Experience Of Restraint Research Articles

An Analysis of a Developmentally Delayed Young Girl

Clinical material is presented from a multi-year treatment of a five-year-old girl with a variety of developmental interferences, making it necessary to consider whether standard technique would suffice. History includes the fact that she was adopted five days after birth and told as early as possible about her adoption; she was placed in a restrictive brace from four months to twenty months because of congenital hip displasia. Sandy's ability to let in the outside world was limited by her intense denial, not looking, not taking in, and by her detachment. Her passivity--whether a defense (modeled on her experience of physical restraint) or an arrest--was a formidable obstacle to the development of active transference moments. I use this case as an opportunity to look at the role of developmental sequences in the context of the analytic process. While I consciously did not do anything different than I would with any child analytic patient, I intuitively stressed certain kinds of interventions.

The experience of physical restraint: A systematic review of qualitative research

The objective of this review was to summarise the experience of physical restraint from the perspectives of the person subject to restraint and of their family. A review of interpretive and descriptive research was undertaken that entailed a comprehensive literature search. Studies were included in the review if they provided qualitative data on this experience. An interpretive data synthesis was undertaken to generate a composite description of the experience of restraint. Findings highlight the predominantly negative impact of physical restraint on the person restrained and their family. These findings support the most minimal use of restraint in health care and give voice to a relatively powerless and vulnerable group of people.

Trauma for all: a pilot study of the subjective experience of physical restraint for mental health inpatients and staff in the UK.

Violence and aggression is common in psychiatric inpatient units. Despite the near universal prevalence of restraint, there is very little published research on either the efficacy or the subjective effects of restraint on staff or patients. In this pilot study, semistructured interviews were given to the patients and staff involved in six untoward incidents in which the patient participant had been subject to manual physical restraint. Participants were interviewed as soon as possible after the occurrence of the incidents. The interviews asked the patient and staff participants to identify and discuss the factors that they found helpful and unhelpful during and in the immediate aftermath of these incidents. The incidents generated strong emotions for all concerned. The patients valued staff time and attention but felt that they received too little attention. Both nurses and patients discriminated between permanent and temporary staff. Patients reported feeling upset, distressed and ignored prior to the incidents and isolated and ashamed afterwards. Postincident debriefing was valued by all but was patchy for staff and rarer still for patients. Patients feared the possibility of being restrained. Half of the patients and several staff members reported that the incidents had reawakened distressing memories of previous traumatic events. Further research on the subjective effects of restraint is urgently needed.

Gabaergic modulation of the stress response in frontal cortex and amygdala.

GABAergic neurotransmission is thought to play an important role in the modulation of the central response to stress. In the present study we evaluate the influence of a brief restraint exposure on GABA-stimulated chloride influx in diverse brain areas presumed to have a major role in the mediation of emotional behaviors following aversive stimulation. A reduced chloride uptake after stress exposure was only observed in frontal cortex and amygdala. Moreover, rats subjected to such stressor performed an anxiogenic behavior when exposed later to the elevated plus-maze. A comparable behavior in the elevated plus-maze was observed between animals that were allowed to chew during the restraint experience and those without any stressful manipulation, suggesting that chewing served as an efficient coping behavioral strategy during such threatening situations. In order to explore if chewing during the restraint experience could suppress the reduction in GABA-stimulated chloride uptake induced by this stressor, rats were allowed or not to chew during restraint and in both cases GABA-stimulated chloride influx was assayed in frontal cortex and amygdala. The finding of this experiment showed that restrained rats that have the possibility to chew exhibited a similar GABA-stimulated chloride uptake in cortical tissue to that shown by control, unstressed rats. Moreover, chewing in response to restraint attenuated the reduction of GABA-stimulated chloride uptake in amygdala, supporting the notion that chewing is an effective coping response to restraint. These experiments suggest that a reduced GABAergic inhibitory control in these areas could be implicated in the emotional sequelae generated by this uncontrollable stressor and that the suppression of this reduction seems to be associated with the occurrence of coping behavioral response to such fear-inducing stimulus.

