Perceptual sensitivity to sensory and affective aspects of dyspnea: Test-retest reliability and effects of fear of suffocation.

Perceptual sensitivity for dyspnea (i.e. breathlessness) is often quantified using the slope of magnitude estimations plotted against the physical stimulus intensities of respiratory loads. This study investigated whether this slope and its stability varies as a function of (1) affective versus sensory aspects of dyspnea, and (2) interindividual differences in Fear of Suffocation. Eighty-three healthy women performed a load magnitude estimation task twice one week apart. Resistive loads of increasing magnitude (0-2.4-5-7.4-12.4-20 cmH20/l/s) were repeatedly presented for a single flow-targeted inspiration. One group rated the intensity of loads, another their unpleasantness. Neither slopes nor intercepts differed between sensory versus affective aspects of dyspnea. Intercepts were lower in the second compared to the first session. Fear of Suffocation was associated with flatter slopes. Test-retest reliabilities were low to moderate suggesting that perceptual sensitivity to dyspnea is less stable than commonly assumed.

The Preference for Strangulation in a Sexually Motivated Serial Killer.

The existing literature on the killing method of choice for sexually motivated serial killers suggests strangulation as the preferable means of homicide, when the victim is female. When homicide victims are male, however, existing research suggests that firearms and blades are preferable methods of causing death. A case is presented here of a sexually motivated male serial killer who exclusively targeted males and who chose strangulation as his means of killing. Analysis suggests that not only is the psychological constitution of the killer an important factor in understanding how they kill victims but, also, the nature of the sexual act is an important determinant in the method of killing in male on male sexually motivated killing.

DSM-5 paraphilic disorders criteria in the light of autoerotic asphyxiophilia and non-sexual form of oxygen restriction. / Kryteria zaburzen parafilnych w DSM-5 wobec asfiksji autoerotycznej i pozaseksualnej formy ograniczania doplywu tlenu.

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders published in 2013 has proved to be particularly interesting in the field of sexuality. It introduced a number of significant changes in the definition of sexual norms, among them a widely discussed distinction between paraphilias and paraphilic disorders. The key criterion separating the abnormal sexual interests from the disordered ones is clinically significant distress resulting directly from sexual behavior and/or the risk of suffering or harm to another person as a result of one's sexual behavior. In the case of masochism - which addresses the phenomenon of suffering quite particularly - this distinction is troublesome. Using the example of autoerotic asphyxia - a behavior from the masochism spectrum - the authors critically examine the proposed DSM-5 method of defining the standards of sexual behavior. Interesting in this regard has been a comparison between autoerotic asphyxia and free diving - a nonsexual activity which, although also associated with possible loss of life by reduction of oxygen, has not been pathologized.

Brief measures of physical and psychological distance to suicide methods as correlates and predictors of suicide risk: A multi-study prospective investigation.

A core component of suicide risk assessment and management is determining one's physical proximity to specific suicide means and counseling individuals to minimize their physical access to these means. However, this approach ignores other potentially relevant parameters, such as perceptions of how psychologically close/distant one feels to a particular suicide method. The present study examined the degree to which novel, brief measures of physical and psychological distance to suicide methods were associated with and prospectively predicted suicide-related outcomes at (1) two-month follow-up among 121 students with current/recent suicidality; and (2) one-week follow-up among 91 community-dwelling adults at high suicide risk. Results indicated that both physical and psychological distance to means were related to suicidal intent at baseline. Additionally, in Study 2, lower psychological distance, but not physical distance, predicted suicidal intent and increased likelihood of having made suicide plans and suicide preparations at one-week follow-up. Overall, these findings highlight the importance of considering not only physical proximity to suicide means, but also psychological distance, pointing to the potential import of assessing and intervening upon psychological distance during lethal means counseling. Our findings also highlight the potential clinical utility of two brief measures of physical and psychological closeness to suicide means.

A singular case of asphyxia by choking on a handkerchief: accidental event or suicide to "shut-up" spirits.

Choking in adults can prove fatal, despite resuscitation attempts. The manner of death can be natural, homicide or accident. When a death is due to choking, one must consider what conditions contributed to or predisposed the person to choking (eg. alcohol, drugs and physical and mental impairments). Homicidal deaths by choking are relatively uncommon, being more frequently accidental. The diagnosis of death by choking is made at autopsy when the airway is found occluded. If the individual had an occluded airway and the object or food was removed during resuscitation, the only way to make the diagnosis would be on the history. Here, we present a case of asphyxia (accidental or suicidal) by choking on a handkerchief in a patient with a long history of schizophrenia. The woman had attempted a previous suicide driven by evil spirits coming from inside her body, especially from the head and throat; in order to "shut-up" the spirit, she was trying to suffocate it with her hands or by a belt from her pants.

