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Combat Stress and The Royal Navy and Royal Marines Charities Partnership to Deliver Mental Health Support

The Royal Navy and Royal Marines Charity has worked in partnership with Combat Stress for many years to support Royal Navy veterans with complex mental health conditions.

In 2020 the RNRMC began a three-year funding agreement with Combat Stress as part of the RNRMC’s Health and Wellbeing Support Programme. This partnership ensures that Royal Navy veterans, like Jim, will continue to receive vital support. Jim had wanted to join the Royal Navy since he was nine years old. When he was 18 that dream came true, but unfortunately his time in the services was not what he imagined.

After joining the Navy, Jim was quickly identified as a promising rugby player and spent much of his time on the rugby pitch. Playing rugby took him to several ships and shore bases over the course of 18 months, but Jim’s life was about to change forever. “In March 1992, after joining the HMS Illustrious, my life was totally changed when I was the victim of a random unprovoked attack shortly after going ashore,” he said. “My attacker, who pushed me through a plate glass window, was later charged with attempted murder. I sustained life-changing physical and mental injuries.
“Due to the nature of my injuries, I had to remain awake, un-anesthetised during surgery and I watched as the medical staff brought a priest in to administer the last rites as they didn’t think I would make it. “But I did, and once my physical injuries were stabilised, I was moved by the Royal Navy to a mental health ward where in June of 1992 I was diagnosed with PTSD. “I spent four weeks undertaking a PTSD awareness course. One element of the course was art therapy and I found painting helped me – in fact, I was encouraged to continue painting and remain busy in order to keep my PTSD at bay. I was also told not to think or talk about my trauma.

“For over 25 years I continued to paint as a way of coping and never spoke about the attack.
“After the course, I was sent back to HMS Dryad, and despite all I had been through, was encouraged to get back to rugby; however, when it came to my first match back, I was convinced I would sustain further injuries and didn’t play. “Shortly afterwards, I was offered a medical discharge which could take several months to arrange, or I could take an honorable discharge based on the exceptional circumstances which would take just 24 hours. I took the second option allowing me to leave as quickly as I could. “I left and got on with life, often travelling extensively with work in order to remain busy. I followed the instruction to keep busy, but I know now this was the wrong choice and wasn’t working.

“I used to relive seeing the priest at the end of my bed at night – just like during surgery. I also used to feel like the blood was pumping out of the scar on my head, just as it did after I’d been attacked. “It was when I was confronted by my daughter, telling me she’d come into my bedroom one night to tell me to turn the telly off that I knew I had to do something. The television wasn’t on –it was me shouting and screaming in my sleep. I knew I used to do this – I had to move into a mess of my own in the Navy because of it – but when I knew it was affecting my family, I decided to do something.”

Jim went to his GP initially and explained that he had been diagnosed with PTSD. However, he didn’t receive the support that he needed. Then in 2017 he reached out to Combat Stress. Finally, Jim started his journey towards recovery. “It wasn’t easy. I was embarrassed to call the helpline. I thought I’d been dealing with my problems but really, I’d just been told to keep busy and push everything to the back of my mind. I felt like a failure.

By working with the specialist team at Combat Stress Jim began to learn management techniques and coping strategies for his mental health issues such as hyperarousal and flashbacks. “I learnt about grounding, mindfulness and did much more art therapy. I received CBT & EMDR treatment which has significantly helped with the reliving. I no longer see the priest. Thanks to CBT/EMDR and the art therapists, I understand why I have these memories and have begun to process them. “I also found the education sessions invaluable – learning about how memories work and how the brain processes them really helped me. The peer support has also played important part of my recovery too, supporting me as I returned back to a Royal Navy shore base and the place of trauma. “Combat Stress also encouraged me to reengage with the veteran community. I hadn’t engaged in anything military since leaving the Navy.

“In 2019 I was selected to attend the Cenotaph on Remembrance Sunday. Since leaving Combat Stress, I had further medical support and discovered through a brain scan that I sustained brain injuries as a result of my attack. This injury was contributing to the sensation of blood pumping, but with medication, this is manageable. “What I learnt at Combat Stress has made a massive difference to me. I know now I needed to process my memories, not just bury them or push them away. I owe my life to the team who were on duty at the Royal Naval Hospital Stonehouse – thank you! Also, a huge thanks to Combat Stress for improving my health and knowledge, enabling me to look forward to a better future.”

If you would like to find out more about Combat Stress or how to access their support, please visit their website, or call their 24 hour helpline on 0800 138 1619.

Reference

Navy News. (2021) Jim’s Journey Out of the Darkness. Navy News. July 2021, pp.33.

What is Pathological Demand Avoidance?

Introduction

Pathological demand avoidance (PDA) is a proposed sub-type of autism spectrum disorder.

Characteristics ascribed to the condition include greater refusal to do what is asked of the person, even to activities the person would normally like. It is not recognised by either the DSM-5 or the ICD-10 and is unlikely to be separated out now that the umbrella diagnosis of ASD has been adopted.

In 2011, it was suggested that these symptoms could represent the condition oppositional defiant disorder (ODD). Elizabeth O’Nions and others, argue that unlike ASD, “children with PDA are said to use socially manipulative avoidance strategies”; and unlike ODD, they “resort to extreme, embarrassing or age-inappropriate behaviour”.

The term was proposed in 1980 by the UK child psychologist Elizabeth Ann Newson.

Brief History

Newson first began to look at PDA as a specific syndrome in the 1980s when certain children referred to the Child Development Clinic at the University of Nottingham appeared to display and share many of the same characteristics. These children had often been referred because they seemed to show many autistic traits but were not typical in their presentation like those with classical autism or Asperger’s syndrome. They had often been labelled as ‘atypical autism’ or Persistent Development Disorder- Not Otherwise Specified (PDD-NOS). Both of these terms were felt by parents to be unhelpful.

When Newson was made professor of developmental psychology at the University of Nottingham in 1994, she dedicated her inaugural lecture to talking about pathological demand avoidance syndrome.

In 1997, the PDA Society was established in the UK by parents of children with a PDA profile of autism. It became a registered charity in January 2016.

In July 2003, Newson published in Archives of Disease in Childhood for PDA to be recognised as a separate syndrome within the pervasive developmental disorders.

In 2020, an Incorporated Association was established in Australia. ‘Pathological Demand Avoidance Australia Inc.’ became a registered charity early 2021.[

Recognition

Pathological demand avoidance is not recognised by the DSM-5 or ICD-10, the two main classification systems for mental disorders. To be recognised a sufficient amount of consensus and clinical history needs to be present, and as a newly proposed condition, PDA had not met the standard of evidence required at the time of recent revisions. However, DSM-5 also moved from sub-type classification to the use of ‘Autistic Spectrum Disorder’ which allows for the behavioural traits of different profiles to be described.

In 2011 the National Institute for Health and Care Excellence commented on the fact that PDA has been proposed as part of the autism spectrum but did not include further discussion within the guideline. NICE guidance also expects an ‘ASD’ diagnosis be accompanied by a diagnostic assessment providing a profile of key strengths and difficulties. Demand Avoidance is listed as a ‘sign or symptom of ASD’.

Christopher Gillberg wrote a commentary article in 2014 which reviewed recent research and stated “Experienced clinicians throughout child psychiatry, child neurology and paediatrics testify to its existence and the very major problems encountered when it comes to intervention and treatment.”

Proposed Diagnostic Criteria

As of 2014 there are no recognised diagnostic criteria. Criteria proposed by Newson include:

  • Passive early history in the first year, avoiding ordinary demands and missing milestones.
  • Continuing to avoid demands, panic attacks if demands are escalated.
  • Surface sociability, but apparent lack of sense of social identity.
  • Lability of mood and impulsivity.
  • Comfortable in role play and pretending.
  • Language delay, seemingly the result of passivity, often caught up quickly.
  • Obsessive behaviour.
  • Neurological signs (awkwardness, similar to autism spectrum disorders).

