), to address this major public health concern. To gain understanding from UK psychiatrists working with adults with intellectual disabilities on the successes and challenges of withdrawing antipsychotics for challenging behaviours. An online questionnaire was sent to all UK psychiatrists working in the field of intellectual disability (estimated 225). Half of the 88 respondents stated that they started withdrawing antipsychotics over 5 years ago and 52.3% stated that they are less likely to initiate an antipsychotic since the launch of STOMP. However, since then, 46.6% are prescribing other classes of psychotropic medication instead of antipsychotics for challenging behaviours, most frequently the antidepressants. Complete antipsychotic discontinuation in over 50% of patients treated with antipsychotics was achieved by only 4.5% of respondents (n = 4); 11.4% reported deterioration in challenging behaviours in over 50% of patients on withdrawal and the same proportion (11.4%) reported no deterioration. Only 32% of respondents made the diagnosis of psychiatric illness in all their patients themselves. Family and paid carers' concern, lack of multi-agency and multidisciplinary input and unavailability of non-medical psychosocial intervention are key reported factors hampering the withdrawal attempt. There is an urgent need to develop national guidelines to provide a framework for systematic psychotropic drug reviews and withdrawal where possible.

Measuring Sequence of Returns Risk

The authors discuss the nature and importance of the concept of sequence risk, the risk that a bad return occurs at a particularly unfortunate time, such as around the point of maximum accumulation or the start of decumulation. This concept is especially relevant in the context of retirement savings, where the implications for withdrawal rates of a bad return can be particularly severe. They show how the popular “glidepath” or target-date savings products are very exposed to such risk. Three different measures of sequence risk are proposed, each of which is intended to inform investors of the probability that a chosen investment strategy may not deliver desired withdrawal rates, and hence these measures are intended to aid investment choices; conventional performance measures such as Sharpe or Sortino ratios are only indirectly related to this ability to achieve a given withdrawal experience. Finally, the authors note that, using US data, very simple portfolios comprising equities and bonds can achieve very low probabilities of failure to achieve popular desired withdrawal rates, such as 5% a year, as long as the equity component is “smoothed” by switching in and out of cash using a simple trend-following rule.