The "choking game": a new craze among Brazilian children and young people. Psychophysiological, behavioral and epidemiological characteristics of 'asphyxial games'. / "Brincadeira do desmaio": uma nova moda mortal entre crianças e adolescentes. Características psicofisiológicas, comportamentais e epidemiologia dos 'jogos de asfixia'.

The 'choking game' is a risk-taking behavior that has spread quickly among children and young people, causing dependence, accidents and even death, including in Brazil. These activities are performed in order to experience fleeting euphoric sensations, attracting numerous participants through the thousands of videos posted on YouTube. The problem of 'asphyxial games' can be observed in the Brazilian digital media, although there is a lack of scientific studies. Through a systematic review of the literature and complementary material, this paper aims to address the 'asphyxial games', warning about the psychophysiological and behavioral effects of these practices, while also presenting international epidemiological data. Sharing this information in academic circles is extremely important given the need to acquire more knowledge on the topic, train professionals and propose preventive measures that raise awareness among children and young people of the potential danger of voluntary fainting. It is equally important to raise awareness among parents and teachers so they can identify the warning signs that children may be engaging in these practices. And finally, it is also necessary to request government support to control exposure to videos that encourage the behavior.

"Brincadeira do desmaio": uma nova moda mortal entre crianças e adolescentes. Características psicofisiológicas, comportamentais e epidemiologia dos 'jogos de asfixia' / The "choking game": a new craze among Brazilian children and young people. Psychophysiological, behavioral and epidemiological characteristics of 'asphyxial games'

Resumo As 'brincadeiras do desmaio' são comportamentos de risco que têm se difundido rapidamente entre crianças e jovens, provocando dependência, acidentes e mesmo mortes, inclusive no Brasil. Estas atividades são realizadas para vivenciarem sensações eufóricas e fugazes, atraindo grande número de adeptos por meio de milhares de vídeos postados no YouTube. A problemática dos 'jogos de asfixia' é observada nas mídias digitais brasileiras, mas carece de estudos científicos. Por meio de revisão sistemática da literatura e de bibliografia complementar, este trabalho objetiva discorrer sobre os 'jogos de asfixia', alertando aos aspectos psicofisiológicos e comportamentais, aos riscos potenciais destas práticas e, também, apresentar dados epidemiológicos internacionais. Compartilhar essas informações no meio acadêmico é de extrema importância dada a necessidade de maiores conhecimentos sobre o tema, de realizar capacitação de profissionais e de propor medidas preventivas que sensibilizem crianças e jovens ao perigo potencial dos desmaios voluntários. Sensibilizar igualmente os pais e professores a atentarem aos sinais decorrentes destas práticas. É também relevante a busca de apoio dos governantes para o controle da divulgação de vídeos incitativos.

Abstract The 'choking game' is a risk-taking behavior that has spread quickly among children and young people, causing dependence, accidents and even death, including in Brazil. These activities are performed in order to experience fleeting euphoric sensations, attracting numerous participants through the thousands of videos posted on YouTube. The problem of 'asphyxial games' can be observed in the Brazilian digital media, although there is a lack of scientific studies. Through a systematic review of the literature and complementary material, this paper aims to address the 'asphyxial games', warning about the psychophysiological and behavioral effects of these practices, while also presenting international epidemiological data. Sharing this information in academic circles is extremely important given the need to acquire more knowledge on the topic, train professionals and propose preventive measures that raise awareness among children and young people of the potential danger of voluntary fainting. It is equally important to raise awareness among parents and teachers so they can identify the warning signs that children may be engaging in these practices. And finally, it is also necessary to request government support to control exposure to videos that encourage the behavior.

Association of adverse childhood experiences with shaking and smothering behaviors among Japanese caregivers.

Shaking and smothering in response to infant crying are life-threatening child abuse. Parental childhood abuse history is known to be one of the most robust risk factors for abusing their offspring. In addition to childhood abuse history, other adverse childhood exposures (ACEs) need to be considered due to co-occurrence. However, few studies have investigated the impact of ACEs on caregivers shaking and smothering their infant. This study aims to investigate the association of ACEs with shaking and smothering among caregivers of infants in Japan. A questionnaire was administered to caregivers participating in a four-month health checkup between September 2013 and August 2014 in Chiba City, Japan, to assess their ACEs (parental death, parental divorce, mentally ill parents, witness of intimate partner violence, physical abuse, neglect, psychological abuse and economic hardship), and shaking and smothering toward their infants (N=4297). Logistic regression analysis was used to examine the cumulative and individual impacts of ACEs on shaking and smothering. Analyses were conducted in 2015. A total of 28.3% reported having experienced at least one ACE during their childhood. We found that only witness of IPV had a significant association with shaking of infant (OR=1.93, 95% CI: 1.03-3.61). The total number of ACEs was not associated with either shaking or smothering. Our findings suggest that shaking and smothering in response to crying can occur regardless of ACEs. Population-based strategies that target all caregivers to prevent shaking and smothering of infants are needed.

