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Patients showing self-mutilation behavior are supposed to be a new group of problematic patients in psychiatric institutions. The theme is presented from an anthropological, phenomenological, nosological and etiological point of view. To understand the genesis we apply biological, behavioristic and psychoanalytical concepts. Finally, using this background therapeutic ideas are discussed.
Central venous catheters are sometimes the cause of life-threatening complications. In two patients with underlying psychiatric disorders we observed an embolism as a result of catheter fragments. The first patient was a 30-year-old woman with a borderline personality disorder and several previous episodes of self-mutilation, psychogenic seizures and disturbances of consciousness. She cut her central venous line positioned in the external jugular vein when she was unattended. The intravasal fragment dislocated into the right ventricle and had to be removed by a forceps used for myocardial biopsies. The second patients was a 34-year-old mentally retarded male with a history of psychomotoric and grand mal seizures who suffered from a prolonged disturbance of consciousness with uncontrolled motor activity after four grand mal seizures. Despite physical restraint, the tip of his central venous catheter inserted through the subclavian vein broke and embolized in the right atrium. The embolus was removed by thoracotomy. To avoid these complications central venous lines should be used only when critically needed in uncooperative patients or those who display disturbance of consciousness and uncontrolled motor activity.
BACKGROUND: Stabbing is an uncommon method of self-harm that has not been previously described in the psychiatric literature. The aim of this study was to describe the clinical features and management of patients presenting with self-inflicted stab injuries. METHOD: Case notes of all patients presenting with deliberate self-inflicted injuries during a 2-year period to a teaching general hospital were screened to identify the sample of interest. Clinical data were then collected by means of a detailed case-note study. RESULTS: Ten patients who deliberately stabbed themselves were identified. The patients fell into two distinct clinical groups: the first consisted mostly of young men with antisocial personalities who were intoxicated at the time of the self-stabbing and who reported ambivalent suicidal intent; the second consisted of psychotic patients, most of whom were actively ill at the time of the self-stabbing, and who reported clear suicidal intent. Patients in the first group were noncompliant with treatment and difficult to engage; those in the second group needed psychiatric hospitalization and often responded to antipsychotic medication. CONCLUSION: Persons who stab themselves tend to fall into two clinical groups that have different diagnoses and management. Distinctions between violent suicidal behavior and self-mutilation are blurred because suicidal intent can be difficult to assess.
Penitentiary medicine combines preventive medicine and treatment which are for the most part carried out in renovated structures. Other than the usual illnesses, these services and their personal are confronted with specific pathologies due to stress, tobacco consumption, insomnia, inactivity, distress, but also hunger strikes and self-mutilation. One particular concern is AIDS and its formidable complications, notably tuberculosis. The important role played by psychiatry and psychotherapeutic support in penitentiary medicine cannot be emphasized enough. Not only are many of the inmates alcoholics or drugs users, many of them are also starved for communication. The Ahens statement (1987), a true codicil of Human Rights, developed by the International Council of Penitentiary Medical Services, formally prohibits doctors to practice any form of torture or experimental medical operations on inmates, and puts medical priority above and beyond any administrative or judiciary considerations. This message is applicable to all prisons, regardless of countries: Europe, the Americas, Africa, Pacific or other. As President of the Council, we have distributed this message throughout the world, to all the various United Nations Agencies, thus teaching Human Rights, including prisoners' rights, in a concrete fashion.
Train suicides have not been widely studied, but this mode of suicide is one which results in high mortality and disfigurement, considerable trauma to bereaved relatives, and often considerable psychological difficulties for those indirectly involved such as train drivers and onlookers. The placement of psychiatric hospitals close to railways and the advisability of erecting barriers have sometimes been hotly debated. This survey of 23 train suicides in Brisbane, Australia, addresses these issues. It shows that 57% of the victims had been treated for schizophrenia, and 57% were also psychiatric inpatients at the time of the incident. Forty eight percent of the deaths occurred close to the regional psychiatric hospital. Fifty two percent were young adults aged 15-29 years. All suicides occurred during daylight or within 2 h of sunset. These results are similar to those from another study in the same city which implicated schizophrenia in jumping from heights--also a grossly self-mutilating behavior. The erection of barriers to reduce mortality from train suicide was not considered a feasible solution for Brisbane, but other cities might benefit from such measures.