The underlying cause for this avoidance is said to be a high level of anxiety, usually from expectations of demands being placed on children, which can lead to a feeling of not being in control of a situation. Children with PDA feel threatened when they are not in control of their environment and their actions, which triggers the fight, flight or freeze response.

What is Parallel Process?

Introduction

Parallel process is a phenomenon noted between therapist and supervisor, whereby the therapist recreates, or parallels, the client’s problems by way of relating to the supervisor.

The individual’s transference and the therapist’s countertransference thus re-appear in the mirror of the therapist/supervisor relationship.

Background

Attention to parallel process first emerged in the nineteen-fifties (1950s). The process was termed reflection by Harold Searles in 1955, and two years later T. Hora (1957) first used the actual term parallel process – emphasising that it was rooted in an unconscious identification with the client/patient which could extend to tone of voice and behaviour. The supervisee thus enacts the central problem of the therapy in the supervision, potentially opening up a process of containment and solution, first by the supervisor and then by the therapist.

Alternatively, the supervisor’s own countertransference may be activated in the parallel process, to be reflected in turn between supervisor and consultant, or back into the original patient/helper dyad. Even then, however, careful examination of the material may still illuminate the original therapeutic difficulty, as reflected in the parallel situation.

What is the Paddington Alcohol Test?

Introduction

The Paddington alcohol test (PAT) was first published in the Journal of Accident and Emergency Medicine in 1996.

Background

It was designed to identify alcohol-related problems amongst those attending accident and emergency departments. It concords well with the Alcohol Use Disorders Identification Test (AUDIT) questionnaire but is administered in a fifth of the time.

When 40-70% of the patients in an accident and emergency department (AED) are there because of alcohol-related issues, it is useful for the staff of the AED to determine which of them are hazardous drinkers so that they can treat the underlying cause and offer brief advice which may reduce the health impact of alcohol for that patient. In accident and emergency departments it is also important to triage incoming patients as quickly as possible, to reduce staff size and cost. In one study, it took an average of 73 seconds to administer the AUDIT questionnaire but only 20 seconds for the PAT.

The working version of the PAT is reviewed at St Mary’s Hospital based on feedback from frontline doctors in the emergency department (A&E). There is also a modified version in use for an English multi-site programme research (Screening and Intervention Programme for Sensible Drinking, SIPS).

The latest version of the PAT is available on the UK Department of Health website, the Alcohol Learning Centre (now part of Public Health England).

On This Day … 07 October

People (Deaths)

  • 1926 – Emil Kraepelin, German psychiatrist and academic (b. 1856).

Emil Kraepelin

Emil Wilhelm Georg Magnus Kraepelin (15 February 1856 to 07 October 1926) was a German psychiatrist.

H.J. Eysenck’s Encyclopaedia of Psychology identifies him as the founder of modern scientific psychiatry, psychopharmacology and psychiatric genetics.

Kraepelin believed the chief origin of psychiatric disease to be biological and genetic malfunction. His theories dominated psychiatry at the start of the 20th century and, despite the later psychodynamic influence of Sigmund Freud and his disciples, enjoyed a revival at century’s end. While he proclaimed his own high clinical standards of gathering information “by means of expert analysis of individual cases”, he also drew on reported observations of officials not trained in psychiatry.

His textbooks do not contain detailed case histories of individuals but mosaic-like compilations of typical statements and behaviours from patients with a specific diagnosis. He has been described as “a scientific manager” and “a political operator”, who developed “a large-scale, clinically oriented, epidemiological research programme”.

What is World Mental Health Day (2021)?

Introduction

World Mental Health Day (10 October) is an international day for global mental health education, awareness and advocacy against social stigma.

Background

It was first celebrated in 1992 at the initiative of the World Federation for Mental Health, a global mental health organisation with members and contacts in more than 150 countries.

This day, each October, thousands of supporters come to celebrate this annual awareness programme to bring attention to mental illness and its major effects on peoples’ lives worldwide.

In some countries this day is part of an awareness week, such as Mental Health Week in Australia.

Brief History

World Mental Health Day was celebrated for the first time on 10 October 1992, at the initiative of Deputy Secretary General Richard Hunter. Up until 1994, the day had no specific theme other than general promoting mental health advocacy and educating the public.

In 1994 World Mental Health Day was celebrated with a theme for the first time at the suggestion of then Secretary General Eugene Brody. The theme was “Improving the Quality of Mental Health Services throughout the World”.

World Mental Health Day is supported by WHO through raising awareness on mental health issues using its strong relationships with the Ministries of health and civil society organizations across the globe. WHO also supports with developing technical and communication material.

On World Mental Health Day 2018, Prime Minister Theresa May appointed Jackie Doyle-Price as the UK’s first suicide prevention minister. This occurred while as the government hosted the first ever global mental health summit.

World Mental Health Day Themes

  • 1994 – Improving the Quality of Mental Health Services throughout the World.
  • 1996 – Women and Mental Health.
  • 1997 – Children and Mental Health.
  • 1998 – Mental Health and Human Rights.
  • 1999 – Mental Health and Aging.
  • 2000-2001 – Mental Health and Work.
  • 2002 – The Effects of Trauma and Violence on Children & Adolescents.
  • 2003 – Emotional and Behavioural Disorders of Children & Adolescents.
  • 2004 – The Relationship Between Physical & Mental Health: co-occurring disorders.
  • 2005 – Mental and Physical Health Across the Life Span.
  • 2006 – Building Awareness – Reducing Risk: Mental Illness & Suicide.
  • 2007 – Mental Health in A Changing World: The Impact of Culture and Diversity.
  • 2008 – Making Mental Health a Global Priority: Scaling up Services through Citizen Advocacy and Action.
  • 2009 – Mental Health in Primary Care: Enhancing Treatment and Promoting Mental Health.
  • 2010 – Mental Health and Chronic Physical Illnesses.
  • 2011 – The Great Push: Investing in Mental Health.
  • 2012 – Depression: A Global Crisis.
  • 2013 – Mental health and older adults.
  • 2014 – Living with Schizophrenia.
  • 2015 – Dignity in Mental Health.
  • 2016 – Psychological First Aid.
  • 2017 – Mental health in the workplace.
  • 2018 – Young people and mental health in a changing world.
  • 2019 – Mental Health Promotion and Suicide Prevention.
  • 2020 – Move for mental health: Increased investment in mental health.
  • 2021 – Mental Health in an Unequal World.

On This Day … 06 October

People (Births)

  • 1915 – Carolyn Goodman, American psychologist and activist (d. 2007).
  • 1934 – Marshall Rosenberg, American psychologist and author (d. 2015).

Carolyn Goodman

Carolyn Elizabeth Goodman (née Drucker; 06 October 1915 to 17 August 2007) was an American clinical psychologist who became a prominent civil rights advocate after her son, Andrew Goodman and two other civil rights workers, James Chaney and Michael Schwerner, were murdered by the Ku Klux Klan in Neshoba County, Mississippi, in 1964.

Politically active until age 90, Goodman came to wide public attention again in 2005. Traveling to Philadelphia, Mississippi, she testified at the murder trial of Edgar Ray Killen, a former Klan leader recently indicted in the case. On 21 June 2005, the 41st anniversary of the killings, a jury acquitted Killen of murder but found him guilty of manslaughter in the deaths of Goodman, Chaney, and Schwerner.

Marshall Rosenberg

Marshall Bertram Rosenberg (06 October 1934 to 07 February 2015) was an American psychologist, mediator, author and teacher. Starting in the early 1960s he developed Nonviolent Communication, a process for supporting partnership and resolving conflict within people, in relationships, and in society. He worked worldwide as a peacemaker and in 1984 founded the Centre for Nonviolent Communication, an international non-profit organisation for which he served as Director of Educational Services.