Natural death in the setting of autoerotic practice.

Deaths in an autoerotic setting are usually due to accidental asphyxia, in which the individual accidently hangs or strangles themselves while inducing hypoxia for the purpose of heightened arousal. Death occurs when the level of hypoxia causes the individual to lose consciousness and is thus unable to prevent the neck compression from becoming lethal. In some cases there is an "escape" mechanism incorporated into the set-up which may fail. In rare cases, death is not as an immediate result of the autoerotic activity and is as a result of natural causes, which may or may not be related to the process. This case demonstrates the death of a 69 year old male which has occurred in the setting of a complex autoerotic environment, not as a result of asphyxiation, but rather as a result of natural causes which is likely to have been brought about by repeated similar activity. The autopsy revealed pulmonary emboli and lower limb deep vein thrombosis. There was no other natural disease of note and no features considered typical of asphyxiation.

Subjective ratings of prolonged inspiratory resistive loaded breathing in males and females.

Dyspnea and fear of suffocation are burdensome to patients with respiratory disease. Inspiratory resistive loads offer an experimental respiratory stimulus to quantify the discriminative domain of respiratory perception. Resistive (R) load magnitude estimation (ME) and subjective ratings were measured over sustained multiple breaths in healthy subjects. There was no significant group difference between the ME for Breath 1 and 20 for small R loads, but a significant gender difference for large R loads. Subjective responses of fear, fear of suffocation, displeasure, chest pressure, faintness, dizziness, fear of losing control, trembling, and tingling were significantly greater for females. These results demonstrate that ME of large resistive sustained loads elicits nonsignificant increases in ME in females, but a significant decrease in ME for males. The maintenance of ME in females co-occurs with increased aversive processing relative to males.

Induction of dyspnea evokes increased anxiety and maladaptive breathing in individuals with high anxiety sensitivity and suffocation fear.

Although respiratory symptoms are relevant for diagnosis and etiology of panic disorder, anxiety responses and breathing behavior evoked by induction of dyspnea have rarely been studied. Therefore, dyspnea sensations and affective evaluations evoked by inspiratory resistive loads of different intensities were first assessed in 23 individuals with high versus 24 participants with low anxiety sensitivity (AS). High AS participants with high fear of suffocation rated loads of the same physical intensity as more unpleasant and reported more intense feelings of dyspnea and more respiratory and panic symptoms than low AS individuals. In the second experiment assessing physiological responses to physically comparable loads, high suffocation fear participants showed an increase in minute ventilation to compensate for fear-induced air hunger. This ventilation behavior results in increased frequency of dyspnea sensations, thus increasing fear of suffocation.

Shibari: double hanging during consensual sexual asphyxia.

We describe a case of shibari, a double hanging sexual asphyxia practice, which ended fatally for one of the two women involved. We present the autopsy findings and a psychiatric and psychometric evaluation of the surviving participant. The survivor had a borderline personality disorder, had suffered sexual abuse as a child, and had a history of illicit substance consumption, self-harm behavior, and sexual dysregulation. This case study raises doubts regarding the safety measures adopted by participants in masochistic practices and the engagement of people with psychiatric disorders in these extremely dangerous games. Further case studies of living participants in such games are likely to shed light on this practice and facilitate treatment.

Learning to fear obstructed breathing: comparing interoceptive and exteroceptive cues.

The present study investigated interoceptive fear conditioning (IFC) to an interoceptive and exteroceptive conditional stimulus (CS) with a severe respiratory load applied for 30s as the unconditional stimulus (US). CSs were another, weak respiratory load in the intero-IFC study (N=74), and a neutral picture in the extero-IFC study (N=42). CSs preceded the US in the paired groups, whereas the unpaired groups received the same number of unpaired CSs and USs. We measured startle blink EMG, self-reported fear and respiration. In the intero-IFC study, the CS-load was associated with larger startle blinks and a smaller decrease in respiratory rate and tidal volume in the paired compared to the unpaired group. In the extero-IFC study, the CS-picture evoked an increase in tidal volume and self-reported fear only in the paired group. In addition, startle potentiation during the CS-picture was greater for the paired than for the unpaired group.

