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Serial lust killing shows features of addiction, and some killers describe themselves as addicted. Comparisons of lust killing with such addictions as gambling, drugs and consensual sex reveal similarities. Following Robinson and Berridge, it is suggested that the motivational process involves dopamine and exhibits sensitization of incentive salience with experience of killing. Lust killing shows several common properties with other addictions: seeking to repeat the first ‘high’, escalation, increased wanting over time, gateway activities (soft drugs → hard drugs; rape → killing), ambivalence in engaging, stress increases the tendency to engage in the addictive activity, a sudden high often followed by an aversive condition, craving and a temporary correction of such feelings as hopelessness, lacking control and powerlessness. The urge to kill can suddenly occupy the conscious mind. Lust killers commonly consume alcohol in association with killing. Comparisons reveal some common properties between lust killing and war-time killing.
We now recognise that withdrawal symptoms from antidepressants are common, and can be severe and long-lasting in some people. Many withdrawal symptoms overlap with symptoms of anxiety or depression, making it difficult to distinguish withdrawal from relapse. We describe how their onset soon after dose reduction, the association of psychological with physical symptoms, their prompt response to reinstatement, and their typical ‘wave’ pattern of onset, peak and resolution can help distinguish withdrawal symptoms from relapse. We also examine evidence that suggests that antidepressant withdrawal symptoms are misdiagnosed as relapse in discontinuation studies aimed at demonstrating the ability of antidepressants to prevent future relapse (relapse prevention properties). In these discontinuation studies people have their antidepressants stopped abruptly, or rapidly, making withdrawal symptoms very likely, and little effort is made to measure withdrawal symptoms or distinguish them from relapse. We conclude that there is currently no robust evidence for the relapse prevention properties of antidepressants, and current guidance might need to be re-evaluated.
This chapter focuses on the rules set out in the 1969 Vienna Convention on the Law of Treaties (VCLT). The chapter begins with the concept of a treaty, before discussing treatymaking, with a particular focus on the conclusion of treaties, their entry into force, and reservations to treaties. The chapter then delves into how treaties operate -- namely, their scope of application and their interpretation. Finally, this chapter looks at the invalidity, suspension, and termination of treaties.
To offer support for patients who decide to discontinue antipsychotic and antidepressant medication, identifying which potentially modifiable factors correlate with discontinuation success is crucial. Here, we analyzed the predictive value of the professional support received, circumstances prior to discontinuation, a strategy of discontinuation, and use of functional and non-functional coping strategies during discontinuation on self-reported discontinuation success and on objective discontinuation.
Patients who had attempted discontinuing antipsychotics (AP) and/or antidepressants (AD) during the past 5 years (n = 316) completed an online survey including questions on subjective and objective discontinuation success, sociodemographic, clinical and medication-related factors, and scales to assess the putative predictors.
A regression model with all significant predictors explained 20–30% of the variance in discontinuation success for AD and 30–40% for AP. After controlling for baseline sociodemographic, clinical and medication-related factors, the most consistent predictor of subjective discontinuation success was self-care behavior, in particular mindfulness, relaxation and making use of supportive relationships. Other predictors depended on the type of medication: For AD, good alliance with the prescribing physician predicted higher subjective success whereas gradual tapering per se was associated with lower subjective success and a lower chance of full discontinuation. In those tapering off AP, leaving time to adjust between dose reductions was associated with higher subjective success and fewer negative effects.
The findings can inform evidence-based clinical guidelines and interventions aiming to support patients during discontinuation. Further studies powered to take interactions between variables into account are needed to improve the prediction of successful discontinuation.