According to his biographer, Marjorie C. Witty, “He has a fierce face – even when he smiles and laughs. The overall impression I received was of intellectual and emotional intensity. He possesses a charismatic presence.”

What is Observational Learning?

Introduction

Observational learning is learning that occurs through observing the behaviour of others.

It is a form of social learning which takes various forms, based on various processes. In humans, this form of learning seems to not need reinforcement to occur, but instead, requires a social model such as a parent, sibling, friend, or teacher with surroundings. Particularly in childhood, a model is someone of authority or higher status in an environment. In animals, observational learning is often based on classical conditioning, in which an instinctive behaviour is elicited by observing the behaviour of another (e.g. mobbing in birds), but other processes may be involved as well.

Human Observational Learning

Many behaviours that a learner observes, remembers, and imitates are actions that models display and display modelling, even though the model may not intentionally try to instil a particular behaviour. A child may learn to swear, smack, smoke, and deem other inappropriate behaviour acceptable through poor modelling. Albert Bandura claims that children continually learn desirable and undesirable behaviour through observational learning. Observational learning suggests that an individual’s environment, cognition, and behaviour all incorporate and ultimately determine how the individual functions and models.

Through observational learning, individual behaviours can spread across a culture through a process called diffusion chain. This basically occurs when an individual first learns a behaviour by observing another individual and that individual serves as a model through whom other individuals learn the behaviour, and so on.

Culture plays a role in whether observational learning is the dominant learning style in a person or community. Some cultures expect children to actively participate in their communities and are therefore exposed to different trades and roles on a daily basis. This exposure allows children to observe and learn the different skills and practices that are valued in their communities.

Albert Bandura, who is known for the classic Bobo doll experiment, identified this basic form of learning in 1961. The importance of observational learning lies in helping individuals, especially children, acquire new responses by observing others’ behaviour.

Albert Bandura states that people’s behaviour could be determined by their environment. Observational learning occurs through observing negative and positive behaviours. Bandura believes in reciprocal determinism in which the environment can influence people’s behaviour and vice versa. For instance, the Bobo doll experiment shows that the model, in a determined environment, affects children’s behaviour. In this experiment Bandura demonstrates that one group of children placed in an aggressive environment would act the same way, while the control group and the other group of children placed in a passive role model environment hardly shows any type of aggression.

In communities where children’s primary mode of learning is through observation, the children are rarely separated from adult activities. This incorporation into the adult world at an early age allows children to use observational learning skills in multiple spheres of life. This learning through observation requires keen attentive abilities. Culturally, they learn that their participation and contributions are valued in their communities. This teaches children that it is their duty, as members of the community, to observe others’ contributions so they gradually become involved and participate further in the community.

Influential Stages and Factors

The stages of observational learning include exposure to the model, acquiring the model’s behaviour and accepting it as one’s own.

Bandura’s social cognitive learning theory states that there are four factors that influence observational learning:

AttentionObservers cannot learn unless they pay attention to what’s happening around them. This process is influenced by characteristics of the model, such as how much one likes or identifies with the model, and by characteristics of the observer, such as the observer’s expectations or level of emotional arousal.
Retention/MemoryObservers must not only recognize the observed behaviour but also remember it at some later time. This process depends on the observer’s ability to code or structure the information in an easily remembered form or to mentally or physically rehearse the model’s actions.
Initiation/MotorObservers must be physically and/intellectually capable of producing the act. In many cases, the observer possesses the necessary responses. But sometimes, reproducing the model’s actions may involve skills the observer has not yet acquired. It is one thing to carefully watch a circus juggler, but it is quite another to go home and repeat those acts.
MotivationThe observer must have motivation to recreate the observed behaviour.


Bandura clearly distinguishes between learning and performance. Unless motivated, a person does not produce learned behaviour. This motivation can come from external reinforcement, such as the experimenter’s promise of reward in some of Bandura’s studies, or the bribe of a parent. Or it can come from vicarious reinforcement, based on the observation that models are rewarded. High-status models can affect performance through motivation. For example, girls aged 11 to 14 performed better on a motor performance task when they thought it was demonstrated by a high-status cheerleader than by a low-status model.

Some have even added a step between attention and retention involving encoding a behaviour.

Observational learning leads to a change in an individual’s behaviour along three dimensions:

  • An individual thinks about a situation in a different way and may have incentive to react to it.
  • The change is a result of a person’s direct experiences as opposed to being in-born.
  • For the most part, the change an individual has made is permanent.

Effect on Behaviour

According to Bandura’s social cognitive learning theory, observational learning can affect behaviour in many ways, with both positive and negative consequences. It can teach completely new behaviours, for one. It can also increase or decrease the frequency of behaviours that have previously been learned. Observational learning can even encourage behaviours that were previously forbidden (for example, the violent behaviour towards the Bobo doll that children imitated in Albert Bandura’s study). Observational learning can also influence behaviours that are similar to, but not identical to, the ones being modelled. For example, seeing a model excel at playing the piano may motivate an observer to play the saxophone.

Age Difference

Albert Bandura stressed that developing children learn from different social models, meaning that no two children are exposed to exactly the same modelling influence. From infancy to adolescence, they are exposed to various social models. A 2013 study found that a toddlers’ previous social familiarity with a model was not always necessary for learning and that they were also able to learn from observing a stranger demonstrating or modelling a new action to another stranger.

It was once believed that babies could not imitate actions until the latter half of the first year. However, a number of studies now report that infants as young as seven days can imitate simple facial expressions. By the latter half of their first year, 9-month-old babies can imitate actions hours after they first see them. As they continue to develop, toddlers around age two can acquire important personal and social skills by imitating a social model.

Deferred imitation is an important developmental milestone in a two-year-old, in which children not only construct symbolic representations but can also remember information. Unlike toddlers, children of elementary school age are less likely to rely on imagination to represent an experience. Instead, they can verbally describe the model’s behaviour. Since this form of learning does not need reinforcement, it is more likely to occur regularly.

As age increases, age-related observational learning motor skills may decrease in athletes and golfers. Younger and skilled golfers have higher observational learning compared to older golfers and less skilled golfers.

Observational Causal Learning

Humans use observational Moleen causal learning to watch other people’s actions and use the information gained to find out how something works and how we can do it ourselves.

A study of 25-month-old infants found that they can learn causal relations from observing human interventions. They also learn by observing normal actions not created by intentional human action.

Comparisons with Imitation

Observational learning is presumed to have occurred when an organism copies an improbable action or action outcome that it has observed and the matching behaviour cannot be explained by an alternative mechanism. Psychologists have been particularly interested in the form of observational learning known as imitation and in how to distinguish imitation from other processes. To successfully make this distinction, one must separate the degree to which behavioural similarity results from:

  • Predisposed behaviour.
  • Increased motivation resulting from the presence of another animal.
  • Attention drawn to a place or object.
  • Learning about the way the environment works, as distinguished from what we think of as.
  • Imitation (the copying of the demonstrated behaviour).

Observational learning differs from imitative learning in that it does not require a duplication of the behaviour exhibited by the model. For example, the learner may observe an unwanted behaviour and the subsequent consequences, and thus learn to refrain from that behaviour. For example, Riopelle (1960) found that monkeys did better with observational learning if they saw the “tutor” monkey make a mistake before making the right choice. Heyes (1993) distinguished imitation and non-imitative social learning in the following way: imitation occurs when animals learn about behaviour from observing conspecifics, whereas non-imitative social learning occurs when animals learn about the environment from observing others.

