Could Animal-Assisted Therapy Help to Reduce Coercive Treatment in Psychiatry?

For psychiatric patients, compulsory admission and coercive measures can constitute distressing and sometimes traumatizing experiences. As a consequence, clinicians aim at minimizing such procedures. At the same time, they need to ensure high levels of safety for patients, staff and the public. In order to prevent compulsory measures and to favor the use of less restrictive alternatives, innovative interventions improving the management of dangerous situations are needed. Animal-assisted therapy (AAT) is being applied in a variety of diagnoses and treatment settings, and could have the potential to reduce aggression and psychopathology. Therefore, AAT might be of use in the prevention and early treatment of aggression, and might constitute a promising component of treatment alternatives to forced interventions. To our knowledge, no study evaluating the effect of AAT on compulsory measures in persons with psychiatric diseases has been published up to date. This narrative expert review including a systematic literature search examines the published literature about the use of AAT in psychiatry. Studies report reduced anxiety and aggressiveness as well as positive effects on general wellbeing, self-efficacy, quality of life and mindfulness. Although literature on the applicability of AAT as a component of preventive or de-escalating treatment settings is sparse, beneficial effects of AAT have been reported. Therefore, we encourage examining AAT as a promising new treatment approach to prevent compulsory measures.

Voxel-Based Morphometry Correlates of an Agitated-Aggressive Syndrome in the At-Risk Mental State for Psychosis and First Episode Psychosis.

There are mixed reports on structural neuroimaging correlates of aggression in schizophrenia with weak evidence due to cohort overlaps and lack of replications. To our knowledge, no study examined volumetric neuroimaging correlates of aggression in early stages of psychosis. An agitated-aggressive syndrome is present in at-risk mental state (ARMS) and in first-episode psychosis (FEP) - it is unclear whether this syndrome is associated with structural brain abnormalities in early stages of psychosis. Using three-dimensional magnetic resonance imaging and a whole brain voxel-based morphometry approach, we examined 56 ARMS patients, 55 FEP patients and 25 healthy controls. We operationalized aggression using the Excited Component of the Brief Psychiatric Rating Scale (BPRS-EC) and dichotomized our patient group by median split into "BPRS-EC high" (n = 49) and "BPRS-EC low" groups (n = 62). The "BPRS-EC high" group had significantly smaller left lingual gyrus volume than HC. This finding was not present in the "BPRS-EC low" group. In addition, grey matter volume in the left lingual gyrus showed a negative linear correlation with BPRS-EC over all subjects (ρ = -0.318; p = 0.0001) and in the patient group (ρ = -0.202; p = 0.033). These findings provide first hints on structural brain abnormalities associated with an agitated-aggressive syndrome in ARMS and FEP patients.

Structural Magnetic Resonance Imaging Correlates of Aggression in Psychosis: A Systematic Review and Effect Size Analysis.

Background: Aggression in psychoses is of high clinical importance, and volumetric MRI techniques have been used to explore its structural brain correlates. Methods: We conducted a systematic review searching EMBASE, ScienceDirect, and PsycINFO through September 2017 using thesauri representing aggression, psychosis, and brain imaging. We calculated effect sizes for each study and mean Hedge's g for whole brain (WB) volume. Methodological quality was established using the PRISMA checklist (PROSPERO: CRD42014014461). Results: Our sample consisted of 12 studies with 470 patients and 155 healthy controls (HC). After subtracting subjects due to cohort overlaps, 314 patients and 96 HC remained. Qualitative analyses showed lower volumes of WB, prefrontal regions, temporal lobe, hippocampus, thalamus and cerebellum, and higher volumes of lateral ventricles, amygdala, and putamen in violent vs. non-violent people with schizophrenia. In quantitative analyses, violent persons with schizophrenia exhibited a significantly lower WB volume than HC (p = 0.004), and also lower than non-violent persons with schizophrenia (p = 0.007). Conclusions: We reviewed evidence for differences in brain volume correlates of aggression in persons with schizophrenia. Our results point toward a reduced whole brain volume in violent as opposed to non-violent persons with schizophrenia. However, considerable sample overlap in the literature, lack of reporting of potential confounding variables, and missing research on affective psychoses limit our explanatory power. To permit stronger conclusions, further studies evaluating structural correlates of aggression in psychotic disorders are needed.