Control and restraint in the UK: service user perspectives

This study examines the experiences of physical restraint procedures reported by in‐patients of a secure mental health service. Interview data were subjected to thematic content analysis in accordance with grounded theory methodology.Patients had differential experiences of similar physical procedures. Most reported some negative psychological experience of restraint. Anger and anxiety were two major themes. Some respondents held the perception that restraint was used to punish patients and several suggested that restraint incited further violence and aggression. Some female service users reported that restraint evoked flashbacks of previous sexual trauma.A subset of female respondents gave contrasting accounts of restraint, suggesting that they purposely brought about the restraint to gain a sense of containment or as a way to release feelings.Possible implications of these responses for clinical practice are discussed.

Elderly patients' reports of physical restraint experiences in intensive care units

Use of physical restraints has undesirable sequelae. As they weigh the risks and benefits of protocols for reducing the use of restraints, staff members in intensive care units, where restraints are most used in hospitals, need to know how well elderly patients remember being restrained and how patients perceive the use of restraints. To estimate the proportion of patients who remember being restrained, describe the experience from the patients' perspectives, and describe any distress caused by use of restraints within the overall experience of being in the intensive care unit. Transcripts of semistructured, audiotaped interviews of patients who had been in the medical or surgical intensive care unit in any of 3 eastern and midwestern medical centers were analyzed by question and for overall themes. Six patients (40%) remembered some aspect of being restrained but did not report great distress. Patients accepted restraints as needed because of the lack of alternatives. Patients reported remembering that they should not perform certain behaviors but being unable to stop themselves. Patients cited hallucinations and intubation as major stressors in the intensive care unit. Patients' continuing health problems after discharge from the intensive care unit severely limited recruitment of subjects. Patients do not remember great distress specifically related to the use of restraints, but the overall situation leading to use of restraints is disturbing if remembered. The discovery of methods to reduce the distress of intubation and hallucinations could decrease use of restraints.

The Experience of Hospitalization and Restraint of Women who have a History of Childhood Sexual Abuse

Within psychiatric settings, many female clients report experiences of childhood sexual abuse (CSA). In this paper we explore the experience of 10 women who were hospitalized in psychiatric settings, restrained, and given forced medication (FM). All the women have histories that included CSA. Some authors have suggested that the experience of psychiatric hospitalization may represent an event that reenacts the experience of trauma. The results suggest that from the perspective of these women, the experience of restraint engendered traumatic emotional reactions such as fear, anxiety, and rage, and in no way was viewed as therapeutic even years later. Women felt powerless and unheard. The women wanted nurses who were empathic and responsive to their human needs as clients, but they felt nurses did not want to hear about the abuse or their internal distress. We hope that the perspective of these women will help in the consideration of alternatives and modifications to the use of restraint in psychiatric settings.

Prevention of stress-induced weight loss by third ventricle CRF receptor antagonist.

We previously reported that rats exposed to repeated restraint (3 h/day for 3 days) experience temporary hypophagia and a sustained reduction in body weight compared with nonrestrained controls. Studies described here determined the involvement of central corticotropin-releasing factor (CRF) receptors in the initiation of this chronic response to acute stress. In experiment 1, Sprague-Dawley rats were fitted with cannulas in the lateral ventricle and infused with 50 micrograms of alphahCRF-(9-41) or saline immediately before restraint on each of the 3 days of restraint. The receptor antagonist inhibited hypophagia and weight loss on day 1 of restraint but not on days 2 and 3. In experiment 2, 10 micrograms of alphahCRF-(9-41) or saline were infused into the third ventricle immediately before each restraint. The receptor antagonist totally blocked stress-induced hypophagia and weight loss. These results demonstrate that CRF receptors located in or near the hypothalamus mediate the acute responses to stress that lead to a permanent change in the hormonal or metabolic processes that determine body weight and body composition.