Not all imitation and learning through observing is the same, and they often differ in the degree to which they take on an active or passive form. John Dewey describes an important distinction between two different forms of imitation: imitation as an end in itself and imitation with a purpose.[19] Imitation as an end is more akin to mimicry, in which a person copies another’s act to repeat that action again. This kind of imitation is often observed in animals. Imitation with a purpose utilizes the imitative act as a means to accomplish something more significant. Whereas the more passive form of imitation as an end has been documented in some European American communities, the other kind of more active, purposeful imitation has been documented in other communities around the world.

Observation may take on a more active form in children’s learning in multiple Indigenous American communities. Ethnographic anthropological studies in Yucatec Mayan and Quechua Peruvian communities provide evidence that the home or community-centred economic systems of these cultures allow children to witness first-hand, activities that are meaningful to their own livelihoods and the overall well-being of the community. These children have the opportunity to observe activities that are relevant within the context of that community, which gives them a reason to sharpen their attention to the practical knowledge they are exposed to. This does not mean that they have to observe the activities even though they are present. The children often make an active decision to stay in attendance while a community activity is taking place to observe and learn. This decision underscores the significance of this learning style in many indigenous American communities. It goes far beyond learning mundane tasks through rote imitation; it is central to children’s gradual transformation into informed members of their communities’ unique practices. There was also a study, done with children, that concluded that Imitated behaviour can be recalled and used in another situation or the same.

Apprenticeship

Apprenticeship can involve both observational learning and modelling. Apprentices gain their skills in part through working with masters in their profession and through observing and evaluating the work of their fellow apprentices. Examples include renaissance inventor/painter Leonardo da Vinci and Michelangelo, before succeeding in their profession they were apprentices.

Learning Without Imitation

Michael Tomasello described various ways of observational learning without the process of imitation in animals (ethology):

ExposureIndividuals learn about their environment through close proximity to other individuals that have more experience. For example, a young dolphin learning the location of a plethora of fish by staying near its mother.
Stimulus EnhancementIndividuals become interested in an object from watching others interact with it. Increased interest in an object may result in object manipulation, which facilitates new object-related behaviours by trial-and-error learning. For example, a young killer whale might become interested in playing with a sea lion pup after watching other whales toss the sea lion pup around. After playing with the pup, the killer whale may develop foraging behaviours appropriate to such prey. In this case, the killer whale did not learn to prey on sea lions by observing other whales do so, but rather the killer whale became intrigued after observing other whales play with the pup. After the killer whale became interested, then its interactions with the sea lion resulted in behaviours that provoked future foraging efforts.
Goal EmulationIndividuals are enticed by the end result of an observed behaviour and attempt the same outcome but with a different method. For example, Haggerty (1909) devised an experiment in which a monkey climbed up the side of a cage, stuck its arm into a wooden chute, and pulled a rope in the chute to release food. Another monkey was provided an opportunity to obtain the food after watching a monkey go through this process on four separate occasions. The monkey performed a different method and finally succeeded after trial and error.

Peer Model Influences

Observational learning is very beneficial when there are positive, reinforcing peer models involved. Although individuals go through four different stages for observational learning: attention; retention; production; and motivation, this does not simply mean that when an individual’s attention is captured that it automatically sets the process in that exact order. One of the most important ongoing stages for observational learning, especially among children, is motivation and positive reinforcement.

Performance is enhanced when children are positively instructed on how they can improve a situation and where children actively participate alongside a more skilled person. Examples of this are scaffolding and guided participation. Scaffolding refers to an expert responding contingently to a novice so the novice gradually increases their understanding of a problem. Guided participation refers to an expert actively engaging in a situation with a novice so the novice participates with or observes the adult to understand how to resolve a problem.

Cultural Variation

Cultural variation can be seen by the extent of information learned or absorbed by children in non-Western cultures through learning by observation. Cultural variation is not restricted only to ethnicity and nationality, but rather, extends to the specific practices within communities. In learning by observation, children use observation to learn without verbal requests for further information, or without direct instruction. For example, children from Mexican heritage families tend to learn and make better use of information observed during classroom demonstration than children of European heritage. Children of European heritage experience the type of learning that separates them from their family and community activities. They instead participate in lessons and other exercises in special settings such as school. Cultural backgrounds differ from each other in which children display certain characteristics in regards to learning an activity. Another example is seen in the immersion of children in some Indigenous communities of the Americas into the adult world and the effects it has on observational learning and the ability to complete multiple tasks simultaneously. This might be due to children in these communities having the opportunity to see a task being completed by their elders or peers and then trying to emulate the task. In doing so they learn to value observation and the skill-building it affords them because of the value it holds within their community. This type of observation is not passive, but reflects the child’s intent to participate or learn within a community.

Observational learning can be seen taking place in many domains of Indigenous communities. The classroom setting is one significant example, and it functions differently for Indigenous communities compared to what is commonly present in Western schooling. The emphasis of keen observation in favour of supporting participation in ongoing activities strives to aid children to learn the important tools and ways of their community. Engaging in shared endeavours – with both the experienced and inexperienced – allows for the experienced to understand what the inexperienced need in order to grow in regards to the assessment of observational learning. The involvement of the inexperienced, or the children in this matter, can either be furthered by the children’s learning or advancing into the activity performed by the assessment of observational learning. Indigenous communities rely on observational learning as a way for their children to be a part of ongoing activities in the community.

Although learning in the Indigenous American communities is not always the central focus when participating in an activity, studies have shown that attention in intentional observation differs from accidental observation. Intentional participation is “keen observation and listening in anticipation of, or in the process of engaging in endeavors”. This means that when they have the intention of participating in an event, their attention is more focused on the details, compared to when they are accidentally observing.

Observational learning can be an active process in many Indigenous American communities. The learner must take initiative to attend to activities going on around them. Children in these communities also take initiative to contribute their knowledge in ways that will benefit their community. For example, in many Indigenous American cultures, children perform household chores without being instructed to do so by adults. Instead, they observe a need for their contributions, understand their role in their community, and take initiative to accomplish the tasks they have observed others doing. The learner’s intrinsic motivations play an important role in the child’s understanding and construction of meaning in these educational experiences. The independence and responsibility associated with observational learning in many Indigenous American communities are significant reasons why this method of learning involves more than just watching and imitating. A learner must be actively engaged with their demonstrations and experiences in order to fully comprehend and apply the knowledge they obtain.

Indigenous Communities of the Americas

Children from indigenous heritage communities of the Americas often learn through observation, a strategy that can carry over into adulthood. The heightened value towards observation allows children to multi-task and actively engage in simultaneous activities. The exposure to an uncensored adult lifestyle allows children to observe and learn the skills and practices that are valued in their communities. Children observe elders, parents, and siblings complete tasks and learn to participate in them. They are seen as contributors and learn to observe multiple tasks being completed at once and can learn to complete a task while still engaging with other community members without being distracted.

Indigenous communities provide more opportunities to incorporate children in everyday life. This can be seen in some Mayan communities where children are given full access to community events, which allows observational learning to occur more often. Other children in Mazahua, Mexico are known to observe ongoing activities intensely. In native northern Canadian and indigenous Mayan communities, children often learn as third-party observers from stories and conversations by others. Most young Mayan children are carried on their mother’s back, allowing them to observe their mother’s work and see the world as their mother sees it. Often, children in Indigenous American communities assume the majority of the responsibility for their learning. Additionally, children find their own approaches to learning. Children are often allowed to learn without restrictions and with minimal guidance. They are encouraged to participate in the community even if they do not know how to do the work. They are self-motivated to learn and finish their chores. These children act as a second set of eyes and ears for their parents, updating them about the community.

