An Overview of Music as a Coping Strategy

Introduction

Music as a coping strategy involves the use of music (through listening or playing music) in order to reduce stress, as well as many of the psychological and physical manifestations associated with it.

The use of music to cope with stress is an example of an emotion-focused, adaptive coping strategy. Rather than focusing on the stressor itself, music therapy is typically geared towards reducing or eliminating the emotions that arise in response to stress. In essence, advocates of this therapy claim that the use of music helps to lower stress levels in patients, as well as lower more biologically measurable quantities such as the levels of epinephrine and cortisol.

Additionally, music therapy programmes have been repeatedly demonstrated to reduce depression and anxiety symptoms in the long term.

Major Theories

In the context of psychology, a coping strategy is any technique or practice designed to reduce or manage the negative effects associated with stress. While stress is known to be a natural biological response, biologists and psychologists have repeatedly demonstrated that stress in excess can lead to negative effects on one’s physical and psychological well-being. Elevated stress levels can lead to conditions including mental illnesses, cardiovascular conditions, eating disorders, gastrointestinal complications, sexual dysfunction, and skin and hair problems. The variety and potential fatality from these conditions push the need for a coping mechanism to reduce the manifestations associated with stress.

While there are hundreds of different coping strategies, the use of music is one specific example of a coping strategy that is used to combat the negative effects of stress. Due to the substantially large number of strategies to choose from, psychologists break down coping strategies into three types:

StrategyOutline
Appraisal-BasedIntended to modify the individual’s thought process Stress is typically eliminated through rationalisation, changes in values or thinking patterns, or with humour.
Problem-BasedTargets the cause of the stress. The process could either involve eliminating or adapting to a stressor in order to cope. An example of a problem based strategy is time management.
Emotion-BasedGeared towards influencing one’s emotional reactions when stressed. Meditation, distractions, or the release of emotion are all forms of emotion-based coping strategies. Mindfulness-based stress reduction is another example of this, as it is a more personal reflection based aspect of coping.

Since music-based coping is designed to modify an individual’s emotional reactions to a certain event, it is best classified as an emotion-based coping strategy. Rather than attempting to directly influence or eliminate a particular stressor, music-based coping relies on influencing an individual’s emotional and mental reaction to the stressor. Music assuages stress by either reducing or altering emotional response or alleviate some of the physiological effects of the stress response.

Major Empirical Findings

Psychologists and medical practitioners have recently focused more time and attention on the concept of music as a coping strategy and the effects of its use on patients. In literature linking music and stress, empirical findings are typically grouped together according to the method in which they are gathered. For example, some methods may include studies like survey questions or more invasive methods of study like invasive psychoacoustic observations. Despite the fact that different methods are used, most of these studies demonstrate the impact different types of music have on human emotions.

Patient Response-Based Findings

One of the more popular methods used to collect data on coping strategies involves the use of non-invasive, patient response-based methods. This method is directed more towards the psychological realm, in that the methods used to collect data were not very invasive but more of a “tell me how you feel” type of question/response system. Once the findings had been gathered, statistical analysis was performed in an effort to discover a correlation between the coping mechanism and its effect on the stress response. These non-invasive treatments are more popular among children and elderly patients, since they prevent the results from being altered due to the patient’s nervousness. Proponents of these methods claim that if children are prompted with general, unthreatening questions, they are much more comfortable and willing to provide accurate accounts of their levels of stress. In several studies using non-invasive methods, music has been documented as being effective in reducing the subject’s perceived level of stress.

Music and Effects on Psychological Trauma

Posttraumatic stress disorder (PTSD) is a psychological stress disorder that involves the experience of strong emotional reactions due to traumatic events in an individual’s past. PTSD is almost always a result of a traumatic experience. Certain triggers, such as images, sounds, or other significant sensory details associated with the experience can evoke extreme stress responses, panic attacks, or severe anxiety. PTSD is commonly experienced by veterans of armed conflicts, and can be frequently diagnosed in victims of rape or other violent assaults.

If an individual diagnosed with PTSD associates a certain song with a traumatic memory, it typically triggers a stronger stress/anxiety response than the individual would otherwise have otherwise experienced when listening to the song. While one cannot assume that music is the only factor that triggers PTSD-influenced stress and panic attacks, these can be especially memorable because of music’s rhythm, beat, and/or memorable lyrics. However, associating music with psychological responses is not necessarily guaranteed to bring up bad memories, because music can often hold psychological connotations to very happy memories. For example, it has been demonstrated that supplying the residents of nursing homes with iPods that feature nostalgic music is a means of reducing the stress of the elderly.

Music has been used to treat dementia patients by utilising methods similar to the treatments that are used in the management of PTSD. However, in the treatment of dementia, more emphasis is placed on providing the patient with music that triggers pleasant memories or feelings, rather than avoiding music that triggers negative emotions. After the music is listened to, one sees the change in mood and attitude from closed and distant to joyful, open and happy.

There is a wealth of anecdotal evidence demonstrating the effectiveness that music can have as a coping response in this regard. For example, if a patient of either PTSD or dementia were to have a loved one die, he or she might associate a certain song with the person being mourned for, and hearing that song could bring about feelings of happiness or deep sadness. In addition, if there was a certain connection between them, such as in marriage, and their wedding song came on, an overly powerful emotional reaction could occur. These overly emotional situations trigger memories and a stress response that anguishes the person remembering these hurtful memories. A certain song that pertains to that memory can trigger nearly any emotion.

Music’s effects on dementia patients have shown to bring them out of their shell, and engage them in singing and being happy, opposed to their usual closed and distant personalities. The patients have been shown to sing and perk up, even cry out of pure joy of the music that they loved in their youth. After the patients listen to their music they were interviewed and actually engaged, because of how happy the music had made them. The patients talked about how much they loved the music and the memories that the music invoked.

Stress and Music in the Medical Field

The use of music as a coping strategy also has applications in the medical field. For example, patients who listen to music during surgery or post-operative recovery have been shown to have less stress than their counterparts who do not listen to music. Studies have shown that the family members and parents of the patient had reduced stress levels when listening to music while waiting, and can even reduce their anxiety for the surgery results. The use of music has also been proven effective in paediatric oncology. Music therapy is mainly used in these cases as a diversion technique, play therapy, designed to distract the patient from the pain or stress experienced during these operations. The focus of the patient is directed at a more pleasurable activity and the mind shifts toward that activity creating a “numbing” effect founded on an “out of sight, out of mind” type approach. This can even transcend to elderly patients in nursing homes and adult day care centres. Music therapy in these places have shown reductions in elder aggression and agitated moods. However, because several of these studies rely mainly on patient responses, some concerns have been raised as to the strength of the correlation between music and stress reduction.

Music as a form of coping has been used multiple times in cancer patients, with promising results. A study done on 113 patients going through stem cell transplants split the patients into two group; one group made their own lyrics about their journey and then produced a music video, and the other group listened to audiobooks. The results of the study showed that the music video group had better coping skills and better social interactions in comparison, by taking their mind of the pain and stress accompanying treatment, and giving them an outlet to express their feelings.

Another study done at UNC showed remarkable improvement in a young girl who was born without the ability to speak. A therapist would come in and sing with her, as the only thing she could do was sing. Miraculously, the singing allowed to her gain the ability of speech, as music and speech are similar in nature and help the brain form new connections. In the same hospital, the therapist visits children daily and plays music with them, singing and using instruments. The music fosters creativity and reduces stress associated with treatments, and takes the children’s minds off of their current surroundings.

It also cannot be ignored the importance of coping strategies in families and caregivers of those going through serious and even terminal illness. These family members are often responsible for a vast majority of the care of their loved ones, on top of the stress of seeing them struggle. Therapists have worked with these family members, singing and playing instruments, to help them take their minds off of the stress of helping their loved ones undergo treatment. Just like in the patients themselves, the music therapy has been shown to help them cope with the intense emotions and situations they deal with on a daily basis.

Physiological Findings

Other studies, which use more invasive techniques to measure the response of individuals to stress, demonstrate that the use of music can mitigate many of the physiological effects often associated with the stress response – such as a lowering of blood pressure or a decrease in heart rate. Most research associated with the use of music as a coping strategy makes use of empirical measurements through devices like an EKG or heart rate monitor in order to provide a stronger correlation between music and its proposed effects on the stress response. In these studies, subjects are typically exposed to a stressor and then assigned music to listen to, while the parties conducting the study measure changes in the subjects’ physiological status.

Some studies, using more invasive physiological research methods, have demonstrated that the use of sedative music or preferred sedative music cause a decrease in tension and state-anxiety levels of adult individuals. This decrease in tension or feeling of anxiety is more prevalent and noticeable in the attempt to return to homeostasis, and shows far less effectiveness during the actual stressful event. Other studies expose their subjects to an immediate physical stressor, such as running on a treadmill, while having them listen to different genres of music. These studies have shown that the respiratory rates of the participants are increased when they listen to faster, upbeat music while running in comparison to no music or sedative music. In addition to the raised respiratory frequency caused by the initial stressor “running” music still had a noticeable physiological effect on the participants.

By and large, a collective review of these studies shows that music can be effective in reducing physiological effects that stress has on the human body. This can be anywhere from changing pulse rates, breathing rates, to even decreasing the occurrence of fatigue. This can even be seen in different tempo’s and pitch, such as low pitch creates a relatively calming effect on the body whereas high pitch tends to generate stressors for the body. Furthermore, it has been suggested that if a patient can control the music that he or she listens to in the recovery process, then the return to normalcy happens at a much faster, more efficient rate than if the subject was assigned a music genre that he or she did not find appealing. With the use of the EKG monitor and other empirical methods of study, researchers are able to remove the superficial qualities associated with patient response-based findings and provide a more substantial correlation between the use of music and its effects on the human stress response.

Specific Techniques

One particular technique that uses music as a coping strategy is choosing and listening to music genres that have been shown to correlate with lower levels of stress. For example, it has been suggested that listening to classical music or self-selected music can lower stress levels in adult individuals. Music that is fast, heavy or even dark in nature may produce an increase in these same stress levels, however many people also find the cathartic effects of music to be intensified with the listening of music that is intense in such a way. Ambient music is a genre of music that is often associated with feelings of calmness or introspectiveness. While listening to self-selected genres, an individual is provided with a sense of control after choosing the type of music he or she would like to listen to. In certain situations, this choice can be one of the few moments where stressed and depressed individuals feel a locus of control over their respective lives. Introducing the feeling of control can be a valuable asset as the individual attempts to cope with his or her stress.

With that in mind, there are a few specific techniques specifically involving the use of music that have been suggested to aid in the reduction of stress and stress-related effects.

  • Listening to softer genres such as classical music.
  • Listening to music of one’s choice and introducing an element of control to one’s life.
  • Listening to music that reminds one of pleasant memories.
  • Avoiding music that reminds one of sad or depressing memories.
  • Listening to music as a way of bonding with a social group.

Another specific technique that can be used is the utilisation of music as a “memory time machine” of sorts. In this regard, music can allow one to escape to pleasant or unpleasant memories and trigger a coping response. It has been suggested that music can be closely tied to re-experiencing the psychological aspects of past memories, so selecting music with positive connotations is one possible way that music can reduce stress.

A technique that is starting to be employed more often is vibroacoustic therapy. During therapy the patient lies on his/her back on a mat with speakers within it that send out low frequency sound waves, essentially sitting on a subwoofer. This therapy has been found to help with Parkinson’s disease, fibromyalgia, and depression. Studies are also being conducted on patients with mild Alzheimer’s disease in hopes to identify possible benefits from vibroacoustic therapy. Vibroacoustic therapy can also be used as an alternative to music therapy for the deaf.

Controversies

Several of the empirical studies carried out to demonstrate the correlation between listening to music and the reduction in the human stress response have been criticised for relying too heavily on a small sample size. Another criticism of these studies is that they have been carried out in response to no stressor in particular. These critics claim that because no specific stressor is identified in many of these studies, it is somewhat difficult to identify whether the stress response was lessened by music or by some other means.

A more theoretical critique of this coping strategy is that the use of music in stress coping is largely a short-term coping response and therefore lacks long-term sustainability. These critics argue that while music may be effective in lowering perceived stress levels of patients, it is not necessarily making a difference on the actual cause of the stress response. Because the root cause of the stress is not affected, it is possible that the stress response may return shortly after therapy is ended. Those who hold this position advocate instead for a more problem-focused coping strategy that directly deals with the stressors affecting the patient.