Prior exposure to a brief restraint session facilitates the occurrence of fear in response to a conflict situation: behavioral and neurochemical correlates

The influence of two different stressors on the behavioral and neurochemical responses to a subsequent exposure to the elevated plus maze (EPM) was examined. Rats were submitted to either a 15-min restraint period or to a 15-min forced swimming test (FS) and one day later exposed to the EPM. Animals with early restraint exhibited a significant decrease in the percent time spent and in the number of entries on the open arms. In addition, restraint induced a reduction in the total number of entries. An identical behavior in the EPM was observed between unstressed rats and those exposed to a previous swimming experience. As a humoral index of stress, corticosterone (CS) secretion in response to each stressor was evaluated. A similar increase of CS release was observed following each aversive stimulus. Exposure to both restraint and EPM decreased the cortical chloride uptake following GABA stimulation. Similar values of chloride flux were obtained from animals submitted to either restraint but without subsequent exposure to the EPM, exposed only to the EPM, or without any manipulation (controls). These findings are discussed in terms of a facilitated behavioral and neurochemical response to a fearful situation following an early and brief restraint experience.

Different effects of repeated stressful experiences on mesocortical and mesolimbic dopamine metabolism

The effects of repeated stressful experiences (10 min restraint, daily) on the levels of dopamine and metabolites in the nucleus accumbens septi and frontal cortex were evaluated. In naive mice, restraint stress increased 3-4-dihydroxyphenylacetic acid, homovanillic acid, and 3-methoxytyramine levels in the nucleus accumbens and 3-4-dihydroxyphenylacetic acid levels in the frontal cortex. The effects of stress on 3-methoxytyramine and homovanillic acid levels in the nucleus accumbens septi disappeared within five days of daily restraint experiences and the increase in 3-4-dihydroxyphenylacetic acid levels was no longer evident by the 10th day. By contrast, the response of mesocortical dopamine system to restraint (increased 3-4-dihydroxyphenylacetic acid levels) was unaffected by either five or 10 days of exposure to the stressor. Moreover, 10 min of restraint were still able to increase 3-4-dihydroxyphenylacetic acid levels in the frontal cortex of mice repeatedly exposed (nine days) to 120 min restraint. These results indicate that the mesolimbic and the mesocortical dopamine systems adapt differently to repeated exposure to a stressor.

Role of hippocampal 5-HT1A receptors on elevated plus maze exploration after a single restraint experience

Previous studies have shown that 2 h restraint stress induces deficits in open arm exploration of an elevated plus maze 24 h later. This effect was attenuated by a post-stress systemic injection of the 5-HT non-selective agonist, 5-methoxy-N,N-dimethyltryptamine (5-McODMT). To verify a possible involvement of hippocampal 5-HT1A receptors in this effect, rats were stereotaxically implanted with canulae in the dorsal hippocampus. Seven days later they received bilateral microinjections of 5-McODMT (20 nmol/0.5 μl) or saline. No difference was found on exploration of an elevated plus maze 24 h later. However, when treatments were performed immediately after 2 h of restraint stress, the drug was able to increase open arm exploration 24 h later. This effect was antagonized by a previous microinjection of (+)WAY-100135 (40 nmol/0.5 μl), a selective 5-HT1A antagonist. The results suggest that hippocampal 5-HT1A receptors may attenuate stress behavioral consequences.

Schizophrenic patients' retrospective attitudes regarding involuntary psychopharmacological treatment and restraint

SummaryThe considerable debate about the justification of coercive measures in psychiatry includes medical, ethical, legal and political arguments, patients' subjective experience of involuntary injections or restraint is barely investigated. A semi-structured interview was used to evaluate retrospective attitudes in 40 (32 schizophrenic) patients, treated involuntarily with injection of neuroleptic drugs or restrained. Of these patients, 48% rated these measures as necessary or positive, 23% as negative, and 30% were indifferent. Only patients with good insight into their disease were able to accept the involuntary treatment retrospectively as positive. Reasons for treatment refusal were inadequacy of the measures (58%), negative previous experience with neuroleptic drugs (47%), eg, akathisia, and reservations against the medical system itself (28%). ‘Fear’ and ‘powerlessness’ were the predominant feelings which patients experienced when confronted with coercive measures. Restraint was more disliked than injections. The results support the notion that disease concept and the ability to acknowledge mental illness are major factors influencing a schizophrenic patient's decision to accept of refuse treatment.

