Strong Fear Research Articles

Becoming the Center of Attention in Social Anxiety Disorder

A detailed understanding of how individuals diagnosed with social anxiety disorder (SAD) respond physiologically under social-evaluative threat is lacking. Our aim was to isolate the specific components of public speaking that trigger fear in vulnerable individuals and best discriminate between SAD and healthy individuals. Sixteen individuals diagnosed with SAD (DSM-IV-TR criteria) and 16 healthy individuals were enrolled in the study from December 2005 to March 2008. Subjects were asked to prepare and deliver a short speech in a virtual reality (VR) environment. The VR environment simulated standing center stage before a live audience and allowed us to gradually introduce social cues during speech anticipation. Startle eye-blink responses were elicited periodically by white noise bursts presented during anticipation, speech delivery, and recovery in VR, as well as outside VR during an initial habituation phase, and startle reactivity was measured by electromyography. Subjects rated their distress at 4 timepoints in VR using a 0-10 scale, with anchors being "not distressed" to "highly distressed." State anxiety was measured before and after VR with the Spielberger State-Trait Anxiety Inventory. Individuals with SAD reported greater distress and state anxiety than healthy individuals across the entire procedure (P values < .005). Analyses of startle reactivity revealed a robust group difference during speech anticipation in VR, specifically as audience members directed their eye gaze and turned their attention toward participants (P < .05, Bonferroni-corrected). The VR environment is sufficiently realistic to provoke fear and anxiety in individuals highly vulnerable to socially threatening situations. Individuals with SAD showed potentiated startle, indicative of a strong phasic fear response, specifically when they perceived themselves as occupying the focus of others' attention as speech time approached. Potentiated startle under social-evaluative threat indexes SAD-related fear of negative evaluation.

Subiektywna śródoperacyjna poprawa słuchu u chorych po stapedotomiach w porównaniu z wynikiem kontrolnego badania słuchu w audiometrii tonalnej progowej

In otosclerosis patients the most common procedure followed at Otosurgical Dept. Medical University of Lodz is stapedotomy with insertion of teflon-piston prosthesis. When surgery is finished a whisper hearing test is done from the 1 meter distance for brief intraoperative hearing improvement assessment. There is a number of patient who report subjective intraoperative hearing improvement which is not confirmed by postoperative pure-tone audiometry (2-3rd post-op day). was the analysis of factors influencing stapedotomy (teflon-piston procedure) patients in which intraoperative hearing improvement was not confirmed by postoperative pure-tone audiometry. Retrospective analysis of postoperative hearing results in patients who underwent stapedotomy (teflon-piston operation) at the Otosurgical Dept. Medical University of Lodz from 2005 to 2009. The total number of 142 stapedotomies were analyzed. In 27 ears no hearing improvement was reported (19.1%). Among them 18 reported intraoperative hearing improvement not confirmed on postoperative pure-tone audiometry and 9 cases intraopertively reported no hearing improvement. Patients in Group A (hearing improvement 1-2 month post stapedotomy)--12 cases (44.4%) with hearing improvement confirmed by pure-tone audiometry and Group B--5 cases (55.6%) in which no sign of hearing improvement in pure-tone audiometry was reported. In patients who intraopertively reported hearing improvement not supported by the pure-tone audiometry the following factors seem to play a vital role: a) strong suggestion and willingness of improvement after surgical treatment, b) specific condition of the whisper hearing test at the operating room environment, c) patient's stress during the surgery and strong fear of possible revision surgery.