This article considers the international legal obligations relevant to States when withdrawing from situations of armed conflict. While a growing literature has focused on precisely when armed conflicts come to a legal end, as well as obligations triggered by the cessation of active hostilities, comparatively little attention has been paid to the legal implications of withdrawals from armed conflict and the contours of the obligations relevant to States in doing so. Following in the wake of just war scholarship endeavouring to distil jus ex bello principles, this article examines States’ obligations when ending their participation in armed conflicts from the perspective of international humanitarian law (IHL). It shows that while it is generally understood that IHL ceases to apply at the end of armed conflict, this is in reality a significant simplification; a number of obligations actually endure. Such rules act as exceptions to the general temporal scope of IHL and continue to govern withdrawing States, in effect straddling the in bello and post bellum phases of armed conflict. The article then develops three key end-of-participation obligations: obligations governing detention and transfer of persons, obligations imposed by Article 1 common to the four Geneva Conventions, and obligations relating to accountability and the consequences of conflict.
Benzodiazepines, Z-drugs and gabapentinoids are commonly prescribed medications with multiple indications that have the potential for misuse and dependence. Benzodiazepines enhance the effect of the neurotransmitter gamma-aminobutyric acid (GABA) at the GABA-A receptor, resulting in sedative, anxiolytic, hypnotic, anticonvulsant and muscle relaxant properties. The ‘Z-drugs’ (zopiclone and zolpidem) are non-benzodiazepine hypnotics that also have an agonist effect at the GABA-A receptor. The gabapentinoids (pregabalin and gabapentin) act to decrease central neuronal excitability by binding to α2-δ protein subunits of voltage-activated calcium channels on the neuronal membrane. They were initially marketed as antiepileptic drugs, but are now licensed for use in neuropathic pain and generalised anxiety disorder. This chapter considers each class in turn, exploring the pharmacokinetics, metabolism and potential desired effects that lead to misuse. A practical method for assessing people with potential dependence is described for each substance, as well as strategies to support stabilisation, withdrawal and relapse prevention.
This chapter looks at ‘club drugs’ and novel psychoactive substances (NPSs; previously known as ‘legal highs’). It examines the acute and chronic adverse health effects of these drugs and focuses in particular on their effects on mental health, including their dependence liability and associated withdrawal symptoms. The chapter is based on the best available research evidence on NPSs, which is currently limited, but nonetheless broadly consistent. It also provides practical patient case studies to illustrate key clinical points. Overall, the evidence suggests that interventions aimed at NPSs must be based on the guiding principles and national guidelines used for the management of substance misuse in general. However, NPSs pose a number of additional challenges, which are highlighted in this chapter. This chapter also establishes a conceptual framework for NPSs, which is crucial in helping clinicians to navigate the hundreds of new substances detected in recent years while allowing them to drawn on their existing experience of substance misuse.
How do voters want their governments to respond when another country unilaterally withdraws from an international institution? We distinguish between negotiation approaches that vary in the degree to which they accommodate the withdrawing state's demands and argue that negotiation preferences are shaped by two issues. The first is voters’ exposure to the costs and benefits of accommodation. This exposure varies across issues, and we argue that citizens will generally prefer non-accommodation on zero-sum issues, but support more accommodation on cooperation issues, where non-accommodation puts existing cooperation gains at risk. Second, withdrawal negotiations create precedents, and citizens should therefore be less willing to accommodate the more they are concerned about the ripple effects of accommodation on the institution's stability. These concerns also confront citizens with two types of dilemmas depending on how favorably they view the institution themselves. To test our argument, we use survey evidence and a conjoint experiment conducted in Germany and Spain during the Brexit negotiations. We find that respondents overall are more willing to accommodate the UK on cooperation issues than on zero-sum issues, but also find evidence that Euroskeptics and Europhiles confront different issue-specific dilemmas. Our paper contributes to a better understanding of the dynamics surrounding the challenges to multilateralism that have proliferated in recent years.
Traditional contraceptive methods are used by 55 million women in developing countries. This study analysed over 80 national surveys to compare traditional with modern method users, by type, region, socio-demographic characteristics, strength of family planning programmes and discontinuation rates. The advance of modern methods has greatly reduced the share held by traditional methods, but the actual prevalence of their use has declined little. Young, sexually active unmarried women use traditional contraception much more than their married counterparts. Discontinuation rates are somewhat lower for traditional methods than for the resupply methods of the pill, injectable and condom; among users of all of these methods, more than a quarter stop use in the first year to switch to alternative methods. Traditional method use is firmly entrenched in many countries, as the initial method tried, a bridge method to modern contraception and even the primary method where other methods are not easily available.