Conclusion

The use of music as a stress coping strategy has a demonstrated effect on the human response to stress. The use of music has been proven to lower the perceived levels of stress in patients, while greatly reducing the physical manifestations of stress as well – such as heart rate, blood pressure, or levels of stress hormones. It seems as though different types of music have different effects on stress levels, with classical and self-selected genres being the most effective. However, despite demonstrated effectiveness in empirical studies, there are many who still question the effectiveness of this coping strategy. Nevertheless, it is still an attractive option for some patients who want an easy and inexpensive way to respond to stress.

This page is based on the copyrighted Wikipedia article < https://en.wikipedia.org/wiki/Music_as_a_coping_strategy >; it is used under the Creative Commons Attribution-ShareAlike 3.0 Unported License (CC-BY-SA). You may redistribute it, verbatim or modified, providing that you comply with the terms of the CC-BY-SA.

What is Mindfulness-Based Stress Reduction?

Introduction

Mindfulness-based stress reduction (MBSR) is an eight-week evidence-based programme that offers secular, intensive mindfulness training to assist people with stress, anxiety, depression and pain.

Developed at the University of Massachusetts Medical Centre in the 1970s by Professor Jon Kabat-Zinn, MBSR uses a combination of mindfulness meditation, body awareness, yoga and exploration of patterns of behaviour, thinking, feeling and action. Mindfulness can be understood as the non-judgemental acceptance and investigation of present experience, including body sensations, internal mental states, thoughts, emotions, impulses and memories, in order to reduce suffering or distress and to increase well-being. Mindfulness meditation is a method by which attention skills are cultivated, emotional regulation is developed, and rumination and worry are significantly reduced. During the past decades, mindfulness meditation has been the subject of more controlled clinical research, which suggests its potential beneficial effects for mental health, as well as physical health. While MBSR has its roots in Buddhist wisdom teachings, the programme itself is secular. The MBSR programme is described in detail in Kabat-Zinn’s 1990 book Full Catastrophe Living.

Brief History

In 1979, Jon Kabat-Zinn founded the Mindfulness Based Stress Reduction Clinic at the University of Massachusetts Medical Centre, and nearly twenty years later the Centre for Mindfulness in Medicine, Health Care and Society at the University of Massachusetts Medical School. Both these institutions supported the growth and implementation of MBSR into hospitals worldwide. Kabat-Zinn described the MBSR program in detail in his bestselling 1990 book Full Catastrophe Living, which was reissued in a revised edition in 2013. In 1993, the MBSR course taught by Jon Kabat-Zinn was featured in Bill Moyer’s Healing from Within. In the year 2015, close to 80% of medical schools are reported to offer some element of mindfulness training, and research and education centres dedicated to mindfulness have proliferated.

Programme

A meta-analysis described MBSR as “a group programme that focuses upon the progressive acquisition of mindful awareness, of mindfulness”. The MBSR programme is an eight-week workshop taught by certified trainers that entails weekly group meetings (2.5 hour classes) and a one-day retreat (seven-hour mindfulness practice) between sessions six and seven, homework (45 minutes daily), and instruction in three formal techniques: mindfulness meditation, body scanning and simple yoga postures. Group discussions and exploration – of experience of the meditation practice and its application to life – is a central part of the program. Body scanning is the first prolonged formal mindfulness technique taught during the first four weeks of the course, and entails quietly sitting or lying and systematically focusing one’s attention on various regions of the body, starting with the toes and moving up slowly to the top of the head. MBSR is based on non-judging, non-striving, acceptance, letting go, beginners mind, patience, trust, and non-centring.

According to Kabat-Zinn, the basis of MBSR is mindfulness, which he defined as “moment-to-moment, non-judgmental awareness.” During the programme, participants are asked to focus on informal practice as well by incorporating mindfulness into their daily routines. Focusing on the present is thought to heighten sensitivity to the environment and one’s own reactions to it, consequently enhancing self-management and coping. It also provides an outlet from ruminating on the past or worrying about the future, breaking the cycle of these maladaptive cognitive processes. The validity and reliability of a weekly single-item practice quality assessment have been confirmed by research. Increases in practice quality predicted improvements in self-report mindfulness and psychological symptoms but not behavioural mindfulness, and longer practice sessions were linked to better practice quality.

Scientific evidence of the debilitating effects of stress on human body and its evolutionary origins were pinpointed by the work of Robert Sapolsky, and explored for lay readers in the book Why Zebras Don’t Get Ulcers. Engaging in mindfulness meditation brings about significant reductions in psychological stress, and appears to prevent the associated physiological changes and biological clinical manifestations that happen as a result of psychological stress. According to early neuroimaging studies, MBSR training has an influence on the areas of the brain responsible for attention, introspection, and emotional processing.

Extent of Practice

According to a 2014 article in Time magazine, mindfulness meditation is becoming popular among people who would not normally consider meditation. The curriculum started by Kabat-Zinn at University of Massachusetts Medical Centre has produced nearly 1,000 certified MBSR instructors who are in nearly every state in the US and more than 30 countries. Corporations such as General Mills have made MBSR instruction available to their employees or set aside rooms for meditation. Democratic Congressman Tim Ryan published a book in 2012 titled A Mindful Nation and he has helped organise regular group meditation periods on Capitol Hill.

Methods of Practice

Mindfulness-based stress reduction classes and programs are offered by various facilities including hospitals, retreat centres, and various yoga facilities. Typically the programs focus on teaching

  • mind and body awareness to reduce the physiological effects of stress, pain or illness
  • experiential exploration of experiences of stress and distress to develop less emotional reactivity
  • equanimity in the face of change and loss that is natural to any human life
  • non-judgemental awareness in daily life
  • promote serenity and clarity in each moment
  • to experience more joyful life and access inner resources for healing and stress management
  • mindfulness meditation

Evaluation of Effectiveness

Mindfulness-based approaches have been found to be beneficial for healthy adults for adolescents and children, healthcare professionals, as well as for different health-related outcomes including eating disorders, psychiatric conditions, pain management, sleep disorders, cancer care, psychological distress, and for coping with health-related conditions. As a major subject of increasing research interest, 52 papers were published in 2003, rising to 477 by 2012. Nearly 100 randomised controlled trials had been published by early 2014.

The development of therapies to improve individuals’ flexibility in switching between using and not using emotion regulation (ER) methods is necessary because it is linked to better mental health, wellbeing, and resilience. According to research, those who attended MBSR training exhibited greater regulatory decision flexibility. In post-secondary students, research on mindfulness-based stress reduction has demonstrated that it can reduce psychological distress, which is common in this age range. In one study, the long-term impact of an 8-week Mindfulness-Based Stress Reduction (MBSR) treatment extended to two months after the intervention was completed.

Individuals with eating disorders have benefited from the mindfulness-based approach. MBSR therapy has been found to assist individuals improve the way they view their bodies. Interventions, such as mindfulness-based approaches, which focus on effective coping skills and improving one’s relationship with themselves through increased self-compassion can positively impact a person’s body image and contribute to overall well-being.

Research suggests mindfulness training improves focus, attention, and ability to work under stress. Mindfulness may also have potential benefits for cardiovascular health. Evidence suggests efficacy of mindfulness meditation in the treatment of substance use disorders. Mindfulness training may also be beneficial for people with fibromyalgia.

In addition, recent research has explored the ability of mindfulness-based stress reduction to increase self-compassion and enhance the well-being of those who are caregivers, specifically mothers, for youth struggling with substance use disorders. Mindfulness-based interventions allowed for the mothers to experience a decrease in stress as well as a better relationship with themselves which resulted in improved interpersonal relationships.

It has been demonstrated that mindfulness-based stress reduction has beneficial impacts on healthy individuals as well as suffering individuals and those close to suffering individuals. Roca et al. (2019) conducted an 8-week mindfulness-based stress reduction programme for healthy participants. Five pillars of MBSR, including mindfulness, compassion, psychological well-being, psychological distress, and emotional-cognitive control were identified. Participants psychological functioning were examined and assessed using questionnaires. Mindfulness and overall well-being was significant between the five pillars observed.

Mindfulness-based interventions and their impact have become prevalent in every-day life, especially when rooted in an academic setting. After interviewing children, of the average age of 11, it was apparent that mindfulness had contributed to their ability to regulate their emotions. In addition to these findings, these children expressed that the more mindfulness was incorporated by their school and teachers, the easier it was to apply its principles.

Mindfulness-based stress approaches have been shown to increase self-compassion. Higher levels of self-compassion have been found to greatly reduce stress. In addition, as self-compassion increases it seems as though self-awareness increases as well. This finding has been observed to occur during treatment as well as a result at the conclusion, and even after, treatment. Self-compassion is both a result and an informative factor of the effectiveness of mindfulness-based approaches.

MBIs (mindfulness-based intervations) showed a positive effect on mental and somatic health in social when compared to other active treatments in adults. This effects may be gender dependent. However, the effects seemed independent of duration and compliance with these kind of intervention.

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What is Social Inhibition?

Introduction

Social inhibition is a conscious or subconscious avoidance of a situation or social interaction.

With a high level of social inhibition, situations are avoided because of the possibility of others disapproving of their feelings or expressions. Social inhibition is related to behaviour, appearance, social interactions, or a subject matter for discussion. Related processes that deal with social inhibition are social evaluation concerns, anxiety in social interaction, social avoidance, and withdrawal.

Also related are components such as cognitive brain patterns, anxious apprehension during social interactions, and internalising problems. It also describes those who suppress anger, restrict social behaviour, withdraw in the face of novelty, and have a long latency to interact with strangers. Individuals can also have a low level of social inhibition, but certain situations may generally cause people to be more or less inhibited. Social inhibition can sometimes be reduced by the short-term use of drugs including alcohol or benzodiazepines.

Major signs of social inhibition in children are cessation of play, long latencies to approaching the unfamiliar person, signs of fear and negative affect, and security seeking. Also in high level cases of social inhibition, other social disorders can emerge through development, such as social anxiety disorder and social phobia.

Background

Social inhibition can range from normal reactions to social situations to a pathological level, associated with psychological disorders like social anxiety or social phobia. Life events are important and are related to our well-being and inhibition levels. In a lab study conducted by Buck and colleagues, social inhibition in everyday life was reviewed. Researchers observed how individuals interacted and communicated about different stimuli. In this study, there were female participants called “senders” who viewed twelve emotionally loaded stimuli. There were also participants in the study called “received” who had to guess which stimuli was viewed by the senders. The senders were either alone, with a friend, or with a stranger while viewing the slides. The results of the study revealed that being with a stranger had inhibitory effects on communication, whereas being with a friend had facilitative effects with some stimuli and inhibitory effects with others. The results show how anyone can be inhibited in daily life, with strangers or even friends. Inhibition can also be determined by one’s sensitivity levels to different social cues throughout the day. Gable and colleagues conducted a study in which they examined different events participants would record at the end of their day. Participants were also measured on the behavioural activation system and the behavioural inhibition system. The results revealed that individuals with more sensitivity on the behavioural inhibition system reported having more negative effects from daily events.

Expression can also be inhibited or suppressed because of anxiety to social situations or simple display rules. Yarczower and Daruns’ study about social inhibition of expression defined inhibition of expression as a suppression of one’s facial behaviour in the presences of someone or a perceived anxious situation. They addressed the display rules we all learn as children; we are told what expressions are suitable for what situations. Then as age increases we are socialised into not expressing strong facial emotions. However, leaving the face with a reduced expression hinders communication. In turn this makes the face a less reliable social cue during social interactions. Friedmen and Miller-Herringer bring these nonverbal expressions to the next level by studying individuals that have a greater level of emotional suppression. They state that without proper emotional expression social interactions can be much more difficult because others may not understand another individual’s emotional state.