Increasing clarity

The fates of biotechnology companies, like those in many other dynamic industries, depend on the outcome of future events, which can be difficult to predict. Seemingly late-stage issues such as regulatory uncertainty dissuade investors, stalling innovation and company growth. Accordingly, increased definition of regulatory processes and opportunities for profitable investment exit can improve the financing climate, and drive innovation. In my editorials earlier this year I have commented on the numerous uncertainties the biotechnology industry faced. What a difference a few months makes! Recent events have clarified several important issues.Although obtaining financing in biotechnology has seldom been described as easy, the situation is far better now than it was a year ago. With a large number of companies having less than a year's cash on hand, there was a strong fear that a majority of biotechnology companies would go bankrupt. This fear was not realized, and it appears that companies were able to adjust their burn rates and fundraising activities to accommodate the financial challenges. While many jobs were cut and R&amp;D scaled back, mass-bankruptcy now seems unlikely and the industry stands well positioned for growth.The passage of the health reform bill has also had a profound impact. Important issues such as the approval pathway for generic biologics and data exclusivity for branded biologics are now better defined. The FDA has been empowered to approve follow-on biologic drugs, and biologic manufacturers have been granted 12 years of exclusivity. For more discussion on biologic exclusivity, see the two commentaries on the topic in issue 16.1.1, 2These important clarifications are offset by some important unresolved issues: The Small Business Innovation Research program, which is an important source of gap financing between academic and development-stage research for American companies, is overdue for reauthorization. While the US congress has failed to renew the program, it appears that the program will continue to be extended through annual 1-year ‘punts’. Another pressing issue is approval time for biologic drugs. While the FDA approved 16 biologic drugs in 2009 – reversing a declining trend – it appears that approval times are increasing. So it appears that while development-stage funding and follow-on biologic approval are becoming better-defined, other issues may be taking their place as key issues.NETWORK ON LinkedInThe Journal of Commercial Biotechnology has a networking group on LinkedIn. You can use this forum to discuss papers, to post jobs, to announce industry events and company updates, and for general networking. The JCB networking forum is available at www.linkedin.com/groups?gid=1241807&amp;trk=hb_side_g. See you there!References Pitts, P.J. (2010) Why data exclusivity is the new patent protection. Journal of Commercial Biotechnology 16 (1): 3–4.Wroblewski, M.S. and Jex, E.A. (2010) Follow-on biologic drug competition – No need for new marketing exclusivities. Journal of Commercial Biotechnology 16 (1): 5–7.

Save Me from Myself: College Students' Fears of Losing Control and Acting Violently

Violent behavior on college campuses has been a long-standing problem that has received increased attention due to recent shootings. At present, the factors that predict college students' violent behavior are not well understood. To increase knowledge in this area, two studies were conducted that examined the prevalence and predictors of college students' fears of committing violent behavior. Data from a single university indicated that less than 2% of the general student body possessed strong fears of acting violently and more than 80% of students had no such fears. Among clients at the university counseling center, 7% expressed strong fears of acting violently whereas 71% of clients had no such fears. Similar prevalence rates were found in a sample of 27,616 clients from 66 university counseling centers. Predictors of fears of acting violently included low academic motivation, suicidal ideation, irritable feelings, fears of having a panic attack in public, having harmed another person previously, having nightmares or flashbacks, and getting into frequent arguments.

Differences in psychological correlates of excess weight between adolescents and young adults in Canada

There is a noticeable rise in the prevalence of excess weight in Canadian youth. Research has shown that certain psychological variables are implicated in the etiology of obesity. Hence, this study had the purpose of examining some of these variables among Canadian youth, and detecting differences between adolescents and young adults. Data from the Canadian Community Health Survey collected in 2003 was used to depict associations between selected psychological variables and excess weight among Canadians aged between 15 and 29 years. Results have shown that satisfaction with the way the body looks and satisfaction with life were inversely associated with excess weight in females. However, in males, satisfaction with life seemed to increase with age. For both genders, significant associations were observed between having a strong fear of being too fat, the respondent opinion of own weight and excess weight. Regarding weight control and eating habits, excess weight was associated with smoking less frequently in males aged between 25 and 29 years. The opposite was observed for females. For both genders, a positive association was observed between avoiding food because of calorie content and excess weight. Present findings highlight gender differences in body image perception, life satisfaction, and weight control practices. Moreover, changes or persistence in these variables between adolescents and young adults have also been detected in both males and females suggesting that early interventions might prevent the persistence of these psychological issues and habits in a older age.