International law depends on foreign relations law not only to establish the means by which states can consent to treaty obligations, but also the means to fulfill any resulting obligations, including by incorporating treaties into domestic law. Given that, the professed indifference of international law towards it—as toward other forms of domestic law—is puzzling. It is also misleading. As is widely evident, international affairs create an opportunity for certain domestic actors, usually executives, to assume additional authority. Less obviously, international law, reflected in the Vienna Convention on the Law of Treaties (VCLT), actually influences foreign relations law relating to the creation and elimination of international treaty obligations – encouraging even those states that possess other constitutional agents to regard executive power as sufficient. The homogenizing effects of particular international law rules is an important complement to the study of comparative foreign relations law.
The second case study chapter analyses the role of the International Criminal Court (ICC) in marketised global justice. A particular focus is on the treaty relationships between the ICC and other organisations, which integrate a global trade regime with a global criminal law regime. To demonstrate how this works, the Cotonou Partnership Agreement (CPA) is analysed. The CPA, a treaty regime that overlooks trade and political relationships between the European Union and seventy-nine African, Caribbean, and Pacific states, is presented as a mechanism that throws light on the ICC’s role in enabling and encasing. This integrated trade law and criminal law perspective offers a novel reading of the 2016 withdrawal announcements of three African states from the ICC. It also presents the reading of new policies by the ICC (in response to the backlash against it) as a ‘re-brand’ and therefore as deeper integration with the market.
The final Chapter 9 addresses both the substantive and institutional aspects of the process of expanding the internal market to third countries without enlarging the Union and provides a conclusion on the viability of the ambition to truly extend the internal market to third countries, either in a comprehensive or sectoral manner, by means of exporting internal market acquis by international agreements.
Parasomnias are involuntary behaviors or subjective experiences during sleep. Our objective was to review existing information on the presence of parasomnias in patients with addictions or during treatment for addictions. Information about parasomnias related to rapid-eye-movement (REM) and non-REM sleep in patients with addictions, while using substances or in abstinence, was reviewed. A systematic search of published articles reporting parasomnias as a consequence of drug use or abuse was conducted in the PubMed and SciELO databases. The search for the studies was performed in three phases: (1) by title, (2) by abstract, and (3) by complete text. The search was performed independently by two researchers, who then compared their results from each screening phase. Seventeen articles were found. The consumption of alcohol was reported in association with arousal disorders, such as sexsomnia and sleep-related eating disorder; and REM sleep behavior disorder was reported during alcohol withdrawal. Cocaine abuse was associated with REM sleep behavior disorder with drug consumption dream content. Overall, we found that several types of parasomnias were very frequent in patients with addictions. To avoid accidents in bedroom, legal problems, and improve evolution and prognosis; must be mandatory to include security measures related to sleep period; avoid pharmacological therapy described as potential trigger factor; improve sleep hygiene; and give pharmacological and behavioral treatments for patients with these comorbid sleep disorders.
Membership is central to the EU, as it is to any other international organisation. Withdrawal has assumed centre-stage through Brexit. While there is literature that is relevant to membership, most notably through academic discourse on differentiated integration, there is little more general inquiry concerning membership, the concept of which has importance and implications over and beyond more particular avenues of scholarship. This article examines the formal and substantive dimensions of membership and withdrawal in the EU.
A high proportion of adults with intellectual disabilities are prescribed off-licence antipsychotics in the absence of a psychiatric illness. The National Health Service in England launched an initiative in 2016, ‘Stopping over-medication of people with a learning disability [intellectual disability], autism or both’ (STOMP), to address this major public health concern.