This being said, there are also four commonly seen irrational cognitive patterns involved in social inhibition. The first pattern centres on self-esteem and perfectionism. In these cases, an individual would inhibit themselves through self-criticism; they want to do everything the “right” way. The second pattern deals with unrealistic approval needs; here individuals want to gain the approval of others and will fear rejection if they express too much. In the third pattern, unrealistic labelling of aggressive and assertive behaviour depicts how many individuals that inhibit themselves may feel as though aggression or assertiveness is bad. They believe if they express these behaviours they will receive a negative label. The last pattern discusses criticism of others, this pattern is a spin-off from the first. They will be highly critical of others much like they are to themselves. Shyness is another factor that is a part of social inhibition. Shyness is associated with low emotional regulations and high negative emotions. In many cases shy individuals have a greater change of social inhibition.

Although social inhibition is a common part of life, individuals can also have high levels of inhibition. Social Inhibition on higher levels can sometimes be a precursor to disorders such as Social Anxiety Disorder. Essex and colleagues found that some early risk factors may play a role in having chronically high inhibition. In this study, mothers, teachers, and the child reported on the child’s behavioural inhibition. The factors that were found to be contributors to social inhibition were female gender, exposure to maternal stress during infancy and the preschool period, and early manifestation of behavioural inhibition. In severe cases, clinical treatment, such as therapy, may be necessary to help with social inhibition or the manifesting social disorder.

Over the Lifespan

Social inhibition can develop over a lifespan. Children can be withdrawn, adolescents can have anxiety to social situations, and adults may have a hard time adjusting to social situations which they have to initiate on their own. To be inhibited can change and be different for many. In many cases, inhibition can lead to other social disorders and phobias.

Infants and Children

In infants and children, social inhibition is characterised by a temperament style that will have children responding negatively and withdrawing from unfamiliar people, situations and objects. In addition to cessation of play, inhibited children may display long latencies to approaching an unfamiliar person, signs of fear and negative affect, and security seeking. Avoiding behaviour can be seen at a very young age. In one study, Fox and colleagues found that even at four months of age some infants had negative responses to unfamiliar visual and audio stimuli. The study was longitudinal; therefore, follow ups revealed that half the infants who had high negative responses continued to show behavioural inhibition through the age of two. Fox’s longitudinal study reported that the expression of behavioural inhibition showed a small degree of continuity. Over time, the toddlers who were quiet and restrained continued the trend into childhood by being cautious, quiet, and socially withdrawn. The uninhibited control group of the same ages continued to interact easily with unfamiliar people and situations. There has also been a link between inhibition at childhood age with social disorders in adolescents and adulthood. Schwartz and Kagan found that in a longitudinal study from ages two to thirteen, sixty-one percent of teens who had inhibitor traits as toddlers reported social anxiety symptoms as adolescents, compared to twenty-seven percent of adolescents who were uninhibited in earlier life. However, not every child that has some withdrawn or inhibited behaviour will be inhibited as an adolescent or manifest a social disorder.

The caregiver alone is not solely responsible for inhibition in children; however, in some cases it can be a factor. Caregivers can affect the inhibition levels of their child by exposing the child to maternal stress during infancy and the preschool period. In addition, in some situations the child may simply have early manifestation of behavioural inhibition. There seems to be no parenting style that researchers agree on to be the best to combat social inhibition. Park and Crinic say that a sensitive, accepting, overprotective parenting is best to reduce the negative behaviours because it will allow the child to be themselves without judgement. However, Kagan hypothesized that firm parenting styles are better suited for socially inhibited children. Researchers supporting sensitive parenting believe that too firm of a parenting style will send a message to children that says they need to change.

Adolescence

Social inhibition has been widely studied in children; however, research on how it develops through adolescence and adulthood is not as prevalent, although anxiety-related social problems are most commonly seen in adolescents. Many of the behavioural traits are the same in adolescence as they are in childhood: withdrawing from unfamiliar people, situations and objects. However, it has been tested that adolescents are more aware of their social situations and are more likely to be inhibited in public settings. Researchers found younger individuals to be more likely to differentiate between public and private settings when inquiring about potentially embarrassing issues. It is also thought that inhibition is in many ways addressed in childhood and adolescence simply because schools facilitate interactions with others. As an adult, the same facilitating circumstance may not occur unless the individual prompts them on their own. Gest states that adults do not have as many casual peer interactions and friendship opportunities that guide and support relationships unless they facilitate them on their own. Adolescent research has also shown that social inhibition is associated with a more negative emotional state in young men than women.

This is in contrast to a study that measured inhibition levels through self reports from the adolescent and their parents. West and Newman found that young American Indian women and their parents reported higher levels of inhibition than young American Indian men; in addition, the parental reports also predicted social anxiety in young American Indian women over young American Indian men. In this same study, relationship development with peers was investigated over time. West and Newman stated that low levels of behavioural inhibition had an association with early social and school situations and that were related to greater levels of socially mediated anxiety, especially negative evaluation of fear by peers. This study then speculates about the possibility that adolescents and children who have a generally positive social experience will be more aware of the status of these positive relationships, therefore more anxious about failure in their social domain. Other studies also discussed how in many cases, early behavioural inhibition is a risk factor for the development of chronic high school-age inhibition and possible social anxiety disorder. Although social inhibition can be a predictor of other social disorders there is not an extremely large portion of adolescents who have developed an anxiety disorder and also had a history of inhibition in childhood.

Besic and Kerr believes that appearance can be a factor for social inhibition. In their study they hypothesized that a way to handle difficult situations with behavioural inhibition was to present an off-putting appearance. They examined “radical” crowds, such as those labelled as goths and punks and if their appearances fulfilled a functions for their inhibition. They state that a radical style could be used to draw away the social boundaries and relieve them of pressures or expectations to interact in unfamiliar situations with unfamiliar peers. Another possibility is that an individual may be self-handicapping to ensure that they will not have to interact with unfamiliar peers. The results revealed that radicals were significantly more inhibited than other groups. However, there are other inhibited individuals in other social classifications. The highest inhibited radical was no more inhibited than the highest inhibited individual in other groups.

Adulthood

Adult cases of social inhibition are hard to come by simply because many see it as something that happens through development. Although research is lacking, developmental considerations suggest there may be a stronger association between behavioral inhibition and peer relations in adulthood. One researcher says this lack of information may be because adults are not put in as many socially interactive situations that would guide them through the situation. It would seem that adults have an increased responsibility to initiate or structure their own social peer relationships; this is where social inhibition could have a more problematic role in adulthood than in childhood. One study that did contribute to adult research used questionnaires to study both clinical and nonclinical adults. Like in adolescence, behavioral inhibition was also found to be associated with anxiety disorders in adulthood. In addition the study found that childhood inhibition was specifically a factor in a lifetime diagnosis of social phobia. Gest also measured adult peer relations, and to what degree they had a positive and active social life. For example, researchers wanted to know if they participated in any recreational activities with others, how often they met with others, and if they had any close confiding relationships. The participants were rated on a 5-point scale on each peer relationship they disclosed. The results revealed that social inhibition had nothing to do with popularity, however it was correlated with peer relations in both genders and emotional stress in only men.

A similar study found that some shy men had a low occupational status at age forty because they entered their career later in life. However, another researcher has commented on this giving this example, perhaps remaining at home longer allows young adults to accumulate educational and financial resources, before moving out and becoming more independent. Additionally it was found that young adults who were inhibited as children were less likely to move away from their families. There is also some discussion of the inhibition through generations and children mirroring their parents. Results indicated that children whose birth mothers met criteria for the diagnosis of social phobia showed elevated levels of observed behavioural inhibition. Social inhibition can decrease with age due to cognitive deficits that can occur in old age. Age-related deficits have an effect on older adults’ ability to differentiate between public and private settings when discussing potentially embarrassing issues, leading them to discuss personal issues in inappropriately public situations. This suggests that deficits in inhibitory ability that lead to inappropriateness are out of the individual’s control.

In Different Contexts

In Schools

Schools can be a place for children to facilitate different social interactions; however, it can also uncover social and school adjustment problems. Coplan claims that Western children with inhibition problems may be at a higher risk of developmental problems in school. Although social inhibition may be a predictor of social and school adjustment problems in children, Chen argues that the effect of social inhibition on school adjustment differs between Western cultures and Chinese culture. Chen found that in Chinese children, behavioural inhibition was associated with greater peer liking, social interaction, positive school attitudes, and school competence and fewer later learning problems, which is also different from western cultures. In other studies, researchers such as Oysterman found there to be difficulties in adjustment in children that were experiencing inhibition. In Western cultures, these difficulties are seen more because of the emphasis on social assertiveness and self-expression as traits that are valued in development. In other cultures children are sometimes expected to be inhibited. This does not contrast with other cultures in which children are socialised and assert themselves. Despite these differences there are also similarities between gender. Boys were more antagonistic in peer interaction and seemed to have more learning problems in school. Girls were more cooperative in peer interaction and had a more positive outlook on school. They formed more affiliations with peers, and performed more completely in school.

Other researchers like Geng have looked to understand social inhibition, effortful control, and attention in school. In Geng’s study, gender came in to play with high socially inhibited girls being extremely aware of their surroundings, possibly paying too much attention to potentially anxious situations. It is well known in a large number of research studies social inhibition had been linked to other anxiety disorders. However Degnan and colleagues believe that being able to regulate your effortful control may serve to reduce the anxiety the comes from inhibition. Nesdale and Dalton investigated inhibition of social group norms in school children between the ages of seven and nine. In schools there becomes an increase in social in-groups and out-groups as children increase in age. This study created different in-groups or exclusive groups and out-groups or inclusive groups. The results showed that students in the inclusive group liked all students more, while students in the exclusive group like their group over other groups. This study could help in the future to facilitate school peer groups more efficiently.

In the Workplace

Social inhibition can manifest in all social situations and relationships. One place that we can see the effects of social inhibition is in the workplace. Research has shown that social inhibition can actually affect the way that one completes a given amount of work. In one experiment, participants completed a task in a laboratory setting, varying whether or not another individual was present in the room with the participants while they attempted to complete the task. The results showed that when another individual was present in the room the person focused on completing the experimental task decreased their body movements, hand movements, and vocalisation, even though the other person did not speak to or even look at the participant. This suggests that just the mere presence of another person in a social situation can inhibit an individual. However, although the individual in charge of completing the experimental task was socially inhibited by the presence of another person in the laboratory, there were no significant links between their social inhibition when completing the task and improved performance on said task. These findings suggest that an individual may socially inhibit themselves in the work place if another person is also in the room, however, such inhibition does not suggest that the inhibited individual is actually performing the duties assigned to them with more accuracy or focus.

In Psychological Disorders

Depression

Links between social inhibition and depression can be found in individuals who experienced social inhibited behaviours during childhood. Researchers from the UK conducted a study in an attempt to explain possible links between social inhibition in infancy and later signs of depression. The researchers based their study on previous information from literature acknowledging that there are social and non-social forms of inhibition, and that social inhibition is significantly related to early social fears. The researchers hypothesized that social inhibition in childhood would be linked to higher levels of depression in later years. Participants completed a number of questionnaires about their experiences of social inhibition in childhood and their current levels of depression. Results showed a significant relationship between depression and recalled social fears, or, social inhibitions during childhood. Furthermore, the researchers related their findings to another study conducted by Muris et al., in 2001 which found that there is an association between social inhibition and depression in adolescents. The study compared adolescents who were not inhibited to those who are, and found that:

“adolescents experiencing high levels of behavioral inhibition were more depressed than their counterparts who experienced intermediate or low levels of behavioral inhibition”.

Another study set out to examine the link between social inhibition and depression, with the basis for their study being that social inhibition (which they explain as a part of type D personality, or distressed personality) is related to emotional distress. The researchers explain that a major factor related to social inhibition is the inhibited individual not expressing their emotions and feelings, a factor that the researchers cite in relation to the link between social inhibition and depression. Overall, the results of the study show that social inhibition (as a factor of type D personality) predicts depression, regardless of the baseline depression level of the individual. Significantly, this study was conducted with young, healthy adults, as opposed to working with those in self-help groups or with individuals who have a pre-existing medical or psychological condition.