Safeguarding children in Bahia, Northeast Brazil

<h3>Context</h3> In Brazil, poverty and inequality go hand in hand with violence. Although Brazil is a middle-income country, over one in five Brazilians live in poverty and accidents and violence are the principal cause of death among children, with some of the highest rates in Brazil9s poorest states. Over the last two decades, Brazil has made great strides in its legislation and policy-making to protect children from abuse and neglect. <h3>Aims</h3> This study aimed to investigate the thoughts and perceptions of professionals concerning the safeguarding systems in Bahia, barriers to recognition, reporting and management of cases of child abuse and neglect, and suggestions for improvements. <h3>Methods</h3> Focus groups were complemented with semi-structured interviews and questionnaires. The study was based in Barra de São Francisco in Bahia, northeast Brazil. Professionals working with children and with Bahia9s safeguarding systems were recruited. Sessions were led by a trained moderator and digitally recorded. The recordings were transcribed and analysed using a constant comparative framework to identify common emergent themes. <h3>Results</h3> Ten focus groups and eight semi-structured interviews were conducted. 55 questionnaires were completed. Findings were consistent across all professional groups and methods of data collection. Participants identified numerous barriers to effective safeguarding, including a strong fear of violent reprisals for reporting cases (despite anonymous reporting systems) and a lack of training and multidisciplinary working. There was a perception that the newly-established Child Protection Agency is ill-equipped to deal with the complexity of cases and that prosecutions are too slow, reducing motivation to report abuse. They felt that better training and stronger communications between professional groups working together to support the Child Protection Agency, would substantially improve the situation. <h3>Conclusions</h3> Using focus groups complemented by semi-structured interviews and questionnaires was a highly effective means of promoting open discussion of the sensitive and complex topic of safeguarding, while ensuring that all views were heard. Although a lack of human and physical resources inevitably hinders safeguarding efforts in Barra, Bahia, participants identified several obstacles which may be addressed using available resources, to help make Brazil9s children9s new Constitutional rights a reality.

Neural processing of negative word stimuli concerning body image in patients with eating disorders: An fMRI study

Eating disorders (EDs) are associated with abnormalities of body image perception. The aim of the present study was to investigate the functional abnormalities in brain systems during processing of negative words concerning body images in patients with EDs. Brain responses to negative words concerning body images (task condition) and neutral words (control condition) were measured using functional magnetic resonance imaging in 36 patients with EDs (12 with the restricting type anorexia nervosa; AN-R, 12 with the binging–purging type anorexia nervosa; AN-BP, and 12 with bulimia nervosa; BN) and 12 healthy young women. Participants were instructed to select the most negative word from each negative body-image word set and to select the most neutral word from each neutral word set. In the task relative to the control condition, the right amygdala was activated both in patients with AN-R and in patients with AN-BP. The left medial prefrontal cortex (mPFC) was activated both in patients with BN and in patients with AN-BP. It is suggested that these brain activations may be associated with abnormalities of body image perception. Amygdala activation may be involved in fearful emotional processing of negative words concerning body image and strong fears of gaining weight. One possible interpretation of the finding of mPFC activation is that it may reflect an attempt to regulate the emotion invoked by the stimuli. These abnormal brain functions may help provide better accounts of the psychopathological mechanisms underlying EDs.

Memory Reconsolidation Mediates the Updating of Hippocampal Memory Content

The retrieval or reactivation of a memory places it into a labile state, requiring a process of reconsolidation to restabilize it. This retrieval-induced plasticity is a potential mechanism for the modification of the existing memory. Following previous data supportive of a functional role for memory reconsolidation in the modification of memory strength, here I show that hippocampal memory reconsolidation also supports the updating of contextual memory content. Using a procedure that separates the learning of pure context from footshock-motivated contextual fear learning, I demonstrate doubly dissociable hippocampal mechanisms of initial context learning and subsequent updating of the neutral contextual representation to incorporate the footshock. Contextual memory consolidation was dependent upon BDNF expression in the dorsal hippocampus, whereas the footshock modification of the contextual representation required the expression of Zif268. These mechanisms match those previously shown to be selectively involved in hippocampal memory consolidation and reconsolidation, respectively. Moreover, memory reactivation is a necessary step in modifying memory content, as inhibition of hippocampal synaptic protein degradation also prevented the footshock-mediated memory modification. Finally, dorsal hippocampal knockdown of Zif268 impaired the reconsolidation of the pure contextual memory only under conditions of weak context memory training, as well as failing to disrupt contextual freezing when a strong contextual fear memory is reactivated by further conditioning. Therefore, an adaptive function of the reactivation and reconsolidation process is to enable the updating of memory content.