To gain understanding from UK psychiatrists working with adults with intellectual disabilities on the successes and challenges of withdrawing antipsychotics for challenging behaviours.
An online questionnaire was sent to all UK psychiatrists working in the field of intellectual disability (estimated 225).
Half of the 88 respondents stated that they started withdrawing antipsychotics over 5 years ago and 52.3% stated that they are less likely to initiate an antipsychotic since the launch of STOMP. However, since then, 46.6% are prescribing other classes of psychotropic medication instead of antipsychotics for challenging behaviours, most frequently the antidepressants. Complete antipsychotic discontinuation in over 50% of patients treated with antipsychotics was achieved by only 4.5% of respondents (n = 4); 11.4% reported deterioration in challenging behaviours in over 50% of patients on withdrawal and the same proportion (11.4%) reported no deterioration. Only 32% of respondents made the diagnosis of psychiatric illness in all their patients themselves. Family and paid carers’ concern, lack of multi-agency and multidisciplinary input and unavailability of non-medical psychosocial intervention are key reported factors hampering the withdrawal attempt.
There is an urgent need to develop national guidelines to provide a framework for systematic psychotropic drug reviews and withdrawal where possible.
On 10 December 2018, the Court of Justice (CJEU) delivered the Wightman judgment and recognized the unilateral revocability of the notification ex Art. 50 Treaty on European Union (TEU). This article offers a critical analysis of the decision by insisting above all on the national background of the ruling and the political risks stemming from the decision. The article is structured as follows. Firstly, it analyses the legal questions of the Scottish case, which constituted the ground for the admissibility of the preliminary ruling and showed the perils for the exercise of national sovereign rights embedded in the lack of clarity on revocation options. It thus reconstructs the critical aspects of the preliminary ruling of the CJEU. Subsequently, the article examines the implications of the ruling for the EU legal order. On the one hand, the analysis considers the conception of the EU membership by comparing the approach of the CJEU and that of Advocate General Campos Sánchez Bordona in Wightman.
Converting from one steroid to another is often necessary and can cause much head scratching. However, help is at hand with this chapter detailing common conversions, and some basic rules on managing and withdrawing steroid therapy.
As the end of 1971 approached, British planners began to think more carefully about Britain’s post-withdrawal role in the Gulf. They calculated that Britain’s ability to remain influential would rest to a large degree on the rulers’ continued dependence on Britons to fill critical advisory and leadership positions related to security matters. After all, the presence of British nationals, whether loaned out by Britain or privately employed, was a critical component in the development of indigenous security forces prior 1971 and one of the central planks of the British relationship with the Gulf ruling families. Because the influence of Britons in key positions in the security apparatus was not dependent on the formal aspects of Britain’s political and military position in the Gulf, it is perhaps not surprising that it continued long after Britain’s formal military withdrawal – right up to the present day.
Two distinct double-blind randomized multicentre studies were undertaken at the same time using the same design. Patients treated for insomnia with zopiclone 7.5 mg or zolpidem 10 mg for at least three months were allocated to two groups: gradual withdrawal or control. In each study the two groups were compared but there was no comparison between zopiclone and zolpidem. The main criteria was the number of patients in each group with “withdrawal syndrome” defined as: the occurrence of an adverse event, or premature discontinuation of treatment or a total score increase of at least 3 points on the Tyrer questionnaire. In both studies the incidence of “withdrawal syndrome” as defined above was significantly higher in the “withdrawal” groups than in the “control” groups 38% vs 20% for zopiclone p = 0.008 and 38% vs 24% for zolpidem P = 0.049. In most cases, the notified symptoms were sleep complaints.
Alcohol withdrawal is a clinically and etiologically heterogeneous syndrome caused by a complex interaction of environmental (e.g., amount of ethanol) and genetic factors. Multiple genes are considered to be involved in various components of the syndrome, each of them contributing only modestly to withdrawal vulnerability. Association studies using candidate genes of the dopamine, serotonin, gabaergic and opioidergic systems are reviewed and methodological limitations are discussed.