"I didn't know I could turn colors": Health problems and health care experiences of women strangled by an intimate partner.

Strangulation is a unique and particularly pernicious form of intimate partner violence. To increase the relatively little that is known about strangulation survivors, focus groups and interviews were conducted as part of a practice-research engagement with a domestic violence shelter. All of the participants had been strangled and, among them, almost all were strangled multiple times. The loss of consciousness was common. Participants associated "choking" with use of body parts and "strangling" with use of objects. Although some minimized the assault, most considered strangulation to be serious and reported a variety of medical conditions following the assault. Few sought medical care. Of those who did, few disclosed the assault, or were asked about strangulation, which commonly resulted in misdirected treatment. Implications for improving detection and treatment are discussed.

The effect of a clinically effective and non-effective dose of lorazepam on 7.5% CO2-induced anxiety.

Symptoms of anxiety induced by 7.5% CO2 inhalation can be attenuated by acute administration of GABA(A) receptor anxiolytics such as lorazepam and alprazolam. This study investigated if these effects are dose-related, by comparing a 0.5 mg dose (considered non-clinically effective) and a 2 mg dose of lorazepam (clinically effective) on 7.5% CO2 inhalation. Eighteen healthy males (mean age 20.6 years, SD 1.29), judged physically and mentally fit, attended three visits, each one week apart, to take each treatment in a randomised double-blind crossover design. Drugs were given 60 min prior to 20 min air inhalation, followed by 20 min 7.5% CO2 inhalation. The order of gas presentation was single blind. Subjective ratings using visual analogue scales (VAS) and questionnaires were recorded before and after each inhalation. Blood pressure (BP), heart rate (HR), respiration rate (RR) and expired CO2 were recorded during each inhalation. Inhalation of 7.5% CO2 significantly raised BP, HR, RR and expired CO2. Ratings of feeling like leaving the room were significantly lower on 2 mg compared with 0.5 mg and placebo, and dose-dependent trends were seen in scores for VAS fearful, anxious, stressed, tense, and worried. Results may be indicative of dose-dependent effects of lorazepam in a CO2 model of anxiety.

Sexual asphyxia causing blunt carotid artery injury and Horner's syndrome.

OBJECTIVE: To highlight a rare cause of Horner's syndrome, and to review the management of blunt carotid artery injury. METHOD: Literature search via PubMed for related articles. RESULTS: Horner's syndrome and blunt carotid artery injury are rare phenomena; sexual asphyxia as a cause has not previously been reported. This case is also the first of its kind to have radiological evidence of injury to the external carotid artery but not the internal carotid artery. In Horner's syndrome, additional symptoms of ipsilateral headache or neck pain, tinnitus, or any cerebral ischaemic symptoms should raise suspicion of blunt carotid injury. CONCLUSION: Blunt carotid artery injury is a potentially fatal condition and can present without radiological evidence. Early recognition and management with anticoagulants or antiplatelet drugs is crucial to prevent mortality and morbidity.

Fear of suffocation alters respiration during obstructed breathing.

We aimed to investigate whether fear of suffocation predicts healthy persons' respiratory and affective responses to obstructed breathing as evoked by inspiratory resistive loads. Participants (N = 27 women, ages between 18 and 21 years) completed the Fear of Suffocation scale and underwent 16 trials in which an inspiratory resistive load of 15 cmH(2)O/l/s (small) or 40 cmH(2)O/l/s (large) was added to the breathing circuit for 40 s. Fear of suffocation was associated with higher arousal ratings for both loads. Loaded breathing was associated with a decrease in minute ventilation, but progressively less so for participants scoring higher on fear of suffocation when breathing against the large load. The present findings document a potentially panicogenic mechanism that may maintain and worsen respiratory discomfort in persons with fear of suffocation.

Learning to fear suffocation: a new paradigm for interoceptive fear conditioning.

The present study aimed to establish a new interoceptive fear conditioning paradigm. The conditioned stimulus (CS) was a flow resistor that slightly obstructs breathing; the unconditional stimulus (US) was a breathing occlusion. The paired group (N = 21) received 6 acquisition trials with paired CS-US presentations. The unpaired group (N = 19) received 6 trials of unpaired CS-US presentations. In the extinction phase, both groups were administered 6 CS-only trials. Measurements included startle eyeblink response, electrodermal responses, and self-reported US expectancy. In the paired group, startle blink responses were larger during CS compared to intertrial interval during acquisition and extinction. Electrodermal and US expectancies were larger for the paired than for the unpaired group during acquisition, but not during extinction. The present paradigm successfully established interoceptive fear conditioning with panic-relevant stimuli.