The Impact of Pass/Fail Grading

To the Editor: We appreciate the excellent commentaries by Durning et al1 and Krupat and Dienstag2 of our recent report3 on the impact of a change to pass/fail grading in the first two years at our medical school. We would like to offer some additional insights about pass/fail grading at our school. Durning et al were disappointed that we found no improvement in students' performance with a change to pass/fail grading. However, the prevailing belief of the faculty at the time of the change was the strong fear that the new grading system would lead to poorer student performance, an outcome not demonstrated by the data. That outcome has greatly strengthened faculty support of pass/fail grading, and there is currently no faculty interest in returning to the previous five-interval grading system. Regarding our report, Krupat and Dienstag noted that “much to the relief of those of us who have a nongraded preclinical curriculum … the change had no demonstrable deleterious effect on several different measures of learning and effort.” However, they wondered if the change in grading was accompanied by any other changes in the curriculum or teaching that would have confounded these results. Fortunately, the curriculum and teaching methods remained the same for the two classes involved in our study, ruling out the curriculum and teaching methods as confounding factors. Krupat and Dienstag also noted that pass/fail grading has the potential to limit the faculty's opportunity to identify and help students who are in the marginal range just above passing. This is not the case: Before, during, and after the study, we have had the same procedures in place to identify the lowest 10% of students in terms of performance on formative course exams, to counsel those students, and to provide tutoring and other interventions. We believe these procedures are compatible with pass/fail grading. The commentaries by During et al and Krupat and Dienstag provide valuable insights about student self-regulation and the complex role of assessment in medical education. We appreciate being a small part of this important dialogue. Jerry G. Short, PhD Associate dean, University of Virginia School of Medicine, Charlottesville, Virginia. Robert A. Bloodgood, PhD Professor of cell biology, University of Virginia School of Medicine, Charlottesville, Virginia; ([email protected]).

Corticosterone facilitates extinction of fear memory in BALB/c mice but strengthens cue related fear in C57BL/6 mice

Corticosterone, the naturally occurring glucocorticoid of rodents is secreted in response to stressors and is known for its facilitating and detrimental effects on emotional learning and memory. The large variability in the action of corticosterone on processing of emotional memories is postulated to depend on genetic background and the spatio-temporal domain in which the hormone operates. To address this hypothesis, mice of two strains with distinct corticosterone secretory patterns and behavioural phenotype (BALB/c and C57BL/6J) were treated with corticosterone (250 μg/kg, i.p.), either 5 min before or directly after acquisition in a fear conditioning task. As the paradigm allowed assessing in one experimental procedure both context- and cue-related fear behaviour, we were able to detect generalization and specificity of fear. BALB/c showed generalized strong fear memory, while C57BL/6J mice discriminated between freezing during context- and cue episodes. Corticosterone had opposite effects on fear memory depending on the strain and time of injection. Corticosterone after acquisition did not affect C57BL/6J mice, but destabilized consolidation and facilitated extinction in BALB/c. Corticosterone 5 min before acquisition strengthened stress-associated signals: BALB/c no longer showed lower fear memory, while C57BL/6J mice displayed increased fear memory and impaired extinction in cue episodes. We propose that corticosterone-induced facilitation of fear memory in C57BL/6J mice can be used to study the development of fear memories, corticosterone administration in BALB/c mice presents a model to examine treatment. We conclude that genetic background and time of corticosterone action are modifiers of fear memory with interesting translational implications for anxiety-related diseases.

Desynchrony of fear in phobic exposure

Intuitively, phobic exposure would seem to be a very stressful experience. However, it is not clear whether the characteristic feature of a classic stress response, activation of the hypothalamic-pituitary-adrenal (HPA) axis, is present in phobic fear. Some instances of phobic fear have been found to be accompanied by robust increases in cortisol, whereas in other instances a dissociation between subjective-behavioural arousal and the HPA-axis has been found. The latter is referred to as desynchrony of fear. The aim of the current study was to test the hypothesis that phobic fear is similar to normal fear and, as such, is accompanied by a robust increase in cortisol values. In all, 16 spider phobic subjects and 16 healthy controls participated in the study. During and following a standardised stepwise exposure paradigm, saliva samples were collected for cortisol determination. In contrast to the controls, the spider phobics reacted with a strong fear reaction to the spiders. However, cortisol levels remained unaffected. The phobic response did not resemble the classic 'fight or flight' response. Some suggest that the HPA-axis response has become extinguished in modern man. Yet, it is possible that phobic fear is not a derivative of an ancient fear but rather a separate entity that relies on other neuroendocrinological systems.