The tremendous increase in interest in eating disorders, and especially in bulimia nervosa, that has occurred since the last 1970s has resulted in a large and contradictory literature about the relationships between eating disorders and addictive disorders, especially alcohol and drug abuse. At first sight, according to the differences observed between these disorders in most of their phenomenological characteristics (age, sex, socio-cultural factors), it may seem difficult to draw a parallel between them. However, studies showed that eating behavior problems, alcohol and drug abuse nowadays shared some common features in adolescents and young people. However that may be, epidemiological studies demonstrated a high prevalence of substance abuse among patients with bulimia. In anorexia nervosa, this prevalence seemed to be lower. However, significant differences have been observed between bulimic and restricting anorexics: substance abuse occurred significantly more frequently in bulimic anorexics than in restricting anorexics and this characteristic was associated with a higher prevalence of impulsive behaviors (i.e. stealing, self-mutilation and suicide attempt), laxative or diuretic use and impairments in social relationships. These clinical features are quite similar to those observed in bulimic patients with substance abuse problems. Follow-up studies also showed that substance abuse problems in anorexia nervosa were associated with the occurrence of bulimic behaviors. On the other hand, family studies reported that a high prevalence of patients with bulimia had at least one first degree relatives with substance abuse problems or an affective disorder. In anorexia nervosa, the prevalence of substance abuse or depression among the family members seemed to be higher in bulimic anorexics than in restricting anorexics.(ABSTRACT TRUNCATED AT 250 WORDS)
This article comprises information on self-mutilation (and specifically on the Deliberate Self-harm Syndrome) which obtained from a study of mainly American and British literature. Included is data obtained from interviews conducted with a sample of South Africans suffering from the syndrome. Etiology was explained from both a psychological and biological perspective. The former highlighted deficiencies in coping and communication skills while the latter highlighted the compulsive and pain-killer role that endorphines play. From case studies and literature it was possible to clearly distinguish the Deliberate Self-harm Syndrome as a distinct disorder-a syndrome consisting of deliberate, repetitive and private acts of self-harm in the form of cutting, burning and banging oneself. This culminates in extreme tension release.
Naltrexone, an opioid antagonist recently advocated for the control of stereotypic behavioral patterns in horses and dogs, induced an intense dose-related pruritic reaction in a dog with tail-chasing and self-mutilating behavior. Used in human beings primarily as an adjunct in the treatment of opioid abusers, naltrexone's adverse effects include dermatologic signs, such as alopecia and pruritus, observed in < 1% of human patients. In contrast to previously reported findings, naltrexone treatment was of limited benefit to the dog of this report. During administration of the drug, stereotypic patterns were reduced but did not disappear. Although naltrexone may be effective in controlling certain obsessive-compulsive disorders, its inconsistent therapeutic value, prohibitive cost to pet owners, and side effects such as the pruritus observed in the dog of this report may restrict use of this drug.
Within the group of in-patients the patients exhibiting self-injurious behavior (SIB) have a significantly more disturbed body image--as assessed by the Holtzman Inkblot Technique (HIT)--than the patients who do not have this symptomatology. The more disturbed the body image, the higher the frequency of SIB. The method of self-injury most frequently reported is cutting the skin of the extremities, followed by burning the skin with cigarettes or open flames. This behavior serves the purpose of alleviating diffuse internal tension, of directing aggression inward, i.e. toward the self, and of terminating depersonalization states. During the act of self-mutilation, the perception of pain is lessened appreciably or inactivated. 48 percent of the female patients in this group suffered sexual abuse during childhood.