Fear

Social inhibition can be affected by fear responses that one has in the early “toddler years” of their life. In 2011, researchers Elizabeth J. Kiel and Kristin A. Buss examined “how attention toward an angry-looking gorilla mask in a room with alternative opportunities for play in 24-month-old toddlers predicted social inhibition when children entered kindergarten”. In the study, the researchers specifically looked at the toddlers’ attention to threat and their fear of novelty in other situations. The researchers paid special attention to these two factors due to previous research suggesting that “sustained attention to putatively threatening novelty relates to anxious behavior in the first 2 years of life”. Also, it has been found in earlier research conducted by Buss and colleagues that no matter the differences, individual responses to novelty during early childhood can be related to later social inhibition. These results already link fear responses, particularly in children, to social inhibition, mainly such inhibition that manifests later on in the individual’s life. Overall, the researchers based their experiment on the notion that the more time a toddler spends being attentive towards a novel potential threat the greater the chance that they will experience issues with the regulation of distress, which can predict anxious behaviour such as social inhibition.

Through a study intended to further connect and understand links between fear and late social inhibitions, the researchers conducted a study where they worked with 24-month-old toddlers. They placed the toddlers in a room called the “risk room” which is set up with a number of play areas for the toddlers to interact with, with one of those areas being a potentially threatening stimulus, in this case, an angry looking gorilla mask. The children are left alone, with only their primary caregiver sitting in the corner of the room, to explore the play areas for three minutes, and then the experimenter returns and instructs the toddler to interact with each of the play areas. The purpose of this was to allow for other experimenters to code the reactions of the toddler to the stimuli around him or her, paying special attention to their attention to threat, their proximity to the threat, and their fear of novelty.

The results of this study indicate that attention to threat (attention given, by the toddler to the feared stimuli) predicts social inhibition in kindergarten. Further, if the child approaches the feared stimuli, the relation to later social inhibition is not significant. When a child’s behaviour is to keep more than two feet away from the threatening stimulus, their behaviour can be seen as linked to later social inhibition. Another important factor that the researchers found when looking at the prediction of social inhibition is the child paying a significant amount of attention to a feared or threatening stimuli in the presence of other, enjoyable activities. Mainly, if the child’s duration of attention to the threatening stimuli is significant even when there are other enjoyable activities available for them to interact with, the link to later social inhibition is stronger due to the fact that “toddler-aged children have increased motoric skill and independence in exploring their environments; so they are capable of using more sophisticated distraction techniques, such as involvement with other activities”.

In another study looking at social inhibition and fear, the researchers made the distinction between different forms of inhibition. Mainly looking at behavioural inhibition the researchers separated the category into two subcategories, social behavioural inhibition and non-social behavioural inhibition. The researchers cite an experiment conducted by Majdandzic and Van den Boom where they used a laboratory setting to attempt to elicit fear in the children. They did this by using both social and non-social stimuli. What Majdandizic and Van der Boom found was a variability in the way that fear was elicited in the children when using either the social or non-social stimuli. Essentially, this study realised that there is a correlation between social stimuli producing fear expressions in children, whereas non-social stimuli is not correlated to fear. This can be evidence of social inhibition due to the social stimuli that result in fear expressions in children.

The researchers of the current study took the results from the Majdandizic and Van der Boom study and expanded on their work by looking at variability in fear expressions in both socially inhibited children and non-socially inhibited children. What they found was that mainly socially inhibited children have effects such as shyness and inhibition with peers, adults, and in performance situations, as well as social phobia and separation anxiety. The stronger link with fear reactions comes mainly from those children who were non-socially behaviourally inhibited. While these results go against previous findings, what the researchers were eager to stipulate was that “the normative development of fear in children have indicated that many specific fears (e.g. fear of animals) decline with age, whereas social fears increase as children get older”.

Social Phobia

Social inhibition is linked to social phobia, in so much as social inhibition during childhood can be seen as a contributing factor to developing social phobia later on in life. While social inhibition is also linked to social anxiety, it is important to point out the difference between social anxiety and social phobia. Social anxiety is marked by a tendency to have high anxiety before a social interaction, but not experience the avoidance of the social activity that is associated with social phobia. Social phobia and social inhibition are linked in a few different ways, one being physiologically. When one is experiencing extreme levels of inhibition they can suffer from symptoms such as accelerated heart rate, increased morning salivary cortisol levels, and muscle tension in their vocal cords. These symptoms are also reported by those with social phobia, which indicates that both social inhibition and social phobia interact with the sympathetic nervous system when the individual encounters a stressful situation.

Further, it is suggested throughout literature that social inhibition during childhood is linked to later social phobia. Beyond that research has indicated that continuity in inhibition plays an important role in the later development of social phobia. Continuity of social inhibition means someone experiencing social inhibition for a number of year continuously. The research explains work done with young teenagers, which found that the teenagers who had been classified as inhibited 12 years earlier were significantly more likely to develop social phobia than young teenagers who were not classified as inhibited. This research pertains to the link between social inhibition and generalised social phobia, rather than specific phobias. When looking at continuity in social inhibition some research offers reasoning as to why the social inhibition may continue long enough to be a predictor of social phobia. Researchers have suggested that if the early childhood relationships are not satisfactory they can influence the child to respond to situations in certain inhibitory ways. When this happens it is often then associated with poor self-evaluation for the child, which can lead to increased social inhibition and social phobia. Also, if a child is neglected or rejected by their peers, rather than by their caregiver, they often develop a sense of social failure, which often extends into social inhibition, and later social phobia. The link between social inhibition and social phobia is somewhat exclusive, when testing for a possible link between non-social inhibition and social phobia no predictive elements were found. It is particularly social inhibition that is linked to social phobia.

The research also suggests that social inhibitions can be divided between different kinds of social fears, or different patterns of inhibition can be seen in individuals. The researchers suggest that certain patterns, or certain social fears, can be better predictors of social phobia than others. Mainly, the researchers suggest that there can be different patterns of social inhibition in relation to an unfamiliar object or encounter. These specific patterns should be looked at in conjunction with motivation and the psychophysiological reaction to the object or encounter to determine the specific patterns that are the better predictors of social phobia.

Another study aimed to examine the link between social inhibition and social phobia also found that social phobia is linked to the social phobic being able to recall their own encounters with social inhibition during childhood. The social phobic participants were able to recall social and school fears from their childhood, but they also were able to recall sensory-processing sensitivity which indicates that the social phobic participants in the study were able to recall having increased sensitivity to the situations and behaviours around them.

Another study explains that social phobia itself has a few different ways it can manifest. The study aims at understanding the link between social inhibition and social phobia, as well as depression in social phobia. What the study found was an important link connecting the severity of social inhibition during childhood to the severity of social phobia and factors of social phobia in later years. Severe social inhibition during childhood can be related to lifetime social phobia. Further, the researchers point out that inhibition during childhood is significantly linked to avoidant personality disorder in social phobia as well as childhood inhibition linked with major depressive disorder in social phobia that spans across the individual’s lifetime. A major suggestion related to the results of the study suggested that while inhibition can be a general predictor of risk factors related to social phobia, it may not be a specific predictor of social phobia alone

Social Anxiety Disorder

Social anxiety disorder is characterised by a fear of scrutiny or disapproval from others. Individuals believe this negative reaction will bring about rejections. Individuals with social anxiety disorder have stronger anxious feeling over a long period of time and are more anxious more often. In many cases, researchers have found that social inhibition can be a factor in developing other disorders such as social anxiety disorder. Being inhibited does not mean that an individual will develop another disorder; however, Clauss and colleagues conducted a study to measure the association between behavioural inhibition and social anxiety disorder. The results of the study discovered that 15% of all children have behavioural inhibition and about half of those children will eventually develop social anxiety disorder. This is why behavioural inhibition is seen as a larger risk factor.

That being said, Lim and colleagues researched the differences between early and late onset of social anxiety disorder and its relation to social inhibition. Through the duration of their study, they found those diagnosed as early onset had complaints other than ones about social anxiety symptoms. Early onset individuals would frequently have more severe symptoms and higher levels of behavioural inhibition. Additional behavioural inhibition was more severe especially in social and school situations with only the early onset cases. Lorian and Grisham researched the relationship between behavioural inhibition, risk-avoidance, and social anxiety symptoms. They found that all three factors correlated with each other and risk avoidance is potentially a mechanism linked to an anxiety pathology.

Reduction

Alcohol Consumption

Social inhibition can be lowered by a few different factors, one of them being alcohol. Alcohol consumption can be seen to lower inhibitions in both men and women. Social inhibitions generally act to control or affect the way that one conducts themselves in a social setting. By lowering inhibitions alcohol can work to increase social behaviours either negatively or positively. Importantly, one must remember that the higher the dosage of alcohol, the greater the damage it will cause to inhibitory control.

By lowering inhibitions, alcohol can cause social behaviours such as aggression, self disclosure, and violent acts. Researchers have suggested that situational cues used to inhibit social behaviours are not perceived the same way after someone consumes enough alcohol to qualify them as drunk:

“interacting parties who are impaired by alcohol are less likely to see justifications for the other’s behavior, are thus more likely to interpret the behavior as arbitrary and provocative, and then, having less access to inhibiting cues and behavioral standards, are more likely to react extremely.”

This idea of increased extreme social behaviours is believed to come as a result of lowered inhibitions after consuming alcohol. Alcohol can lower inhibitions for a number of reasons, it can reduce one’s self-awareness, impair perceptual and cognitive functioning, allows for instigator pressures to have more influence over an individual, and can reduce one’s ability to read inhibitory social cues and standards of conduct.

When attempting to examine the effects that alcohol consumption has on social inhibition researchers found that after being provoked sober individuals used inhibiting cues, such as the innocence of the instigator and the severity of the retaliation to control their response to the aggressive provocation. However, the researchers found that an intoxicated individual did not have these same inhibitions and, as a result, exhibited more extreme behaviours of retaliated aggression to the provocation without processing information they would normally consider about the situation. On average, drunken individuals exhibited more aggression, self-disclosure, risk taking behaviours, and laughter than sober individuals. Extreme behaviours are not as common in sober individuals because they are able to read inhibitory cues and social conduct norms that drunken individuals are not as inclined to consider. These negative social behaviours, then, are a result of lowered social inhibitions.

Alcohol consumption also has the ability to lower inhibitions in a positive way. Research has been conducted looking at the way an intoxicated person is more inclined to be helpful. Researchers were of the same opinion that alcohol lowers inhibitions and allows for more extreme behaviours, however, they tested to see if this would be true for more socially acceptable situations, such as helping another person. The researchers acknowledged that, generally, an impulse to help another is initiated but then inhibitions will cause the potential helper to consider all factors going into their decision to help or not to help such as, lost time, boredom, fatigue, monetary costs, and possibility of personal harm. The researchers suggest that while one may be inhibited and therefore less likely to offer help when completely sober, after consuming alcohol enough damage will be done to their inhibitory functioning to actually increase helping. While this suggestion differs from socially negative behaviours that are seen after social inhibitions have been lowered, it is consistent with the idea that alcohol consumption can lower inhibitions and, as a result, produce more socially extreme behaviours when compared to a sober counterpart.

Alcohol consumption can lower social inhibitions in both men and women, producing social behaviours not typical in the individuals’ day-to-day sober lives. For example, in social settings women will tend to be uncomfortable with sexual acts and provocations as well as feeling uncomfortable in social settings that are generally male dominated such as strip clubs or bars. However, consumption of alcohol has been seen to lower these inhibitions, making women feel freer and more ready to participate socially in events and behaviours that they would normally feel inhibited from participating in if they were sober. As an example, women participating in bachelorette parties generally consume copious amounts of alcohol for the event. As a result, the females feel less inhibited and are more likely to then engage in behaviour that they would normally view as deviant or inappropriate. In an examination of bachelorette parties it was found that when those attending the party consumed only a couple of drinks behaviour minimally reflected any alcohol consumption, assuming that the party guests were still socially inhibited and less inclined to perform deviant behaviours. Similarly, “levels of intoxication were correlated with the atmosphere of the party, such that parties with little or no alcohol were perceived as less ‘wild’ than parties a lot of alcohol consumption.” Conceivably, the bachelorette parties show tendencies of “wild” behaviour after excessive alcohol consumption, which consequently lowers the inhibitions of the consumers.

When surveyed a number of women who had attended a bachelorette party, or had one in their honour, in the past year reported that their behaviour when under the influence of alcohol was different from their behaviour when sober. One party guest reported:

“People drink … to lose inhibitions and stuff that is done… I would never do sober. It lowers inhibitions – that is the main point of it.”