Xenophobic Attacks On Black Non-South Africans In South Africa: The Communication Imperatives

Although xenophobia is typically defined as a “hatred or fear of foreigners” (South African Pocket Oxford Dictionary of Current English, 1994) or a “strong fear or dislike of people from other countries” (Longman Dictionary of Contemporary English, New Edition, 2003), the concept goes beyond this. Research evidences have established xenophobia as a feeling of dislike and hatred by locals which often results in “intense tension and violence against its foreigner-victims (Kollapan, 1999; Tshitereke, 1999; and Harris, 2002). In advocating a re-writing of the dictionary definition of xenophobia, Harris (2002: 170) notes as follows: It [xenophobia] is not just an attitude; it is an activity. It is not just a dislike or fear of foreigners: it is a violent practice that results in bodily harm and damage. He also goes on to propound a refinement of the definition of xenophobia in such a way as to include its specific target, because, as he rightly observes: in South Africa, not all foreigners are uniformly victimised. Rather, black foreigners, particularly those from Africa are the target and they “comprise the majority of victims.”.IFE Psychologia – Special Issue: Xenophobia Vol. 16 (2) 2008: pp. 105-121

What if there were no God? Politically conservative and liberal Christians imagine their lives without faith

A sample of devout Christian adults, ranging widely in political orientation, described what their lives (and the world) might be like had they never embraced faith. Politically conservative Christians (also scoring high on right-wing authoritarianism) tended to imagine a life deficient in impulse control, wherein unrestrained sexual and aggressive urges, addictive behaviors, and human selfishness undermined the social good. By contrast, politically liberal Christians (also scoring low on right-wing authoritarianism) imagined an empty and barren world, devoid of the emotional intensity that makes life worth living. Gender differences were also observed, but they did not interfere with the relation between political orientation and the narrative themes. In accord with theoretical writings regarding normative and humanistic ideologies, the findings suggest that, at least among American Christians, political conservatism may entail a fear of, or strong sensitivity to, the prospects of conflict and chaos, whereas political liberalism may entail an equally strong fear of, or sensitivity to, emptiness.

Subjective Knowledge and Fear Appeal Effectiveness: Implications for Message Design

This research investigates the role of perceived health knowledge on the effectiveness of fear-based persuasive appeals. Undergraduates (N = 263) read a strong fear, weak fear, or efficacy-only message encouraging breast or testicular self-examination. As expected, results indicated that men high in subjective knowledge were less reactant and more persuaded by the efficacy-only message whereas those low in subjective knowledge did not evidence this pattern. Contrary to expectation, women high in subjective knowledge had comparable reactions to each of the 3 messages. Implications for fear appeal theory and message design are discussed.

Cross-Cultural Study of Conviction Subtype Taijin Kyofu

Conviction subtype Taijin-Kyofu (c-TK) is a subgroup of mental disorder characterized by conviction and strong fear of offending others in social situations. Although the concept of c-TK overlaps with that of social anxiety disorder (SAD), patients with c-TK often may not be diagnosed as such within the current Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV criteria. We propose the Nagoya-Osaka criteria to amend this situation. This study examined the cross-cultural interrater reliability of the proposed criteria. Eighteen case vignettes of patients with a variety of complaints focused around social anxieties were collected from 6 different countries, and diagnosed by 13 independent raters from various nationalities according to the original DSM-IV and the expanded criteria. The average agreement ratio for the most frequent diagnostic category in each case was 61.5% with DSM-IV and 87.6% with the modified DSM-IV with Nagoya-Osaka criteria (p < 0.001). These findings indicate that the Nagoya-Osaka criteria for SAD can improve interrater reliability of SAD.

The Experience of Emotion : an Intentionalist Theory

The experience of emotion is a fundamental part of human conscious ness. Think, for example, of how different our conscious lives would be without such experiences as joy, anger, fear, disgust, pity, anxiety, and embarrassment. It is uncontroversial that these experiences typically have an intentional content. Anger, for example, is normally directed at someone or something. One may feel angry at one's stock broker for providing bad advice or angry with the cleaning lady for dropping the vase. But it is not uncontroversial that emotional experiences are always intentional. John Searle, for example, remarks, Many conscious states are not Intentional, e.g., a sudden sense of elation ... (1983, p. 2). Moreover, many animals experience emotions and it is natural to suppose that such emotions lack the sophistication of beliefs or thoughts. When a dog experiences delight in seeing its master after an absence of several days, the suggestion that at least part of the dog's experience of delight is a belief (or thought) that its master has returned home seems to import into the experience something that at best is associated with it and perhaps is not really a state to which the dog is subject at all. And even in the case of human beings, emotional experience often does not seem to involve thought. Consider the experience of disgust, to take one obvious example.' Nor is a salient belief required. One may have a strong fear of spiders and yet not believe that spiders typically pose any risk to humans. But if emotional experiences need not involve beliefs or thoughts, then just how are they intentional?2 Recent theories of consciousness have not devoted as much attention to the