Functional Neuroimaging Correlates of Aggression in Psychosis: A Systematic Review With Recommendations for Future Research.

Background and methods: Aggression in psychosis is clinically important. We systematically compiled the evidence on functional correlates of aggression in psychosis searching PubMed, EMBASE, ScienceDirect, and PsycINFO until September 2017. We included studies reporting functional brain imaging correlates of aggression comparing: (1) affective or non-affective psychosis groups with a history of violence or with aggression operationalized using questionnaires, (2) affective or non-affective psychosis groups with a history of violence or with aggression operationalized using questionnaires to controls, (3) affective or non-affective psychosis groups with a history of violence or with aggression operationalized using questionnaires to controls with diagnoses other than affective or non-affective psychoses. We applied no language restriction and required patients to have a DSM or ICD diagnosis of affective or non-affective psychosis. Results: Our sample consisted of 12 studies with 334 patients and 113 controls. During n-back tasks, violent (VS) as opposed to non-violent persons with schizophrenia (NVS) hypoactivated their inferior parietal lobe. When anticipating shock, VS vs. NVS hyperactivated their medial prefrontal gyrus, cuneus, middle temporal gyrus, and middle occipital gyrus. When viewing negative emotional pictures, VS vs. NVS hyperactivated the middle frontal gyrus, inferior frontal gyrus, anterior cingulate, lingual gyrus, precentral gyrus, globus pallidus, mid-cingulate, and precuneus. Limitations: Due to the small number of available studies, sample overlap, and insufficient reporting of relevant moderators we could not conduct a meta-analysis. Conclusions: We found non-systematic functional correlates of aggression in schizophrenia. Only few studies using varied paradigms and often overlapping samples have been conducted. There have been no attempts to replicate any of the observed findings in the published literature. Focusing on future directions, we recommend that authors adhere to clear definitions of aggression, measurements of psychopathology, comorbidities, and medication. In particular, replication studies would allow for a better synthesis of the findings. PROSPERO Registration Number: CRD42016048579.

Tracking local anesthetic effects using a novel perceptual reference approach.

Drug effects of loco-regional anesthetics are commonly measured by unidimensional pain rating scales. These scales require subjects to transform their perceptual correlates of stimulus intensities onto a visual, verbal, or numerical construct that uses a unitless cognitive reference frame. The conceptual understanding and execution of this magnitude estimation task may vary among individuals and populations. To circumvent inherent shortcomings of conventional experimental pain scales, this study used a novel perceptual reference approach to track subjective sensory perceptions during onset of an analgesic nerve block. In 34 male subjects, nociceptive electric stimuli of 1-ms duration were repetitively applied to left (target) and right (reference) mandibular canines every 5 s for 600 s, with a side latency of 1 ms. Stimulus strength to the target canine was programmed to evoke a tolerable pain intensity perception and remained constant at this level throughout the experiment. A dose of 0.6 ml of articaine 4% was submucosally injected at the left mental foramen. Subjects then reported drug effects by adjusting the stimulus strength (in milliamperes) to the reference tooth, so that the perceived intensity in the reference tooth was equi-intense to the target tooth. Pain and stimulus perception offsets were indicated by subjects. Thus, the current approach for matching the sensory experience in one anatomic location after regional anesthesia allows detailed tracking of evolving perceptual changes in another location. This novel perceptual reference approach facilitates direct and accurate quantification of analgesic effects with high temporal resolution. We propose using this method for future experimental investigations of analgesic/anesthetic drug efficacy.