Children aged 6 to 8 in an indigenous heritage community in Guadalajara, Mexico participated in hard work, such as cooking or running errands, thus benefiting the whole family, while those in the city of Guadalajara rarely did so. These children participated more in adult regulated activities and had little time to play, while those from the indigenous-heritage community had more time to play and initiate in their after-school activities and had a higher sense of belonging to their community. Children from formerly indigenous communities are more likely to show these aspects than children from cosmopolitan communities are, even after leaving their childhood community

Within certain indigenous communities, people do not typically seek out explanations beyond basic observation. This is because they are competent in learning through astute observation and often nonverbally encourage to do so. In a Guatemalan footloom factory, amateur adult weavers observed skilled weavers over the course of weeks without questioning or being given explanations; the amateur weaver moved at their own pace and began when they felt confident. The framework of learning how to weave through observation can serve as a model that groups within a society use as a reference to guide their actions in particular domains of life. Communities that participate in observational learning promote tolerance and mutual understand of those coming from different cultural backgrounds.

Other Human and Animal Behaviour Experiments

When an animal is given a task to complete, they are almost always more successful after observing another animal doing the same task before them. Experiments have been conducted on several different species with the same effect: animals can learn behaviours from peers. However, there is a need to distinguish the propagation of behaviour and the stability of behaviour. Research has shown that social learning can spread a behaviour, but there are more factors regarding how a behaviour carries across generations of an animal culture.

Learning in Fish

Experiments with ninespine sticklebacks showed that individuals will use social learning to locate food.

Social Learning in Pigeons

A study in 1996 at the University of Kentucky used a foraging device to test social learning in pigeons. A pigeon could access the food reward by either pecking at a treadle or stepping on it. Significant correspondence was found between the methods of how the observers accessed their food and the methods the initial model used in accessing the food.

Acquiring Foraging Niches

Studies have been conducted at the University of Oslo and University of Saskatchewan regarding the possibility of social learning in birds, delineating the difference between cultural and genetic acquisition. Strong evidence already exists for mate choice, bird song, predator recognition, and foraging.

Researchers cross-fostered eggs between nests of blue tits and great tits and observed the resulting behaviour through audio-visual recording. Tits raised in the foster family learned their foster family’s foraging sites early. This shift – from the sites the tits would among their own kind and the sites they learned from the foster parents – lasted for life. What young birds learn from foster parents, they eventually transmitted to their own offspring. This suggests cultural transmissions of foraging behaviour over generations in the wild.

Social Learning in Crows

The University of Washington studied this phenomenon with crows, acknowledging the evolutionary tradeoff between acquiring costly information firsthand and learning that information socially with less cost to the individual but at the risk of inaccuracy. The experimenters exposed wild crows to a unique “dangerous face” mask as they trapped, banded, and released 7-15 birds at five different study places around Seattle, Washington. An immediate scolding response to the mask after trapping by previously captured crows illustrates that the individual crow learned the danger of that mask. There was a scolding from crows that were captured that had not been captured initially. That response indicates conditioning from the mob of birds that assembled during the capture.

Horizontal social learning (learning from peers) is consistent with the lone crows that recognized the dangerous face without ever being captured. Children of captured crow parents were conditioned to scold the dangerous mask, which demonstrates vertical social learning (learning from parents). The crows that were captured directly had the most precise discrimination between dangerous and neutral masks than the crows that learned from the experience of their peers. The ability of crows to learn doubled the frequency of scolding, which spread at least 1.2 km from where the experiment started to over a 5-year period at one site.

Propagation of Animal Culture

Researchers at the Département d’Etudes Cognitives, Institut Jean Nicod, Ecole Normale Supérieure acknowledged a difficulty with research in social learning. To count acquired behaviour as cultural, two conditions need must be met: the behaviour must spread in a social group, and that behaviour must be stable across generations. Research has provided evidence that imitation may play a role in the propagation of a behaviour, but these researchers believe the fidelity of this evidence is not sufficient to prove the stability of animal culture.

Other factors like ecological availability, reward-based factors, content-based factors, and source-based factors might explain the stability of animal culture in a wild rather than just imitation. As an example of ecological availability, chimps may learn how to fish for ants with a stick from their peers, but that behaviour is also influenced by the particular type of ants as well as the condition. A behaviour may be learned socially, but the fact that it was learned socially does not necessarily mean it will last. The fact that the behaviour is rewarding has a role in cultural stability as well. The ability for socially-learned behaviours to stabilise across generations is also mitigated by the complexity of the behaviour. Different individuals of a species, like crows, vary in their ability to use a complex tool. Finally, a behaviour’s stability in animal culture depends on the context in which they learn a behaviour. If a behaviour has already been adopted by a majority, then the behaviour is more likely to carry across generations out of a need for conforming.

Animals are able to acquire behaviours from social learning, but whether or not that behaviour carries across generations requires more investigation.

Hummingbird Experiment

Experiments with hummingbirds provided one example of apparent observational learning in a non-human organism. Hummingbirds were divided into two groups. Birds in one group were exposed to the feeding of a knowledgeable “tutor” bird; hummingbirds in the other group did not have this exposure. In subsequent tests the birds that had seen a tutor were more efficient feeders than the others.

Bottlenose Dolphin

Herman (2002) suggested that bottlenose dolphins produce goal-emulated behaviours rather than imitative ones. A dolphin that watches a model place a ball in a basket might place the ball in the basket when asked to mimic the behaviour, but it may do so in a different manner seen.

Rhesus Monkey

Kinnaman (1902) reported that one rhesus monkey learned to pull a plug from a box with its teeth to obtain food after watching another monkey succeed at this task.

Fredman (2012) also performed an experiment on observational behavior. In experiment 1, human-raised monkeys observed a familiar human model open a foraging box using a tool in one of two alternate ways: levering or poking. In experiment 2, mother-raised monkeys viewed similar techniques demonstrated by monkey models. A control group in each population saw no model. In both experiments, independent coders detected which technique experimental subjects had seen, thus confirming social learning. Further analyses examined copying at three levels of resolution.

The human-raised monkeys exhibited the greatest learning with the specific tool use technique they saw. Only monkeys who saw the levering model used the lever technique, by contrast with controls and those who witnessed poking. Mother-reared monkeys instead typically ignored the tool and exhibited fidelity at a lower level, tending only to re-create whichever result the model had achieved by either levering or poking.

Nevertheless, this level of social learning was associated with significantly greater levels of success in monkeys witnessing a model than in controls, an effect absent in the human-reared population. Results in both populations are consistent with a process of canalisation of the repertoire in the direction of the approach witnessed, producing a narrower, socially shaped behavioural profile than among controls who saw no model.

Light Box Experiment

Pinkham and Jaswal (2011) did an experiment to see if a child would learn how to turn on a light box by watching a parent. They found that children who saw a parent use their head to turn on the light box tended to do the task in that manner, while children who had not seen the parent used their hands instead.

Swimming Skill Performance

When adequate practice and appropriate feedback follow demonstrations, increased skill performance and learning occurs. Lewis (1974) did a study of children who had a fear of swimming and observed how modelling and going over swimming practices affected their overall performance. The experiment spanned nine days, and included many steps. The children were first assessed on their anxiety and swimming skills. Then they were placed into one of three conditional groups and exposed to these conditions over a few days.

At the end of each day, all children participated in a group lesson. The first group was a control group where the children watched a short cartoon video unrelated to swimming. The second group was a peer mastery group, which watched a short video of similar-aged children who had very good task performances and high confidence. Lastly, the third group was a peer coping group, whose subjects watched a video of similar-aged children who progressed from low task performances and low confidence statements to high task performances and high confidence statements.

The day following the exposures to each condition, the children were reassessed. Finally, the children were also assessed a few days later for a follow up assessment. Upon reassessment, it was shown that the two model groups who watched videos of children similar in age had successful rates on the skills assessed because they perceived the models as informational and motivational.

Do-as-I-do Chimpanzee

Flexible methods must be used to assess whether an animal can imitate an action. This led to an approach that teaches animals to imitate by using a command such as “do-as-I-do” or “do this” followed by the action that they are supposed to imitate. Researchers trained chimpanzees to imitate an action that was paired with the command. For example, this might include a researcher saying “do this” paired with clapping hands. This type of instruction has been utilised in a variety of other animals in order to teach imitation actions by utilising a command or request.