The Lesch-Nyhan syndrome results from a complete or virtually complete deficiency of the purine salvage enzyme, hypoxanthine guanine phosphoribosyl transferase (HPRT). The disease is characterized by hyperuricemia, choreoathetosis, spasticity, compulsive self-mutilation, and mental retardation. Patients with a partial deficiency of HPRT are spared most of the neurological disorder of Lesch-Nyhan syndrome. The specific relationship between HPRT deficiency and the neurological dysfunction in the Lesch-Nyhan syndrome is not known, at present. The genetic lesion which result in HPRT deficiency are heterogeneous. About 90 different mutations were found in over 110 families. The DNA-based mutation detection technique can be used for the diagnosis of affected males and for the determination of carrier status of asymptomatic females. This technique is also applicable for the prenatal diagnosis for Lesch-Nyhan syndrome. Transgenic mice, deficient in HPRT activity, have been obtained but they do not show any neurological dysfunction. After administration of 9-ethyladenine, however, they showed the self-injury behavior.
A fourteen-month-old girl, who had shown remittent fever frequently from the neonatal period, hypohidrosis, frequent change of face color and self-mutilation of the 1st and 2nd fingers of both hands and tongue in the first months of her life, developed an acute encephalopathy with generalized tonic convulsion outdoors on a sunny hot day. Generalized tonic convulsion subsided within two days, but doll's eye phenomenon, loss of pupillary reaction to light, palpebral myoclonus, and ballismus of arms and legs followed L-dopa showed some effect on the ballismus 1 month after the attack. During the hospital stay, biopsy of sural nerve was performed. Morphometric and ultrastructural studies of the sural nerve demonstrated decreased numbers of unmyelinated and small myelinated fibers. Skin biopsy of the leg revealed sweat glands with no nerve terminals, axons and Schwann cells around them. She was diagnosed as having hereditary sensory and autonomic neuropathy type IV based on the histological and clinical findings. After discharge, bone fracture was found three times without any evidence of trauma. Acute encephalopathy, probably produced in relation to the underlying neuropathy, was considered to be due to heat stroke.
Psittacines embody in an ideal fashion the child-like characteristics that humans adore. Animal lovers are unable to resist their expressive eyes, brightly coloured plumage, tameness and mimicry of human speech. The desire of pet-owners to have a tame, speaking bird with a very strong bond to its owner is achieved through hand-rearing, but this results in psychoreactive behavioural abnormalities in these highly social birds due to abnormal fixation. The signs and causes of these behavioural abnormalities, also called cage neuroses, are explained. The complex of feather-plucking, feather-ingestion and self-mutilation is considered in depth, and there are numerous illustrations.
The prevalence rate of transsexualism varies from 1 to 50,000, to 1 to 100,000. Although it remains an infrequent affliction, transsexualism generates usually major suffering and may be responsible of many complications like suicide, self-mutilations, affective disorders and social disabilities. Since the first descriptions of Esquirol in the nineteenth, the medical community has always been questioned on medical, legal, social or ethical aspects of transsexualism. The aetiology of the trouble is still unknown. In the absence of biological marker, the syndrome of transsexualism can be defined only with clinical criteria. The main differential diagnosis are sexual ambiguities and psychotic disorders. For the specialists, satisfying the patients demand of a surgical and social reassignment still remains the only way to improve their clinical condition and avoid the onset of many dramatic complications. Without any treatment, the evolution of the trouble is chronic, without remission. Longitudinal studies of transsexual patients with a five year follow-up demonstrated subjective improvement in two thirds of the patients and don't find either higher rates of suicides nor psychotic decompensations after surgery and hormonotherapy. Clinical and neuropsychological studies of sexually differentiated cognitive abilities of transsexual patients, before and after hormonotherapy, could allow us in improving the understanding of sexual differences of the brain.
The authors report 20 cases of trauma of the male external genital organs observed over a 10-year period, due to various causes, particularly road accidents, domestic quarrels, and self-mutilation. Lesions of the testis and its appendages were frequent and treatment was usually surgical.