Cultural and Social Perspectives on Attitudes, Noise, and Risk Behavior in Children and Young Adults

Interdisciplinary research is critical to the prevention of hearing loss in children and young adults. To meet that goal, this paper focuses on the relationship between the prevalence of noise-induced hearing loss, attitudes to noise and exposure, and how hearing protection use seems to be linked to cultural and socioeconomic factors. Results of a series of studies point to attitudes as one explanatory factor. Additionally, the experience of hearing symptoms such as tinnitus and noise sensitivity increases the likelihood that adolescents and young adults will choose to wear earplugs when attending clubs or discotheques. This behavior can be referred to as an important “trigger” mechanism for the development of health-related behavior. Some general theories on health behavior are discussed to understand the role attitudes play for hearing prevention in young people. Finally, the finding that adolescents seeking professional help for tinnitus appear to have strong fears related to anxious thoughts and reactions associated with the condition is addressed. These fears can be a sign of a phobic reaction, something that most often first appears during adolescence. For these reasons, interdisciplinary research in the investigation of tinnitus distress and hearing conservation in young people seems to be the most relevant approach.

Safety and Security in Small-Scale Recovery Housing for People With Severe Mental Illness: An Inner-City Case Study

Safety and Security in Small-Scale Recovery Housing for People With Severe Mental Illness: An Inner-City Case Study

Os prejuízos funcionais de pessoas com transtorno de ansiedade social: uma revisão

O transtorno de ansiedade social caracteriza-se pelo medo acentuado e persistente de situações sociais ou de desempenho, podendo influenciar a vida cotidiana dos portadores. Objetiva-se identificar, na literatura indexada, estudos empíricos com instrumentos de avaliação que abordem os prejuízos funcionais experimentados por pessoas com transtorno de ansiedade social no desempenho de atividades cotidianas e analisar as implicações de tais dificuldades. Procedeu-se a uma busca sistemática junto às bases de dados indexadas, identificando dez artigos, que foram agrupados em dois conjuntos: a) os relativos à proposição de instrumentos de avaliação e análise das qualidades psicométricas (n = 4); e b) os relativos ao impacto do transtorno de ansiedade social para a qualidade de vida e para as atividades cotidianas (n = 6). Os estudos psicométricos ressaltaram a pouca atenção dada a instrumentos validados para avaliar especificamente os prejuízos funcionais. Os trabalhos relativos ao impacto na qualidade de vida e nas atividades cotidianas constataram a presença de insatisfação com a vida e com a saúde em pacientes com transtorno de ansiedade social. A análise da literatura apontou para a importância da avaliação dos prejuízos funcionais do transtorno de ansiedade social no funcionamento cotidiano, por meio de medidas objetivas. Destaca-se a relevância de tais avaliações no planejamento e na intervenção de atividades voltadas ao transtorno de ansiedade social no contexto das práticas multidisciplinares de saúde mental.

Medical errors – a hospital in Nepal searches for answers

Medical errors are recognized as a significant issue in medical practice. Ethical and professional guide-lines emphasize the responsibility of physicians to disclose errors to patients. However, in practice, even in the developed world this often does not happen. This study which involved 12 focus groups formed from 127 members of staff within Patan Hospital in the Kathmandu Valley sought to understand Nepali staff attitudes to medical errors and suggest how they could be handled. Most agreed, for good reasons of honesty and patient autonomy, that admission of errors is important, but the doctors struggled to decide how it should be done. For most of the staff the educational level was a key decider as to what would be disclosed. Most agreed that the socio-legal climate in Nepal, and the possible financial implications, made it difficult to be completely honest. Other strong fears included patient harm, violence from the patient, damage to the hospital's reputation and to the reputation of the doctors and possible loss of jobs for nurses. We recommend that the hospital initiate a clear hospital policy on dealing with errors and that they should: implement the development of incident reporting forms; set up an error investigation team; provide specific training in communicating about errors for the appropriate staff.