Observational Learning in Everyday Life

Observational learning allows for new skills to be learned in a wide variety of areas. Demonstrations help the modification of skills and behaviours.

Learning Physical Activities

When learning skills for physical activities can be anything that is learned that requires physical movement, this can include learning a sport, learning to eat with a fork, or learning to walk. There are multiple important variables that aid in modifying physical skills and psychological responses from an observational learning standpoint. Modelling is a variable in observational learning where the skill level of the model is considered. When someone is supposed to demonstrate a physical skill such as throwing a baseball the model should be able to execute the behaviour of throwing the ball flawlessly if the model of learning is a mastery model. Another model to utilise in observational learning is a coping model, which would be a model demonstrating a physical skill that they have not yet mastered or achieved high performance in. Both models are found to be effective and can be utilised depending on the what skills is trying to be demonstrated. These models can be used as interventions to increase observational learning in practice, competition, and rehabilitation situations.

Neuroscience

Recent research in neuroscience has implicated mirror neurons as a neurophysiological basis for observational learning. These specialised visuomotor neurons fire action potentials when an individual performs a motor task and also fire when an individual passively observes another individual performing the same motor task. In observational motor learning, the process begins with a visual presentation of another individual performing a motor task, this acts as a model. The learner then needs to transform the observed visual information into internal motor commands that will allow them to perform the motor task, this is known as visuomotor transformation. Mirror neuron networks provide a mechanism for visuo-motor and motor-visual transformation and interaction. Similar networks of mirror neurons have also been implicated in social learning, motor cognition and social cognition.

Clinical Perspective

Autism Spectrum Disorder

Discreet trial training (DTT) is a structured and systematic approach utilized in helping individuals with autism spectrum disorder learn. Individuals with autism tend to struggle with learning through observation, therefore something that is reinforcing is necessary in order to motivate them to imitate or follow through with the task. When utilising DTT to teach individuals with autism modelling is utilised to aid in their learning. Modelling would include showing how to reach the correct answer, this could mean showing the steps to a math equation. Utilising DTT in a group setting also promotes observational learning from peers as well.

What is Nitemazepam?

Introduction

Nitemazepam (or 3-hydroxynimetazepam) is a benzodiazepine derivative which was first synthesised in the 1970s but was never marketed.

It is the 7-nitro instead of 7-chloro analogue of temazepam, and also the 3-hydroxy derivative of nimetazepam, and an active metabolite.

It has in more recent years been sold as a designer drug, first being definitively identified in Europe in 2017.

Not to be confused with Nimetazepam or Nitrazepam.

What is Nitrazepam?

Introduction

Nitrazepam, sold under the brand name Mogadon among others, is a hypnotic drug of the benzodiazepine class used for short-term relief from severe, disabling anxiety and insomnia. It also has sedative (calming) properties, as well as amnestic (inducing forgetfulness), anticonvulsant, and skeletal muscle relaxant effects.

It was patented in 1961 and came into medical use in 1965.

Not to be confused with Nimetazepam and Nitemazepam.

Medical Use

Nitrazepam is used to treat short-term sleeping problems (insomnia), namely difficulty falling asleep, frequent awakening, early awakening, or a combination of each. Nitrazepam is sometimes tried to treat epilepsy when other medications fail. It has been found to be more effective than clonazepam in the treatment of West syndrome, which is an age-dependent epilepsy, affecting the very young. In uncontrolled studies, nitrazepam has shown effectiveness in infantile spasms and is sometimes considered when other anti-seizure drugs have failed. However, drowsiness, hypotonia, and most significantly tolerance to anti-seizure effects typically develop with long-term treatment, generally limiting Nitrazepam to acute seizure management.

Side Effects

More Common

More common side effects may include: Central nervous system depression, including somnolence, dizziness, depressed mood, fatigue, ataxia, headache, vertigo, impairment of memory, impairment of motor functions, hangover feeling in the morning, slurred speech, decreased physical performance, numbed emotions, reduced alertness, muscle weakness, double vision, and inattention have been reported. Unpleasant dreams and rebound insomnia have also been reported.

Nitrazepam is a long-acting benzodiazepine with an elimination half-life of 15-38 hours (mean elimination half-life 26 hours). Residual “hangover” effects after nighttime administration of nitrazepam such as sleepiness, impaired psychomotor and cognitive functions may persist into the next day, which may impair the ability of users to drive safely and increases the risk of falls and hip fractures.

Less Common

Less common side effects may include: Hypotension, faintness, palpitation, rash or pruritus, gastrointestinal disturbances, and changes in libido are less common. Very infrequently, paradoxical reactions may occur, for example, excitement, stimulation, hallucinations, hyperactivity, and insomnia. Also, depressed or increased dreaming, disorientation, severe sedation, retrograde amnesia, headache, hypothermia, and delirium tremens are reported. Severe liver toxicity has also been reported.

Cancer

Benzodiazepine use is associated with an increased risk of developing cancer. However, conflicting evidence implies that further research is needed in order to conclude that products of this class really do induce cancer.

Mortality

Nitrazepam therapy, compared with other drug therapies, increases risk of death when used for intractable epilepsy in an analysis of 302 patients. The risk of death from nitrazepam therapy may be greater in younger patients (children below 3.4 years in the study) with intractable epilepsy. In older children (above 3.4 years), the tendency appears to be reversed in this study. Nitrazepam may cause sudden death in children. It can cause swallowing incoordination, high-peaked oesophageal peristalsis, bronchospasm, delayed cricopharyngeal relaxation, and severe respiratory distress necessitating ventilatory support in children. Nitrazepam may promote the development of parasympathetic overactivity or vagotonia, leading to potentially fatal respiratory distress in children.

Liver

Nitrazepam has been associated with severe hepatic disorders, similar to other nitrobenzodiazepines. Nitrobenzodiazepines such as nitrazepam, nimetazepam, flunitrazepam, and clonazepam are more toxic to the liver than other benzodiazepines as they are metabolically activated by CYP3A4 which can result in cytotoxicity. This activation can lead to the generation of free radicals and oxidation of thiol, as well as covalent binding with endogenous macromolecules; this results, then, in oxidation of cellular components or inhibition of normal cellular function. Metabolism of a nontoxic drug to reactive metabolites has been causally connected with a variety of adverse reactions

Other Long-Term Effects

Refer to Effects Long-Term Benzodiazepine Use.

Long-term use of nitrazepam may carry mental and physical health risks, such as the development of cognitive deficits. These adverse effects show improvement after a period of abstinence. Some other sources however seem to indicate that there is no relation between the use of benzodiazepine medication and dementia. Further research is needed in order to assert that this class of medication does really induce cognitive decline.

Abuse Potential

Refer to Benzodiazepine Use Disorder.

Recreational use of nitrazepam is common.

A monograph for the drug says: “Treatment with nitrazepam should usually not exceed seven to ten consecutive days. Use for more than two to three consecutive weeks requires complete re-evaluation of the patient. Prescriptions for nitrazepam should be written for short-term use (seven to ten days) and it should not be prescribed in quantities exceeding a one-month supply. Dependence can occur in as little as four weeks.”

Tolerance

Tolerance to nitrazepam’s effects often appears with regular use. Increased levels of GABA in cerebral tissue and alterations in the activity state of the serotoninergic system occur as a result of nitrazepam tolerance. Tolerance to the sleep-inducing effects of nitrazepam can occur after about seven days; tolerance also frequently occurs to its anticonvulsant effects.

However, other sources indicate that continuous use does not necessarily lead to reduced effectiveness, which implies that tolerance is not automatic and that not all patients exhibit tolerance to the same extent.

Dependence and Withdrawal

Refer to Benzodiazepine Withdrawal Syndrome.