These reports suggest that “alcohol was used to lower inhibitions about being too sexual, about the risk of being perceived as promiscuous, or about being sexual in public. Women commented that they felt freer to talk about sex while under the influence of alcohol, to flirt with male strangers, or to dance with a male stripper.” The research collected surrounding women and their alcohol consumption in these settings provide examples of the reduction of social inhibitions in relation to excess alcohol consumption

Power

Social inhibitions can also be reduced by means unrelated to an actual substance. Another way that social inhibition can be decreased is by the attainment of power. Research has examined the way that having either elevated or reduced power affects social interactions and well-being in social situations. Such research has shown a relationship between elevated power and decreased social inhibitions. This relationship of those with elevated power and those with reduced power can be seen in all forms of social interactions, and is marked by elevated power individuals often having access to resources that the reduced power individuals do not have. Decreased social inhibition is seen in those with elevated power for two main reasons, one being that they have more access to resources, providing them with comforts and stability. The second reason is that their status as a high power individual often provides the powerful individual a sense of being above social consequences, allowing them to act in ways that a reduced power individual may not.

The elevated power individuals will experience reduced social inhibition in various ways, one being that they are more likely to approach, rather than avoid, another person. Also, with the reduced inhibition associated with high power individuals, they are more likely to initiate physical contact with another person, enter into their personal space, and they are more likely to indicate interest in intimacy. High power people tend to be socially disinhibited when it comes to sexual behaviour and sexual concepts. Consistent with this expectation, a study working with male and female participants found that when the male and female felt equally powerful they tended to interact socially with one another in a disinhibited manner.

Further, the research suggests that as a result of their reduced social inhibition, powerful individuals will be guided to behave in a way that fits with their personality traits in a social situation in which they feel powerful. Similarly, in a laboratory study it was found that when one person in a group feels powerful their reduced social inhibition can result in decreased manners. The study found that, when offered food, the powerful individual is more likely to take more than the other individuals in the room. This can be seen as the powerful individual exhibiting reduced social inhibitions, as they reduce their attention to common social niceties such as manners and sharing.

Increase

Power

Certain factors can increase social inhibition in individuals. Increased inhibitions can occur in different situations and for different reasons. One major factor that contributes to the increase of social inhibition is power. Reduced power is linked to an array of negative affect, one of which being increased social inhibitions. Power, in this instance, can be defined as a fundamental factor in social relationships that is central to interactions, influencing behaviour and emotional display. Further, power is such an essential factor in social relationships because power determines who is the giver and who is the receiver in the exchange of rewards and resources. Power is present in all social relationships, not just typical hierarchical establishments such as in employment or school settings. Power, then, is related to increased social inhibitions when an individual feels that they are in a powerless or diminished power position. Those who are deemed to be high in power are generally richer in resources and freedom, as well as decreased levels of social inhibition, whereas those who are deemed to be low in power are generally low in resources, constrained, and prone to experiencing increased social inhibition.

Research shows that individuals who are considered to be low in power experience more social threats and punishments, and generally have less access to social resources. As a result of this these individuals are prone to developing more sensitivity to criticism from others, and are more susceptible to accepting when someone constrains them. These factors contribute to increasing social inhibition in those individuals. Similarly, studies have shown that the absence of power can heighten the processes associated with social inhibition. Experiments on the interaction between power and inhibition have shown that when participants are in a situation where they perceive more punishments and threats their cognition and behaviour will show more signs of social inhibition related affect. Environments which distinguish the differences between the powerful and the powerless can lead to the social inhibition of the power reduced individuals as a response to their social interactions with the heightened power individuals.

Some of the social inhibited behaviours that a low-power individual will experience in these social situations will be embarrassment and fear and they may even go on to feel guilt, sadness, and shame. Further, low power individuals can be seen socially inhibiting themselves in ways that can, in the end, favour the high-power individuals. These can include inhibiting themselves from providing input on ideas, hesitating in normal speech, and even increasing their facial muscle actions in order to keep themselves from displaying emotions. When the low-power individuals are in a social situation with a high-power individual they will also commonly exhibit social inhibition by inhibiting their postural constriction and reducing their gestures. Researchers have generalised these suggestions of interaction between a high-power individual and low-power individuals to say that these expressions of social inhibition are expected to carry over into all areas of social interaction for the low-power individual. That is to say that low-power individuals will not only exhibit social inhibition when in the presence of a high-power individual. They will continue to be socially inhibited in all social aspects of their lives as a result of their low-power status. Further, low-power individuals tend to devote increased attention to the actions and behaviours of others.

Biological Factors

Another possible explanation for increased social inhibition has to do with biological factors. A study of brain activity in those who rate high on the scale for social inhibition showed a number of brain areas that are related to the heightened inhibitions. In their study the researchers aimed to find the link between socially inhibited individuals and an over activation of the cortical social brain network. The researchers did this by examining the brain activity of individuals who rate high in social inhibition as they respond to video clips of facial and bodily expressions that were potentially threatening. What the researchers found was that those who rate high in social inhibition show an overactive orbitofrontal cortex, left temporo-parietal junction, and right extrastriate body area. When the threat -related activity was being presented to the participants, these areas of the brain showed increased activity in comparison to those who do not rate high for social inhibition. What the researchers speculate is that, in this instance, hyperactivity in these brain structures does not mean better functioning. Further, “the orbitofrontal cortex is connected with areas that underlie emotional function and empathy”. This relates to one’s ability to stimulate how another person feels in their own facial displays. The over activity and decreased function of these brain structures can affect individuals by increasing social inhibition and behaviours related to social inhibition.

Personality Traits

Further, there is speculation that social inhibition can also be increased by the type of personality an individual has and behaviours that those individuals inherently display. Namely, those who are dependent and reassurance seeking are more commonly likely to display increased social inhibition.

Clinical Levels

Although social inhibition can occur as part of ordinary social situations, a chronically high level of social inhibition may lead some individuals to develop other social or anxiety disorders that would also need to be handled clinically. Through childhood, adolescence, and adulthood, clinical levels of social inhibition can be measured. Social inhibition can be a precursors for other social disorders that can develop in adolescence or adulthood

Measures

There are many implications for the diagnoses of social inhibition, however there are many cost-efficient ways to measure and treat this social disorder. One measure that has reliably assessed the traits of social inhibition is the seven-item inhibition scale of the Type D Scale-14. Another measure is the Behavioural Inhibition Observation System (BIOS). In clinical trials this measure is to be used for children completed by parents, teachers, and clinicians. Other scales are the:

  • Behavioural Inhibition Questionnaire (BIQ);
  • Behavioural Inhibition Instrument (BII);
  • Behavioural Inhibition Scale (BIS);
  • Preschool Behavioural Inhibition Scale (P-BIS); and
  • Behavioural Inhibition Scale for children ages 3-6.

There are also many versions of these scales that are specifically for parents, teachers, or even the child or possibly an inhibited individual to take. There are also times when these measures are grouped together; in many cases the Behavioural Inhibition System scale and Behavioural Activation System scale are used together. These two measure are the most widely used and together they consist of behavioural inhibition and behavioural activation scales that deal with reward response and fun seeking. The Behavioural Paradigm System is an observation system that allows measurements of behavioural inhibition in systematic natural environments. With this system researchers will observe cessation of play and vocalisation, long latencies to approaching the unfamiliar person, signs of fear and negative affect, and security seeking in environments such as classrooms, playgrounds, and in home settings. This paradigm was followed by many adaptations, one specifically was the adaptation of the Observational Paradigm. In an additional study by Ballespi and colleagues the paradigm was changed to be more suitable for a school environment. The adapted paradigm met three important criteria, the tests were suitable for a school environment, there had to be materials for the test that could be transported easily, and the observation of behavioural inhibition signs had to have the potential to be seen in a short period of time.

Ballespi and colleagues discussed one of the most recent measurement systems in the Behavioural Inhibition Observation System. This new system will allow clinicians to provide a quick measure for behavioural inhibition. This system is used during the first meeting with the child. In this first meeting, the child will be exposed to a strange, unfamiliar situation. The scale will then be completed after the therapist has time to observe the child in an interview setting. Researchers want to find a way to have an actual measure for inhibition, however this is difficult. There is a difference in observations, a parent or teachers is going to observe the child over long periods of time in several natural situations. The parents do not actually observe the child but instead rate the behaviour inhibition on the ideas they have formed about the child. The clinician will not have all this information and will base his or her first measure on observation alone; they measure state while parents and teachers measure traits. This is where the differences come up in measure however after several visits the measures of the clinicians, teachers, and parents become more similar.

Treatments

Treatments used for social inhibition are primarily assertive trainings introduced by therapies. These treatments are about teaching the inhibited individual to express and assert their feeling instead of inhibiting them. Assertiveness training is an important operation for behavioural therapist because it can help with behavioural issues, as well as interpersonal inadequacies, and anxiety in adults. In some cases this training can go by a different name because assertiveness is sometimes categorised by aggression therefore it can also be called appropriate expression training.

In one study discussing assertive training Ludwig and Lazarus found irrational cognitive patterns that inhibited individuals have to deal with and how to overcome them. The four patterns are self-criticism/Perfectionism, unrealistic approval needs, unrealistic labelling of aggression/assertive behaviour, and criticism of others. There are three different phases that work to combat the irrational cognitive patterns and inhibitory actions during social situations. These phases are meant to be actively practiced. The individual will receive homework assignments, and have to do role-playing exercises to overcome their inhibitions. The first phase discussed was about talking more. Ludwig states that there cannot just be an increase in talking but also an increase in expressing and talking about how one feels. The point of this phase is to get an individual talking no matter how ridiculous or trivial it may seem. Phase two is about dealing with the responses that come from talking more. When an inhibited individual starts talking more they may become embarrassed. However, with positive reactions from others they will learn that being embarrassed about some of the comments made is not devastating, and in turn the individual may talk and act more freely. In addition to the positive feedback the individual will review particularly embarrassing moment to assess why they were embarrassed to help combat those thoughts. If the inhibited person can understand the irrational thoughts they will eventually feel less embarrassed and act more freely. Role playing is also a way to help the individual understand different social behaviours. Mirroring is a way some therapist will show the client their own behaviour. The last phase deals with additional strategies that can help through social situation such as expressing disagreement, dealing with interruptions, initiating more conversations topics, and more self-disclosure. Ludwig and colleagues also make sure to explain that no one should compulsively apply these behavioural techniques in all situations. An individual should not go over board using them; additionally there are times when initiating some conversation topics and talking more are inappropriate.

Group therapies are also used in the treatment using assertiveness. Hedquist and Weinhold investigated two group counselling strategies with socially anxious and unassertive college students. The first strategy is a behavioural rehearsal group, which aims to assist members to learn more efficient responses in social situations. This was to be accomplished by rehearsing several difficult social situations. The second strategy was a social learning group that was about honesty about everything; any withholding behaviours were seen as being dishonest. Another rule was every individual had to take responsibility for everything that said. The results of this study showed that both strategies helped significantly in treating the anxiety and unassertiveness.

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Yes or No: Brain Electrodes May Be Long-Lasting Aid for Depression?

In connection with our previous post ‘Yes or No: There is a Link Between Depression and Serotonin?’, a small study (of 25 participants over 6-9 years) reported in the New Scientist (Klein, 2020) suggests that brain electrodes may be a long-lasting aid for those suffering with depression (Bergfeld et al., 2022).

References

Bergfeld, I.O., Ooms, P., Lok, A., de Rue, L., Vissers, P., de Knijff, D., Horst, F., Beute, G., van den Munckhof, P., Schuurman, P.R & Denys, D. (2022) Efficacy and Quality of Life after 6-9 Years of Deep Brain Stimulation for Depression. Brain Stimulation. 15(4), pp.957-964. https://www.brainstimjrnl.com/article/S1935-861X(22)00114-0/fulltext.

Klein, A. (2022) Brain Electrodes May Be Long-Lasting Aid for Depression. New Scientist. 09 July 2022, pp.12.

Yes or No: Is there a Link Between Depression and Serotonin?

Every year many suffering with depression are prescribed antidepressants to manage their condition, with antidepressants being described – by a spokesperson for the Royal College of Psychiatrists – as “an effective evidence-based treatment” (The Pharmaceutical Journal, 2022).