The neurochemical dysfunction present in patients showing self-mutilating behavior (SMB) is not well understood. In animal models, rapid eye movement (REM) sleep deprivation enhances the SMB induced by the chronic administration of d-amphetamine. To understand the mechanism underlying these effects the levels of dopamine (DA), noradrenaline (NA) and serotonin (5-HT) were measured in REM sleep deprived only, and in REM sleep deprived and d-amphetamine treated rats. DA levels were elevated (31%) after REM sleep deprivation (48 h) in the neostriatum and the cerebral cortex (33%), while the levels of NA and 5-HT remained constant. A 6-day treatment with d-amphetamine (7.5 mg/kg; i.p.) failed to affect, in REM sleep deprived rats, DA, NA and 5-HT levels. It was also found that REM sleep deprivation had no effects on the d-amphetamine induced [3H]DA release from slices of the same regions. Our results suggests that dopaminergic mechanisms are involved in the effects of REM sleep deprivation on SMB.
Dermatitis in a breeding colony of black (C57BL/6 Nya) mice was characterized by intense pruritus leading to self-mutilation and death. The cause appeared to be infestation with the mite, Myobia musculi. Ulceration of the skin resulted in exudation of serum proteins and exposure of the animals' immune defenses to microorganisms and irritants, with subsequent hyperplasia of regional lymph nodes and spleen. Affected mice had an increase in sessile plasma cells, serum immunoglobulin concentration, and percent of circulating granulocytes. The mites were eliminated by treatment with a dichlorvos-ronnel combination in liquid form, which was dispensed onto the bedding with an automatic syringe. The incidence of dermatitis was reduced to zero. Our experience with M musculi in two other strains of mice, both white, indicates that pathogenicity of this mite for mice varies according to the strain, sex, age, and individual differences in sensitivity of the mice as well as the mating ratios employed.
OBJECTIVE: To assess the efficacy of clomipramine for treatment of canine compulsive disorder (CCD). DESIGN: Randomized, placebo-controlled, double-blind, balanced AB-BA crossover clinical study. ANIMALS: 51 dogs with CCD. PROCEDURES: Dogs were given clomipramine (3 mg/kg [1.3 mg/lb] of body weight, PO, q 12 h) for 4 weeks and placebo for 4 weeks. At the end of each treatment each owner rated the severity of their dog's behavior, using 2 validated rating scales. Statistical analysis was made by ordinal regression. Compliance, adverse effects, and the effectiveness of masking were also assessed. Each dog's behavior was reevaluated 1 to 2 years after completing the study. RESULTS: Behaviors included spinning (n = 17) and self-mutilation by licking (acral lick dermatitis, 12). Both rating scales demonstrated a treatment effect. Compliance was satisfactory, and masking was effective. Sedation and reduced appetite were reported more commonly when dogs were given clomipramine than when they were given placebo. Forty-five dogs available for follow-up evaluation still had their behaviors; 6 dogs were lost to follow-up evaluation. CLINICAL IMPLICATIONS: Results suggest that clomipramine was effective in dogs with CCD and was not associated with serious adverse effects. However, treatment for 4 weeks was not curative. Behavior modification is likely to be necessary to manage CCD.
OBJECTIVE: Hypoxanthine-guanine phosphoribosyltransferase (HPRT) deficiency is characterized by an increase in renal uric acid excretion, usually with hyperuricemia and may be associated with more or less important neurological symptoms. Based on a series of 20 patients from 16 Spanish families we propose that HPRT deficiency could be clinically classified in four different groups. In the more severe form (classic Lesch-Nyhan syndrome) HPRT deficiency is characterized by choreoathetosis, spasticity, mental retardation and compulsive self-mutilation behavior. The pathophysiology of the neurological symptoms remains unclear and there is no effective therapy. This review is intended to provide a research strategy for a better knowledge of the neurological pathophysiology of HPRT deficiency. DEVELOPMENT: We have analyzed the knowledge on the neurological symptoms of HPRT deficiency. This knowledge comes from histopathological studies of the brains from Lesch-Nyhan patients, chemical studies of the cerebrospinal fluid, experimental animal models (pharmacologic and lesioning and genetic approaches), and human in vivo studies with positron-emission tomography. CONCLUSIONS: The observed findings suggest that the neurological symptoms of Lesch-Nyhan syndrome could be related with the neonatal neuronal and/or dopaminergic terminations damage. This damage could be due to lost or reorganization of dopaminergic system, and is associated with a reduced dopamine levels and with hypersensitivity of the D1 subclass dopamine receptors.