Nitrazepam can cause dependence, addiction, and benzodiazepine withdrawal syndrome. Withdrawal from nitrazepam may lead to withdrawal symptoms which are similar to those seen with alcohol and barbiturates. Common withdrawal symptoms include anxiety, insomnia, concentration problems, and fatigue. Discontinuation of nitrazepam produced rebound insomnia after short-term single nightly dose therapy.

Special Precautions

Benzodiazepines require special precautions if used in alcohol- or drug-dependent individuals and individuals with comorbid psychiatric disorders. Caution should be exercised in prescribing nitrazepam to anyone who is of working age due to the significant impairment of psychomotor skills; this impairment is greater when the higher dosages are prescribed.

Nitrazepam in doses of 5 mg or more causes significant deterioration in vigilance performance combined with increased feelings of sleepiness. Nitrazepam at doses of 5 mg or higher impairs driving skills and like other hypnotic drugs, it is associated with an increased risk of traffic accidents. In the elderly, nitrazepam is associated with an increased risk of falls and hip fractures due to impairments of body balance. The elimination half-life of nitrazepam is 40 hours in the elderly and 29 hours in younger adults. Nitrazepam is commonly taken in overdose by drug abusers or suicidal individuals, sometimes leading to death. Nitrazepam is teratogenic if taken in overdose during pregnancy with 30% of births showing congenital abnormalities. It is a popular drug of abuse in countries where it is available.

Doses as low as 5 mg can impair driving skills. Therefore, people driving or conducting activities which require vigilance should exercise caution in using nitrazepam or possibly avoid it altogether.

Elderly

Nitrazepam, similar to other benzodiazepines and nonbenzodiazepines, causes impairments in body balance and standing steadiness in individuals who wake up at night or the next morning. Falls and hip fractures are frequently reported. Combination with alcohol increases these impairments. Partial but incomplete tolerance develops to these impairments. Nitrazepam has been found to be dangerous in elderly patients due to a significantly increased risk of falls. This increased risk is probably due to the drug effects of nitrazepam persisting well into the next day. Nitrazepam is a particularly unsuitable hypnotic for the elderly as it induces a disability characterised by general mental deterioration, inability to walk, incontinence, dysarthria, confusion, stumbling, falls, and disorientation which can occur from doses as low as 5 mg. The nitrazepam-induced symptomatology can lead to a misdiagnosis of brain disease in the elderly, for example dementia, and can also lead to the symptoms of postural hypotension which may also be misdiagnosed. A geriatric unit reportedly was seeing as many as seven patients a month with nitrazepam-induced disabilities and health problems. The drug was recommended to join the barbiturates in not being prescribed to the elderly. Only nitrazepam and lorazepam were found to increase the risk of falls and fractures in the elderly. CNS depression occurs much more frequently in the elderly and is especially common in doses above 5 mg of nitrazepam. Both young and old patients report sleeping better after three nights’ use of nitrazepam, but they also reported feeling less awake and were slower on psychomotor testing up to 36 hours after intake of nitrazepam. The elderly showed cognitive deficits, making significantly more mistakes in psychomotor testing than younger patients despite similar plasma levels of the drug, suggesting the elderly are more sensitive to nitrazepam due to increased sensitivity of the aging brain to it. Confusion and disorientation can result from chronic nitrazepam administration to elderly subjects. Also, the effects of a single dose of nitrazepam may last up to 60 hours after administration.

Children

Nitrazepam is not recommended for use in those under 18 years of age. Use in very young children may be especially dangerous. Children treated with nitrazepam for epilepsies may develop tolerance within months of continued use, with dose escalation often occurring with prolonged use. Sleepiness, deterioration in motor skills and ataxia were common side effects in children with tuberous sclerosis treated with nitrazepam. The side effects of nitrazepam may impair the development of motor and cognitive skills in children treated with nitrazepam. Withdrawal only occasionally resulted in a return of seizures and some children withdrawn from nitrazepam appeared to improve. Development, for example the ability to walk at five years of age, was impaired in many children taking nitrazepam, but was not impaired with several other nonbenzodiazepine antiepileptic agents. Children being treated with nitrazepam have been recommended to be reviewed and have their nitrazepam gradually discontinued whenever appropriate. Excess sedation, hypersalivation, swallowing difficulty, and high incidence of aspiration pneumonia, as well as several deaths, have been associated with nitrazepam therapy in children.

Pregnancy

Nitrazepam is not recommended during pregnancy as it is associated with causing a neonatal withdrawal syndrome and is not generally recommended in alcohol- or drug-dependent individuals or people with comorbid psychiatric disorders. The Dutch, British and French system called the System of Objectified Judgement Analysis for assessing whether drugs should be included in drug formularies based on clinical efficacy, adverse effects, pharmacokinetic properties, toxicity, and drug interactions was used to assess nitrazepam. A Dutch analysis using the system found nitrazepam to be unsuitable in drug-prescribing formularies.

The use of nitrazepam during pregnancy can lead to intoxication of the newborn. A neonatal withdrawal syndrome can also occur if nitrazepam or other benzodiazepines are used during pregnancy with symptoms such as hyperexcitability, tremor, and gastrointestinal upset (diarrhoea or vomiting) occurring. Breast feeding by mothers using nitrazepam is not recommended. Nitrazepam is a long-acting benzodiazepine with a risk of drug accumulation, though no active metabolites are formed during metabolism. Accumulation can occur in various body organs, including the heart; accumulation is even greater in babies. Nitrazepam rapidly crosses the placenta and is present in breast milk in high quantities. Therefore, benzodiazepines including nitrazepam should be avoided during pregnancy. In early pregnancy, nitrazepam levels are lower in the baby than in the mother, and in the later stages of pregnancy, nitrazepam is found in equal levels in both the mother and the unborn child. Internationally benzodiazepines are known to cause harm when used during pregnancy and nitrazepam is a category D drug during pregnancy.

Benzodiazepines are lipophilic and rapidly penetrate membranes, so rapidly penetrate the placenta with significant uptake of the drug. Use of benzodiazepines such as nitrazepam in late pregnancy in especially high doses may result in floppy infant syndrome. Use in the third trimester of pregnancy may result in the development of a severe benzodiazepine withdrawal syndrome in the neonate. Withdrawal symptoms from benzodiazepines in the neonate may include hypotonia, and reluctance to suckle, to apnoeic spells, cyanosis, and impaired metabolic responses to cold stress. These symptoms may persist for hours or months after birth.

Other Precautions

Caution in Hypotension

Caution in those suffering from hypotension, nitrazepam may worsen hypotension.

Caution in Hypothyroidism

Caution should be exercised by people who have hypothyroidism, as this condition may cause a long delay in the metabolism of nitrazepam leading to significant drug accumulation.

Contraindications

Nitrazepam should be avoided in patients with chronic obstructive pulmonary disease (COPD), especially during acute exacerbations of COPD, because serious respiratory depression may occur in patients receiving hypnotics.

As with other hypnotic drugs, nitrazepam is associated with an increased risk of traffic accidents. Nitrazepam is recommended to be avoided in patients who drive or operate machinery. A study assessing driving skills of sedative hypnotic users found the users of nitrazepam to be significantly impaired up to 17 hours after dosing, whereas users of temazepam did not show significant impairments of driving ability. These results reflect the long-acting nature of nitrazepam.

Interactions

Nitrazepam interacts with the antibiotic erythromycin, a strong inhibitor of CYP3A4, which affects concentration peak time. Alone, this interaction is not believed to be clinically important. However, anxiety, tremor, and depression were documented in a case report involving a patient undergoing treatment for acute pneumonia and renal failure. Following administration of nitrazepam, triazolam, and subsequently erythromycin, the patient experienced repetitive hallucinations and abnormal bodily sensations. Co-administration of benzodiazepine drugs at therapeutic doses with erythromycin may cause serious psychotic symptoms, especially in persons with other, significant physical complications.