Within England, UK, “From 2021-22, there was a 5% rise in the number of adults receiving them – from 7.9 million in the previous 12 months to 8.3 million. [… with …] “An estimated 83.4 million antidepressant drug items were prescribed between 2021 and 2022, which marks a 5% increase from the previous year.” (BBC, 2022).

Within the US, Brody and Gu (2020) reported that “During 2015–2018, 13.2% of adults aged 18 and over used antidepressant medications in the past 30 days. [… and … ] In 2018, an estimated 7.2% of American adults had a major depressive episode in the past year. Carey and Geberloff reported in 2018 that “Nearly 25 million adults, like Ms. Toline, have been on antidepressants for at least two years, a 60 percent increase since 2010.”

Now it is important to remember that:

  • Depression is associated with diminished quality of life and increased disability;
  • Antidepressants are one of the primary treatments for depression;
  • Antidepressants are among the most frequently used therapeutic medications in the UK and US; and
  • There is research to suggest antidepressants work, at least in some people.

However, a new major analysis (by Moncrief et al., 2022) reported in the New Scientist suggests there is no link between serotonin levels and depression, raising questions about antidepressants that focus on this brain-signalling molecule (Wild, 2022, p.20).

Although this analysis suggests antidepressants might not be as effective as previously stated, brain electrodes might be. Read our next post about brain electrodes and depression here.

References

BBC (British Broadcasting Corporation). (2022) Nearly Half a Million More Adults on Antidepressants in England. Available from World Wide Web: https://www.bbc.co.uk/news/health-62094744. [Accessed: 17 November, 2022].

Carey, B. & Gebeloff, R. (2018) Many People Taking Antidepressants Discover They Cannot Quit. Available from World Wide Web: https://www.nytimes.com/2018/04/07/health/antidepressants-withdrawal-prozac-cymbalta.html. [Accessed: 17 November, 2022].

Moncrief, J., Cooper, R.E., Stockman, T., Amendola, S., Hengartner, M.P. & Horowitz, M.A. (2022) The Serotonin Theory of Depression: A Systematic Umbrella Review of the Evidence. Molecular Psychiatry. doi.org/gqh6nd.

The Pharmaceutical Journal. (2022) Antidepressant Prescribing Increases by 35% in Six Years. Available from World Wide Web: https://pharmaceutical-journal.com/article/news/antidepressant-prescribing-increases-by-35-in-six-years. [Accessed: 17 November, 2022].

Wild, S. (2022) No Link between Depression and Serotonin, Finds Major Analysis. New Scientist. 30 July 2022, pp.20.

What is Butriptyline?

Introduction

Butriptyline, sold under the brand name Evadyne among others, is a tricyclic antidepressant (TCA) that has been used in the United Kingdom and several other European countries for the treatment of depression but appears to no longer be marketed. Along with trimipramine, iprindole, and amoxapine, it has been described as an “atypical” or “second-generation” TCA due to its relatively late introduction and atypical pharmacology. It was very little-used compared to other TCAs, with the number of prescriptions dispensed only in the thousands.

Brief History

Butriptyline was developed by Wyeth, an American pharmaceutical company, and introduced in the United Kingdom in either 1974 or 1975.

Medical Uses

Butriptyline was used in the treatment of depression. It was usually used at dosages of 150-300 mg/day.

Side Effects

Butriptyline is closely related to amitriptyline, and produces similar effects as other TCAs, but its side effects like sedation are said to be reduced in severity and it has a lower risk of interactions with other medications.

Butriptyline has potent antihistamine effects, resulting in sedation and somnolence. It also has potent anticholinergic effects, resulting in side effects like dry mouth, constipation, urinary retention, blurred vision, and cognitive/memory impairment. The drug has relatively weak effects as an alpha-1 blocker and has no effects as a norepinephrine reuptake inhibitor, so is associated with little to no antiadrenergic and adrenergic side effects.

Overdose

Refer to Tricyclic Antidepressant Overdose.

Pharmacology

Pharmacodynamics

In vitro, butriptyline is a strong antihistamine and anticholinergic, moderate 5-HT2 and α1-adrenergic receptor antagonist, and very weak or negligible monoamine reuptake inhibitor. These actions appear to confer a profile similar to that of iprindole and trimipramine with serotonin-blocking effects as the apparent predominant mediator of mood-lifting efficacy.

However, in small clinical trials, using similar doses, butriptyline was found to be similarly effective to amitriptyline and imipramine as an antidepressant, despite the fact that both of these TCAs are far stronger as both 5-HT2 antagonists and serotonin–norepinephrine reuptake inhibitors. As a result, it may be that butriptyline has a different mechanism of action, or perhaps functions as a prodrug in the body to a metabolite with different pharmacodynamics.

Pharmacokinetics

Therapeutic concentrations of butriptyline are in the range of 60-280 ng/mL (204-954 nmol/L). Its plasma protein binding is greater than 90%.

Chemistry

Butriptyline is a tricyclic compound, specifically a dibenzocycloheptadiene, and possesses three rings fused together with a side chain attached in its chemical structure. Other dibenzocycloheptadiene TCAs include amitriptyline, nortriptyline, and protriptyline. Butriptyline is an analogue of amitriptyline with an isobutyl side chain instead of a propylidene side chain. It is a tertiary amine TCA, with its side chain-demethylated metabolite norbutriptyline being a secondary amine. Other tertiary amine TCAs include amitriptyline, imipramine, clomipramine, dosulepin (dothiepin), doxepin, and trimipramine. The chemical name of butriptyline is 3-(10,11-dihydro-5H-dibenzo[a,d]cycloheptene-5-yl)-N,N,2-trimethylpropan-1-amine and its free base form has a chemical formula of C21H27N with a molecular weight of 293.446 g/mol. The drug has been used commercially both as the free base and as the hydrochloride salt. The CAS Registry Number of the free base is 15686-37-0 and of the hydrochloride is 5585-73-9.

Society and Culture

Generic Names

Butriptyline is the English and French generic name of the drug and its International Non-Propriety Name (INN), British Approved Name (BAN), and Denomination Commune Francaise (DCF), while butriptyline hydrochloride is its BANM and (United States Adopted Name (USAN). Its generic name in Latin is butriptylinum, in German is butriptylin, and in Spanish is butriptylina.

Brand Names

Butriptyline has been marketed under the brand names Evadene, Evadyne, Evasidol, and Centrolese.

Availability

Butriptyline has been marketed in Europe, including in the United Kingdom, Belgium, Luxembourg, Austria, and Italy.

This page is based on the copyrighted Wikipedia article < https://en.wikipedia.org/wiki/Butriptyline >; it is used under the Creative Commons Attribution-ShareAlike 3.0 Unported License (CC-BY-SA). You may redistribute it, verbatim or modified, providing that you comply with the terms of the CC-BY-SA.

What is Sertraline?

Introduction

Sertraline, sold under the brand name Zoloft among others, is an antidepressant of the selective serotonin reuptake inhibitor (SSRI) class.

The efficacy of sertraline for depression is similar to that of other antidepressants, and the differences are mostly confined to side effects. Sertraline is better tolerated than the older tricyclic antidepressants, and it may work better than fluoxetine for some subtypes of depression. Sertraline is effective for panic disorder, social anxiety disorder, generalised anxiety disorder (GAD), and obsessive-compulsive disorder (OCD). However, for OCD, cognitive behavioural therapy (CBT), particularly in combination with sertraline, is a better treatment. Although approved for post-traumatic stress disorder, sertraline leads to only modest improvement in this condition. Sertraline also alleviates the symptoms of premenstrual dysphoric disorder and can be used in sub-therapeutic doses or intermittently for its treatment.

Sertraline shares the common side effects and contraindications of other SSRIs, with high rates of nausea, diarrhoea, insomnia, and sexual side effects, but it appears not to lead to much weight gain, and its effects on cognitive performance are mild. Similar to other antidepressants, the use of sertraline for depression may be associated with a higher rate of suicidal thoughts and behaviour in people under the age of 25. It should not be used together with MAO inhibitor medication: this combination causes serotonin syndrome. Sertraline taken during pregnancy is associated with a significant increase in congenital heart defects in newborns.

Sertraline was invented and developed by scientists at Pfizer and approved for medical use in the United States in 1991. It is on the World Health Organisation’s List of Essential Medicines. It is available as a generic medication. In 2016, sertraline was the most commonly prescribed psychiatric medication in the US and in 2019, it was the twelfth most commonly prescribed medication in the US, with over 37 million prescriptions.

Brief History

The history of sertraline dates back to the early 1970s, when Pfizer chemist Reinhard Sarges invented a novel series of psychoactive compounds, including lometraline, based on the structures of the neuroleptics thiothixene and pinoxepin. Further work on these compounds led to tametraline, a norepinephrine and weaker dopamine reuptake inhibitor. Development of tametraline was soon stopped because of undesired stimulant effects observed in animals. A few years later, in 1977, pharmacologist Kenneth Koe, after comparing the structural features of a variety of reuptake inhibitors, became interested in the tametraline series. He asked another Pfizer chemist, Willard Welch, to synthesize some previously unexplored tametraline derivatives. Welch generated a number of potent norepinephrine and triple reuptake inhibitors, but to the surprise of the scientists, one representative of the generally inactive cis-analogues was a serotonin reuptake inhibitor. Welch then prepared stereoisomers of this compound, which were tested in vivo by animal behavioural scientist Albert Weissman. The most potent and selective (+)-isomer was taken into further development and eventually named sertraline. Weissman and Koe recalled that the group did not set up to produce an antidepressant of the SSRI type – in that sense their inquiry was not “very goal driven”, and the discovery of the sertraline molecule was serendipitous. According to Welch, they worked outside the mainstream at Pfizer, and even “did not have a formal project team”. The group had to overcome initial bureaucratic reluctance to pursue sertraline development, as Pfizer was considering licensing an antidepressant candidate from another company.

Sertraline was approved by the US Food and Drug Administration (FDA) in 1991 based on the recommendation of the Psychopharmacological Drugs Advisory Committee; it had already become available in the United Kingdom the previous year. The FDA committee achieved a consensus that sertraline was safe and effective for the treatment of major depression. During the discussion, Paul Leber, the director of the FDA Division of Neuropharmacological Drug Products, noted that granting approval was a “tough decision”, since the treatment effect on outpatients with depression had been “modest to minimal”. Other experts emphasized that the drug’s effect on inpatients had not differed from placebo and criticised poor design of the clinical trials by Pfizer. For example, 40% of participants dropped out of the trials, significantly decreasing their validity.

Until 2002, sertraline was only approved for use in adults ages 18 and over; that year, it was approved by the FDA for use in treating children aged 6 or older with severe OCD. In 2003, the UK Medicines and Healthcare products Regulatory Agency issued a guidance that, apart from fluoxetine (Prozac), SSRIs are not suitable for the treatment of depression in patients under 18. However, sertraline can still be used in the UK for the treatment of OCD in children and adolescents. In 2005, the FDA added a boxed warning concerning paediatric suicidal behaviour to all antidepressants, including sertraline. In 2007, labelling was again changed to add a warning regarding suicidal behaviour in young adults ages 18 to 24.

Medical Uses

Sertraline has been approved for major depressive disorder (MDD), obsessive-compulsive disorder (OCD), posttraumatic stress disorder (PTSD), premenstrual dysphoric disorder (PMDD), panic disorder, and social anxiety disorder (SAD). Sertraline is not approved for use in children except for those with OCD.

Depression

Multiple controlled clinical trials established efficacy of sertraline for the treatment of depression. Sertraline is also an effective antidepressant in the routine clinical practice. Continued treatment with sertraline prevents both a relapse of the current depressive episode and future episodes (recurrence of depression).

In several double-blind studies, sertraline was consistently more effective than placebo for dysthymia, a more chronic variety of depression, and comparable to imipramine in that respect. Sertraline also improves the depression of dysthymic patients to a greater degree than psychotherapy.

Limited paediatric data also demonstrates reduction in depressive symptoms in the paediatric population though remains a second line therapy after fluoxetine.

Comparison with Other Antidepressants

In general, sertraline efficacy is similar to that of other antidepressants. For example, a meta-analysis of 12 new-generation antidepressants showed that sertraline and escitalopram are the best in terms of efficacy and acceptability in the acute-phase treatment of adults with depression. Comparative clinical trials demonstrated that sertraline is similar in efficacy against depression to moclobemide, nefazodone, escitalopram, bupropion, citalopram, fluvoxamine, paroxetine, venlafaxine, and mirtazapine. Sertraline may be more efficacious for the treatment of depression in the acute phase (first 4 weeks) than fluoxetine.