Genotype-dependent effects of chronic stress on apomorphine-induced alterations of striatal and mesolimbic dopamine metabolism

After 10 daily consecutive restraint experiences, DBA/2 (DBA) mice showed an increase of climbing behavior after injection of 0.25 mg/kg of the dopamine (DA) agonist apomorphine (APO), while no changes were observed following vehicle or 1 mg/kg of APO. By contrast, chronically stressed C57BL/6 (C57) mice showed a clear-cut decrease of climbing behavior at the dose of 0.25 mg/kg of APO and a similar, although less pronounced, effect of stress on the behavior of mice injected either with vehicle or with 1 mg/kg APO. The DA agonist at these same doses decreased 3,4-dihydroxyphenylacetic acid (DOPAC), homovanillic acid (HVA) and 3-methoxytyramine (3-MT) concentrations in the caudatus putamen (CP) and nucleus accumbens septi (NAS) of both strains. Higher DOPAC, HVA and 3-MT concentrations were evident in stressed DBA mice receiving 0.25 mg/kg but not 1 mg/kg of APO, in both CP and NAS. Concerning C57 mice, lower concentrations of the 3 metabolites were present at both doses of APO in the NAS of stressed mice in comparison with non-stressed animals, while no significant stress-related effects were evident in the CP. Non-significant differences between control and stressed mice of both strains were evident as regards DA concentrations in CP and NAS. These results suggest that repeated stressful experiences lead to a hyposensitivity of DA presynaptic receptors in DBA mice while they produce a sensitization of mesolimbic DA presynaptic receptors possibly accompanied by down-regulation of postsynaptic DA receptors in the C57 strain.

Physical Restraint of the Hospitalized Elderly

Twenty elderly restrained patients and their primary nurses (N = 18) were studied to determine (a) the subjective impact of physical restraints on the patient and (b) the nurses' beliefs about use of restraints. Despite reported cognitive impairments, patients vividly described anger, discomfort, resistance, and fear in response to the experience of physical restraint. The decision to restrain posed a conflict between protection of the patient and beliefs about professional behavior for the nursing staff. Lack of interdisciplinary collaboration in decisions to use a physical restraint was also apparent. The findings suggest that the use of physical restraint is not a benign practice and support the need for developing alternatives more consistent with professional practice and quality care.

A radioimmunoassay for tetrahydrocortisol

A radioimmunoassay for urinary tetrahydrocortisol (THF) is described. Antibodies were produced in rabbits against a THF-monohemisuccinate:bovine serum albumin conjugate. The radioimmunoassay procedure involves enzymic hydrolysis of the urine, extraction with ethyl acetate, radioimmunoassay, and separation of free from bound steroid with Somogyi reagents. The antibody showed some cross-reaction with tetrahydro substance S (36%) which does not occur in urine in appreciable amounts and with tetrahydrocortisone (10%) which does. An analysis of monkey urine extracts before and after tlc purification revealed that the THF antibody was specific enough to permit assay of urines for THF during stress experiments without a purification step. THF values obtained correlated very highly with 17-hydroxycorticosteroid values on the same urines obtained from monkeys during a chair restraint experience ( r = 0.97). Also for comparison purposes these same urines were assayed for free THF, total cortisol, and free cortisol. The free (unconjugated) steroids showed the greatest percentage increase over basal levels.

RESTRAINT AND SPEECH

The incidence of delay in language development and difficulties in speech articulation was determined in 71 children selected because of a history of prior physical immobilization. Ten children were referred for psychological evaluation after contact with a speech department, 44 presented with a variety of learning and behavioral difficulties, and 17 children were known through social contacts. Nine children were clearly brain damaged while 13 showed questionable evidence of brain damage. Language delay and speech articulation problems occurred in at least 55% of the children in the various groups. Young age (4.7 months) at the time of the initial restraint experience, but not the duration of the initial restraint experience, was positively related to the presence of language delay and articulation problems. Interference with sensorimotor function not directly involved in receptive or expressive speech functions might well he implicated in language and speech disturbances.