Oral contraceptive pills reduce the clearance of nitrazepam, which may lead to increased plasma levels of nitrazepam and accumulation. Rifampin significantly increases the clearance of nitrazepam, while probenecid significantly decreases its clearance. Cimetidine slows down the elimination rate of nitrazepam, leading to more prolonged effects and increased risk of accumulation. Alcohol in combination with nitrazepam may cause a synergistic enhancement of the hypotensive properties of both benzodiazepines and alcohol. Benzodiazepines including nitrazepam may inhibit the glucuronidation of morphine, leading to increased levels and prolongation of the effects of morphine in rat experiments.

Pharmacology

Nitrazepam is a nitrobenzodiazepine. It is a 1,4 benzodiazepine, with the chemical name 1,3-Dihydro-7-nitro-5-phenyl-2H-1,4- benzodiazepin-2-one.

It is long acting, lipophilic, and metabolised hepatically by oxidative pathways. It acts on benzodiazepine receptors in the brain which are associated with the GABA receptors, causing an enhanced binding of GABA to GABAA receptors. GABA is a major inhibitory neurotransmitter in the brain, involved in inducing sleepiness, muscular relaxation, and control of anxiety and seizures, and slows down the central nervous system. Nitrazepam is similar in action to the z-drug zopiclone prescribed for insomnia. The anticonvulsant properties of nitrazepam and other benzodiazepines may be in part or entirely due to binding to voltage-dependent sodium channels rather than benzodiazepine receptors. Sustained repetitive firing seems to be limited by benzodiazepines effect of slowing recovery of sodium channels from inactivation in mouse spinal cord cell cultures. The muscle relaxant properties of nitrazepam are produced via inhibition of polysynaptic pathways in the spinal cord of decerebrate cats. It is a full agonist of the benzodiazepine receptor. The endogenous opioid system may play a role in some of the pharmacological properties of nitrazepam in rats. Nitrazepam causes a decrease in the cerebral contents of the amino acids glycine and alanine in the mouse brain. The decrease may be due to activation of benzodiazepine receptors. At high doses decreases in histamine turnover occur as a result of nitrazepam’s action at the benzodiazepine-GABA receptor complex in mouse brain. Nitrazepam has demonstrated cortisol-suppressing properties in humans. It is an agonist for both central benzodiazepine receptors and to the peripheral-type benzodiazepine receptors found in rat neuroblastoma cells.

EEG and Sleep

In sleep laboratory studies, nitrazepam decreased sleep onset latency. In psychogeriatric inpatients, it was found to be no more effective than placebo tablets in increasing total time spent asleep and to significantly impair trial subjects’ abilities to move and carry out everyday activities the next day, and it should not be used as a sleep aid in psychogeriatric inpatients.

The drug causes a delay in the onset, and decrease in the duration of REM sleep. Following discontinuation of the drug, REM sleep rebound has been reported in some studies. Nitrazepam is reported to significantly affect stages of sleep – a decrease in stage 1, 3, and 4 sleep and an increase in stage 2. In young volunteers, the pharmacological properties of nitrazepam were found to produce sedation and impaired psychomotor performance and standing steadiness. EEG tests showed decreased alpha activity and increased the beta activity, according to blood plasma levels of nitrazepam. Performance was significantly impaired 13 hours after dosing with nitrazepam, as were decision-making skills. EEG tests show more drowsiness and light sleep 18 hours after nitrazepam intake, more so than amylobarbitone. Fast activity was recorded via EEG 18 hours after nitrazepam dosing. An animal study demonstrated that nitrazepam induces a drowsy pattern of spontaneous EEG including high-voltage slow waves and spindle bursts increase in the cortex and amygdala, while the hippocampal theta rhythm is desynchronised. Also low-voltage fast waves occur particularly in the cortical EEG. The EEG arousal response to auditory stimulation and to electric stimulation of the mesencephalic reticular formation, posterior hypothalamus and centromedian thalamus is significantly suppressed. The photic driving response elicited by a flash light in the visual cortex is also suppressed by nitrazepam. Estazolam was found to be more potent however. Nitrazepam increases the slow wave light sleep (SWLS) in a dose-dependent manner whilst suppressing deep sleep stages. Less time is spent in stages 3 and 4 which are the deep sleep stages, when benzodiazepines such as nitrazepam are used. The suppression of deep sleep stages by benzodiazepines may be especially problematic to the elderly as they naturally spend less time in the deep sleep stage.

Pharmacokinetics

Nitrazepam is largely bound to plasma proteins. Benzodiazepines such as nitrazepam are lipid-soluble and have a high cerebral uptake. The time for nitrazepam to reach peak plasma concentrations following oral administration is about 2 hours (0.5 to 5 hours). The half-life of nitrazepam is between 16.5 and 48.3 hours. In young people, nitrazepam has a half-life of about 29 hours and a much longer half-life of 40 hours in the elderly. Both low dose (5 mg) and high dose (10 mg) of nitrazepam significantly increases growth hormone levels in humans.

Nitrazepam’s half-life in the cerebrospinal fluid, 68 hours, indicates that nitrazepam is eliminated extremely slowly from the cerebrospinal fluid. Concomitant food intake has no influence on the rate of absorption of nitrazepam nor on its bioavailability. Therefore, nitrazepam can be taken with or without food.

Overdose

Nitrazepam overdose may result in stereotypical symptoms of benzodiazepine overdose including intoxication, impaired balance and slurred speech. In cases of severe overdose this may progress to a comatose state with the possibility of death. The risk of nitrazepam overdose is increased significantly if nitrazepam is abused in conjunction with opioids, as was highlighted in a review of deaths of users of the opioid buprenorphine. Nitrobenzodiazepines such as nitrazepam can result in a severe neurological effects. Nitrazepam taken in overdose is associated with a high level of congenital abnormalities (30% of births). Most of the congenital abnormalities were mild deformities.

Severe nitrazepam overdose resulting in coma causes the central somatosensory conduction time (CCT) after median nerve stimulation to be prolonged and the N20 to be dispersed. Brain-stem auditory evoked potentials demonstrate delayed interpeak latencies (IPLs) I-III, III-V and I-V. Toxic overdoses therefore of nitrazepam cause prolonged CCT and IPLs. An alpha pattern coma can be a feature of nitrazepam overdose with alpha patterns being most prominent in the frontal and central regions of the brain.

Benzodiazepines were implicated in 39% of suicides by drug poisoning in Sweden, with nitrazepam and flunitrazepam accounting for 90% of benzodiazepine implicated suicides, in the elderly over a period of 2 decades. In three quarters of cases death was due to drowning, typically in the bath. Benzodiazepines were the predominant drug class in suicides in this review of Swedish death certificates. In 72% of the cases benzodiazepines were the only drug consumed. Benzodiazepines and in particular nitrazepam and flunitrazepam should therefore be prescribed with caution in the elderly. In a brain sample of a fatal nitrazepam poisoning high concentrations of nitrazepam and its metabolite were found in the brain of the deceased person.

In a retrospective study of deaths, when benzodiazepines were implicated in the deaths, the benzodiazepines nitrazepam and flunitrazepam were the most common benzodiazepines involved. Benzodiazepines were a factor in all deaths related to drug addiction in this study of causes of deaths. Nitrazepam and flunitrazepam were significantly more commonly implicated in suicide related deaths than natural deaths. In four of the cases benzodiazepines alone were the only cause of death. In Australia, nitrazepam and temazepam were the benzodiazepines most commonly detected in overdose drug related deaths. In a third of cases benzodiazepines were the sole cause of death.

Individuals with chronic illnesses are much more vulnerable to lethal overdose with nitrazepam, as fatal overdoses can occur at relatively low doses in these individuals.