There are differences between sertraline and some other antidepressants in their efficacy in the treatment of different subtypes of depression and in their adverse effects. For severe depression, sertraline is as good as clomipramine but is better tolerated. Sertraline appears to work better in melancholic depression than fluoxetine, paroxetine, and mianserin and is similar to the tricyclic antidepressants such as amitriptyline and clomipramine. In the treatment of depression accompanied by OCD, sertraline performs significantly better than desipramine on the measures of both OCD and depression. Sertraline is equivalent to imipramine for the treatment of depression with co-morbid panic disorder, but it is better tolerated. Compared with amitriptyline, sertraline offered a greater overall improvement in quality of life of depressed patients.

Depression in Elderly

Sertraline used for the treatment of depression in elderly (older than 60) patients is superior to placebo and comparable to another SSRI fluoxetine, and tricyclic antidepressants (TCAs) amitriptyline, nortriptyline and imipramine. Sertraline has much lower rates of adverse effects than these TCAs, with the exception of nausea, which occurs more frequently with sertraline. In addition, sertraline appears to be more effective than fluoxetine or nortriptyline in the older-than-70 subgroup. Accordingly, a meta-analysis of antidepressants in older adults found that sertraline, paroxetine and duloxetine were better than placebo. On the other hand, in a 2003 trial the effect size was modest, and there was no improvement in quality of life as compared to placebo. With depression in dementia, there is no benefit of sertraline treatment compared to either placebo or mirtazapine.

Obsessive-Compulsive Disorder

Sertraline is effective for the treatment of OCD in adults and children. It was better tolerated and, based on intention-to-treat analysis, performed better than the gold standard of OCD treatment clomipramine. Continuing sertraline treatment helps prevent relapses of OCD with long-term data supporting its use for up to 24 months. It is generally accepted that the sertraline dosages necessary for the effective treatment of OCD are higher than the usual dosage for depression. The onset of action is also slower for OCD than for depression. The treatment recommendation is to start treatment with a half of maximal recommended dose for at least two months. After that, the dose can be raised to the maximal recommended in the cases of unsatisfactory response.

CBT alone was superior to sertraline in both adults and children; however, the best results were achieved using a combination of these treatments.

Panic Disorder

Sertraline is superior to placebo for the treatment of panic disorder. The response rate was independent of the dose. In addition to decreasing the frequency of panic attacks by about 80% (vs. 45% for placebo) and decreasing general anxiety, sertraline resulted in improvement of quality of life on most parameters. The patients rated as “improved” on sertraline reported better quality of life than the ones who “improved” on placebo. The authors of the study argued that the improvement achieved with sertraline is different and of a better quality than the improvement achieved with placebo. Sertraline is equally effective for men and women, and for patients with or without agoraphobia. Previous unsuccessful treatment with benzodiazepines does not diminish its efficacy. However, the response rate was lower for the patients with more severe panic. Starting treatment simultaneously with sertraline and clonazepam, with subsequent gradual discontinuation of clonazepam, may accelerate the response.

Double-blind comparative studies found sertraline to have the same effect on panic disorder as paroxetine or imipramine. While imprecise, comparison of the results of trials of sertraline with separate trials of other anti-panic agents (clomipramine, imipramine, clonazepam, alprazolam, and fluvoxamine) indicates approximate equivalence of these medications.

Other Anxiety Disorders

Sertraline has been successfully used for the treatment of social anxiety disorder. All three major domains of the disorder (fear, avoidance, and physiological symptoms) respond to sertraline. Maintenance treatment, after the response is achieved, prevents the return of the symptoms. The improvement is greater among the patients with later, adult onset of the disorder. In a comparison trial, sertraline was superior to exposure therapy, but patients treated with the psychological intervention continued to improve during a year-long follow-up, while those treated with sertraline deteriorated after treatment termination. The combination of sertraline and CBT appears to be more effective in children and young people than either treatment alone.

Sertraline has not been approved for the treatment of generalised anxiety disorder; however, several guidelines recommend it as a first-line medication referring to good quality controlled clinical trials.

Premenstrual Dysphoric Disorder

Sertraline is effective in alleviating the symptoms of premenstrual dysphoric disorder (PMDD), a severe form of premenstrual syndrome. Significant improvement was observed in 50-60% of cases treated with sertraline vs. 20-30% of cases on placebo. The improvement began during the first week of treatment, and in addition to mood, irritability, and anxiety, improvement was reflected in better family functioning, social activity and general quality of life. Work functioning and physical symptoms, such as swelling, bloating and breast tenderness, were less responsive to sertraline. Taking sertraline only during the luteal phase, that is, the 12-14 days before menses, was shown to work as well as continuous treatment. Continuous treatment with sub-therapeutic doses of sertraline (25 mg vs. usual 50-100 mg) is also effective.

Other Indications

Sertraline is approved for the treatment of post-traumatic stress disorder (PTSD). National Institute of Clinical Excellence recommends it for patients who prefer drug treatment to a psychological one. Other guidelines also suggest sertraline as a first-line option for pharmacological therapy. When necessary, long-term pharmacotherapy can be beneficial. There are both negative and positive clinical trial results for sertraline, which may be explained by the types of psychological traumas, symptoms, and comorbidities included in the various studies. Positive results were obtained in trials that included predominantly women (75%) with a majority (60%) having physical or sexual assault as the traumatic event. Contrary to the above suggestions, a meta-analysis of sertraline clinical trials for PTSD found it to be not significantly better than placebo. Another meta-analysis relegated sertraline to the second line, proposing trauma focused psychotherapy as a first-line intervention. The authors noted that Pfizer had declined to submit the results of a negative trial for the inclusion into the meta-analysis making the results unreliable.

Sertraline when taken daily can be useful for the treatment of premature ejaculation. A disadvantage of sertraline is that it requires continuous daily treatment to delay ejaculation significantly.

A 2019 systematic review suggested that sertraline may be a good way to control anger, irritability and hostility in depressed patients and patients with other comorbidities.

Contraindications

Sertraline is contraindicated in individuals taking monoamine oxidase inhibitors or the antipsychotic pimozide. Sertraline concentrate contains alcohol and is therefore contraindicated with disulfiram. The prescribing information recommends that treatment of the elderly and patients with liver impairment “must be approached with caution”. Due to the slower elimination of sertraline in these groups, their exposure to sertraline may be as high as three times the average exposure for the same dose.

Side Effects

Nausea, ejaculation failure, insomnia, diarrhoea, dry mouth, somnolence, dizziness, tremor, headache, excessive sweating, fatigue, and decreased libido are the common adverse effects associated with sertraline with the greatest difference from placebo. Those that most often resulted in interruption of the treatment are nausea, diarrhoea and insomnia. The incidence of diarrhoea is higher with sertraline – especially when prescribed at higher doses – in comparison with other SSRIs.

Over more than six months of sertraline therapy for depression, people showed a nonsignificant weight increase of 0.1%. Similarly, a 30-month-long treatment with sertraline for OCD resulted in a mean weight gain of 1.5% (1 kg). Although the difference did not reach statistical significance, the average weight gain was lower for fluoxetine (1%) but higher for citalopram, fluvoxamine and paroxetine (2.5%). Of the sertraline group, 4.5% gained a large amount of weight (defined as more than 7% gain). This result compares favourably with placebo, where, according to the literature, 3-6% of patients gained more than 7% of their initial weight. The large weight gain was observed only among female members of the sertraline group; the significance of this finding is unclear because of the small size of the group.

Over a two-week treatment of healthy volunteers, sertraline slightly improved verbal fluency but did not affect word learning, short-term memory, vigilance, flicker fusion time, choice reaction time, memory span, or psychomotor coordination. In spite of lower subjective rating, that is, feeling that they performed worse, no clinically relevant differences were observed in the objective cognitive performance in a group of people treated for depression with sertraline for 1.5 years as compared to healthy controls. In children and adolescents taking sertraline for six weeks for anxiety disorders, 18 out of 20 measures of memory, attention and alertness stayed unchanged. Divided attention was improved and verbal memory under interference conditions decreased marginally. Because of the large number of measures taken, it is possible that these changes were still due to chance. The unique effect of sertraline on dopaminergic neurotransmission may be related to these effects on cognition and vigilance.

Sertraline has a low level of exposure of an infant through the breast milk and is recommended as the preferred option for the antidepressant therapy of breast-feeding mothers. There is 29-42% increase in congenital heart defects among children whose mothers were prescribed sertraline during pregnancy, with sertraline use in the first trimester associated with 2.7-fold increase in septal heart defects.

Abrupt interruption of sertraline treatment may result in withdrawal or discontinuation syndrome. Dizziness, insomnia, anxiety, agitation, and irritability are its common symptoms. It typically occurs within a few days from drug discontinuation and lasts a few weeks. The withdrawal symptoms for sertraline are less severe and frequent than for paroxetine, and more frequent than for fluoxetine. In most cases symptoms are mild, short-lived, and resolve without treatment. More severe cases are often successfully treated by temporary reintroduction of the drug with a slower tapering off rate.

Sertraline and SSRI antidepressants in general may be associated with bruxism and other movement disorders. Sertraline appears to be associated with microscopic colitis, a rare condition of unknown aetiology.

Sexual

Like other SSRIs, sertraline is associated with sexual side effects, including sexual arousal disorder, erectile dysfunction and difficulty achieving orgasm. While nefazodone and bupropion do not have negative effects on sexual functioning, 67% of men on sertraline experienced ejaculation difficulties versus 18% before the treatment. Sexual arousal disorder, defined as “inadequate lubrication and swelling for women and erectile difficulties for men”, occurred in 12% of people on sertraline as compared with 1% of patients on placebo. The mood improvement resulting from the treatment with sertraline sometimes counteracted these side effects, so that sexual desire and overall satisfaction with sex stayed the same as before the sertraline treatment. However, under the action of placebo the desire and satisfaction slightly improved. Some people continue experiencing sexual side effects after they stop taking SSRIs.

Suicide

The US Food and Drug Administration (FDA) requires all antidepressants, including sertraline, to carry a boxed warning stating that antidepressants increase the risk of suicide in persons younger than 25 years. This warning is based on statistical analyses conducted by two independent groups of FDA experts that found a 100% increase of suicidal thoughts and behaviour in children and adolescents, and a 50% increase – in the 18-24 age group.

Suicidal ideation and behaviour in clinical trials are rare. For the above analysis, the FDA combined the results of 295 trials of 11 antidepressants for psychiatric indications in order to obtain statistically significant results. Considered separately, sertraline use in adults decreased the odds of suicidal behaviour with a marginal statistical significance by 37% or 50% depending on the statistical technique used. The authors of the FDA analysis note that “given the large number of comparisons made in this review, chance is a very plausible explanation for this difference”. The more complete data submitted later by the sertraline manufacturer Pfizer indicated increased suicidal behaviour. Similarly, the analysis conducted by the UK Medicines and Healthcare Products Regulatory Agency (MHRA) found a 50% increase of odds of suicide-related events, not reaching statistical significance, in the patients on sertraline as compared to the ones on placebo.

Overdose

Acute overdosage is often manifested by emesis, lethargy, ataxia, tachycardia and seizures. Plasma, serum or blood concentrations of sertraline and norsertraline, its major active metabolite, may be measured to confirm a diagnosis of poisoning in hospitalised patients or to aid in the medicolegal investigation of fatalities. As with most other SSRIs its toxicity in overdose is considered relatively low.

Interactions

As with other SSRIs, sertraline may increase the risk of bleeding with NSAIDs (non-steroidal anti-inflammatory drugs such as ibuprofen, naproxen, mefenamic acid), antiplatelet drugs, anticoagulants, omega-3 fatty acids, vitamin E, and garlic supplements due to sertraline’s inhibitory effects on platelet aggregation via blocking serotonin transporters on platelets. Sertraline, in particular, may potentially diminish the efficacy of levothyroxine.

Sertraline is a moderate inhibitor of CYP2D6 and CYP2B6 in vitro. Accordingly, in human trials it caused increased blood levels of CYP2D6 substrates such as metoprolol, dextromethorphan, desipramine, imipramine and nortriptyline, as well as the CYP3A4/CYP2D6 substrate haloperidol. This effect is dose-dependent; for example, co-administration with 50 mg of sertraline resulted in 20% greater exposure to desipramine, while 150 mg of sertraline led to a 70% increase. In a placebo-controlled study, the concomitant administration of sertraline and methadone caused a 40% increase in blood levels of the latter, which is primarily metabolized by CYP2B6.

Sertraline had a slight inhibitory effect on the metabolism of diazepam, tolbutamide and warfarin, which are CYP2C9 or CYP2C19 substrates; the clinical relevance of this effect was unclear. As expected from in vitro data, sertraline did not alter the human metabolism of the CYP3A4 substrates erythromycin, alprazolam, carbamazepine, clonazepam, and terfenadine; neither did it affect metabolism of the CYP1A2 substrate clozapine.

Sertraline had no effect on the actions of digoxin and atenolol, which are not metabolised in the liver. Case reports suggest that taking sertraline with phenytoin or zolpidem may induce sertraline metabolism and decrease its efficacy, and that taking sertraline with lamotrigine may increase the blood level of lamotrigine, possibly by inhibition of glucuronidation.

CYP2C19 inhibitor esomeprazole increased sertraline concentrations in blood plasma by approximately 40%.

Clinical reports indicate that interaction between sertraline and the MAOIs isocarboxazid and tranylcypromine may cause serotonin syndrome. In a placebo-controlled study in which sertraline was co-administered with lithium, 35% of the subjects experienced tremors, while none of those taking placebo did.

Sertraline may interact with grapefruit juice.

Pharmacology

Pharmacodynamics

Sertraline is a selective serotonin reuptake inhibitor (SSRI). By binding serotonin transporter (SERT) it inhibits neuronal reuptake of serotonin and potentiates serotonergic activity in the central nervous system. Over time, this leads to a downregulation of pre-synaptic 5-HT1A receptors, which is associated with an improvement in passive stress tolerance, and delayed downstream increase in expression of brain-derived neurotrophic factor (BDNF), which may contribute to a reduction in negative affective biases. It does not significantly affect norepinephrine transporter (NET), serotonin, dopamine, adrenergic, histamine, acetylcholine, GABA or benzodiazepine receptors.

Sertraline also shows relatively high activity as an inhibitor of the dopamine transporter (DAT) and antagonist of the sigma σ1 receptor (but not the σ2 receptor). However, sertraline affinity for its main target (SERT) is much greater than its affinity for σ1 receptor and DAT. Although there could be a role for the σ1 receptor in the pharmacology of sertraline, the significance of this receptor in its actions is unclear. Similarly, the clinical relevance of sertraline’s blockade of the dopamine transporter is uncertain.

Pharmacokinetics

Absorption

Following a single oral dose of sertraline, mean peak blood levels of sertraline occur between 4.5 and 8.4 hours. Bioavailability is likely linear and dose-proportional over a dose range of 150 to 200 mg. Concomitant intake of sertraline with food slightly increases sertraline peak levels and total exposure. There is an approximate 2-fold accumulation of sertraline with continuous administration and steady-state levels are reached within one week.

Distribution

Sertraline is highly plasma protein bound (98.5%) across a concentration range of 20 to 500 ng/mL. Despite the high plasma protein binding, sertraline and its metabolite desmethylsertraline at respective tested concentrations of 300 ng/mL and 200 ng/mL were found not to interfere with the plasma protein binding of warfarin and propranolol, two other highly plasma protein-bound drugs.

Metabolism

Sertraline is subject to extensive first-pass metabolism, as indicated by a small study of radiolabelled sertraline in which less than 5% of plasma radioactivity was unchanged sertraline in two males. The principal metabolic pathway for sertraline is N-demethylation into desmethylsertraline (N-desmethylsertraline) mainly by CYP2B6. Reduction, hydroxylation, and glucuronide conjugation of both sertraline and desmethylsertraline also occur. Desmethylsertraline, while pharmacologically active, is substantially (50-fold) weaker than sertraline as a serotonin reuptake inhibitor and its influence on the clinical effects of sertraline is thought to be negligible. Based on in vitro studies, sertraline is metabolized by multiple cytochrome 450 isoforms; however, it appears that in the human body CYP2C19 plays the most important role, followed by CYP2B6. In addition to the cytochrome P450 system, sertraline can be oxidatively deaminated in vitro by monoamine oxidases; however, this metabolic pathway has never been studied in vivo.

Elimination

The elimination half-life of sertraline is on average 26 hours, with a range of 13 to 45 hours. The half-life of sertraline is longer in women (32 hours) than in men (22 hours), which leads to 1.5-fold higher exposure to sertraline in women compared to men. The elimination half-life of desmethylsertraline is 62 to 104 hours.

In a small study of two males, sertraline was excreted to similar degrees in urine and faeces (40 to 45% each within 9 days). Unchanged sertraline was not detectable in urine, whereas 12 to 14% unchanged sertraline was present in faeces.

Pharmacogenomics

CYP2C19 and CYP2B6 are thought to be the key cytochrome P450 enzymes involved in the metabolism of sertraline. Relative to CYP2C19 normal (extensive) metabolisers, poor metabolisers have 2.7-fold higher levels of sertraline and intermediate metabolisers have 1.4-fold higher levels. In contrast, CYP2B6 poor metabolisers have 1.6-fold higher levels of sertraline and intermediate metabolisers have 1.2-fold higher levels.

Society and Culture

Generic Availability

The US patent for Zoloft expired in 2006, and sertraline is available in generic form and is marketed under many brand names worldwide.

In May 2020, the FDA placed Zoloft on the list of drugs currently facing a shortage.

Other Uses

Lass-Flörl et al., 2003 finds sertraline significantly inhibits phospholipase B in the fungal genus Candida, reducing virulence. It is also a very effective leishmanicide. Specifically, Palit & Ali 2008 find that sertraline kills almost all promastigotes of Leishmania donovani.

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What is the Hospital Anxiety and Depression Scale?

Introduction

Hospital Anxiety and Depression Scale (HADS) was originally developed by Zigmond and Snaith (1983) and is commonly used by doctors to determine the levels of anxiety and depression that a person is experiencing.

The HADS is a fourteen item scale that generates: Seven of the items that relate to anxiety and seven that relate to depression. Zigmond and Snaith created this outcome measure specifically to avoid reliance on aspects of these conditions that are also common somatic symptoms of illness, for example fatigue and insomnia or hypersomnia. This, it was hoped, would create a tool for the detection of anxiety and depression in people with physical health problems.

Items on the Questionnaire

The items on the questionnaire that relate to anxiety are

  • I feel tense or wound up.
  • I get a sort of frightened feeling as if something awful is about to happen.
  • Worrying thoughts go through my mind.
  • I can sit at ease and feel relaxed.
  • I get a sort of frightened feeling like ‘butterflies’ in the stomach.
  • I feel restless as I have to be on the move.
  • I get sudden feelings of panic.

The items that relate to depression are:

  • I still enjoy the things I used to enjoy.
  • I can laugh and see the funny side of things.
  • I feel cheerful.
  • I feel as if I am slowed down.
  • I have lost interest in my appearance.
  • I look forward with enjoyment to things.
  • I can enjoy a good book or radio or TV programme.

Scoring the Questionnaire

Each item on the questionnaire is scored from 0-3 and this means that a person can score between 0 and 21 for either anxiety or depression.

Caseness of Anxiety and Depression

A number of researchers have explored HADS data to establish the cut-off points for caseness of anxiety or depression. Bjelland et al. (2002) through a literature review of a large number of studies identified a cut-off point of 8/21 for anxiety or depression. For anxiety (HADS-A) this gave a specificity of 0.78 and a sensitivity of 0.9. For depression (HADS-D) this gave a specificity of 0.79 and a sensitivity of 0.83.

Factor Structure

There are a large number of studies that have explored the underlying factor structure of the HADS. Many support the two-factor structure but there are others that suggest a three or four factor structure. Some argue that the tool is best used as a unidimensional measure of psychological distress.

Criticisms

The factor structure of the HADS has been questioned. Coyne and Sonderen argue in a letter published in the same issue, that Cosco, et al. provides grounds for abandoning HADS altogether. The HADS has also been criticised for its over reliance on anhedonia as being the core symptom of depression, how single-item measures of depression may have the same predictive value as the HADS scale, as well as its use of British colloquial expressions which can be difficult to translate.

This page is based on the copyrighted Wikipedia article <https://en.wikipedia.org/wiki/Hospital_Anxiety_and_Depression_Scale >; it is used under the Creative Commons Attribution-ShareAlike 3.0 Unported License (CC-BY-SA). You may redistribute it, verbatim or modified, providing that you comply with the terms of the CC-BY-SA.

Magic Medicine (2018)

Introduction

Can magic mushrooms cure depression? This documentary follows the first medical trial to explore the use of psilocybin as a treatment for clinical depression.

Outline

In 2012 a team of medical researchers asked themselves, “what would happen if we gave psilocybin (magic mushrooms) to people suffering from severe depression”? It took them three years to get the necessary permissions to find out.

Production & Filming Details

  • Director(s):
    • Monty Wales.
  • Producer(s):
    • Lizzie Gillett.
    • Monty Wales.
  • Writer(s):
    • Monty Wales.
  • Music:
    • Christopher White.
  • Cinematography:
    • Monty Wales.
  • Editor(s):
    • John Mister.
  • Production:
    • Life Cycle Films.
  • Distributor(s):
    • Dartmouth Films (2018) (UK) (theatrical).
  • Release Date: 09 November 2018 (London, UK).
  • Running Time: 79 minutes.
  • Rating: 15.
  • Country: UK.
  • Language: English.

The Psychedelic Drug Trial (2021)

Introduction

With exclusive access to a ground-breaking trial, this film asks if psychedelic drugs combined with psychological support can help tackle one of the biggest medical challenges we face – depression.

Outline

The Psychedelic Drug Trial has exclusive access to a ground-breaking new trial at Imperial College London. The trial sees, for the first time ever under controlled conditions, a psychedelic drug tested head-to-head against a standard antidepressant as a treatment for depression.

The film follows a pioneering team of scientists and psychotherapists, led by Professor David Nutt, Dr Robin Carhart-Harris and Dr Rosalind Watts, as they compare the effects of psilocybin (the active ingredient of magic mushrooms) with an antidepressant (an SSRI called escitalopram) on a small group of participants with clinical depression. This is scientific research at its most cutting edge. With over seven million people being prescribed antidepressants each year in England alone, this drug trial is an important milestone in understanding a completely different treatment for depression.

Filmed over 16 months, this film explores both the immediate and long-term impacts of the trial on the lives of participants. It investigates whether psychedelic drugs combined with psychological support could help tackle one of the biggest medical challenges faced today and what it takes to conduct research in uncharted scientific territory.

How do psychedelic drugs measure up against the industry-standard antidepressants that have been popular since the 1990s? The empirical results of the trial are explored alongside the participants’ powerful lived experience.

About the Trial

All psychedelic drug use shown in this programme was part of a carefully controlled clinical trial under the supervision of specially trained psychotherapists.

The trial was run by Professor Nutt, Dr Carhart-Harris and Dr Watts and their team at Imperial College from 2019 to 2020. Fifty-nine participants took part, the trial is now finished.

The psychedelic drugs used in the trial are illegal in the UK and not available for medical treatment. You should always consult your doctor before you stop, change or start any new treatment.

Production & Filming Details

  • Director(s):
    • Sam Eastall.
  • Producer(s):
    • Caroline Lai … line producer.
    • Alice Martineau … producer.
    • Anna Murphy … executive producer.
    • Sabine Pusch … edit producer.
    • Caroline Willis … line producer.
  • Writer(s):
  • Music:
  • Cinematography:
    • Richard Jephcote … director of photography.
  • Editor(s):
    • Zoe Davis … editor.
    • Alex Spence … assistant editor.
  • Production:
    • Grain Media.
  • Distributor(s):
    • BBC Two (2021) (UK) (TV).
    • British Broadcasting Corporation (BBC) (2021) (UK) (all media).
  • Release Date: 19 May 2021 (UK).
  • Running Time: 59 minutes.
  • Rating: Unknown.
  • Country: UK.
  • Language: English.