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PubMed1997

Childhood antecedents of self-destructiveness in borderline personality disorder.

OBJECTIVE: To assess the relationship between lifetime patterns of self-destructive behaviour and various parameters of childhood abuse and neglect in patients with borderline personality disorder (BPD) compared with other personality disorder (OPD) controls. METHOD: The subjects were 42 inpatients with the diagnosis of BPD and 17 OPD controls. Lifetime patterns of self-destructive behaviour were assessed using the Lifetime Borderline Symptom Index. Childhood experiences were assessed using a semistructured interview by raters who were blind to diagnosis. RESULTS: Chronic self-destructive behaviour discriminated patients with BPD from OPD controls. In the borderline group, parental sexual abuse was significantly related to suicidal behaviour and both parental sexual abuse and emotional neglect were significantly related to self-mutilation. CONCLUSION: Both parental sexual abuse and emotional neglect appear to play a role in the etiology of self-destructive behaviour in BPD. The results highlight the importance of considering the effects of sexual abuse within its environmental context and suggest that the etiology of borderline symptoms is likely multifactorial.

Adolescent↗
PubMedDate not supplied

[Study of the relationships between self-injurious behavior and pain reactivity in infantile autism].

Autism can be considered as an early general developmental disorder, characterized by problems of social interaction, problems of verbal and non verbal communication, and behavioral or ideational stereotypes. However, within autism we observe a clinical heterogeneity of autistic disorders which suggests the possibility of autistic subtypes. Several authors hypothesize an analgesia among autistic children; this analgesia may be related to self-mutilation found among autistics. The current research had two objectives: 1) to develop and validate evaluation tools for measuring aggression directed towards the self (Yale-Paris Self-Injurious Behavior Scale: YAPA SIB) and pain reactivity (Pre-Linguistic Behavioral Pain Reactivity Scale: PLBPRS); instruments appropriate for autistics and capable of showing different behavioral sub-types; 2) to study in 80 autistic children pain reactivity, self-injurious behavior, and their relation in different observational situations. The results show that the scales of self-injurious behavior and pain reactivity have good discriminative capacity, good test-retest reliability, and good validity. The results suggest additionally that the apparent decreased pain reactivity observed in autistics does not derive from a real analgesia but from a different mode of pain expression related to difficulties with verbal communication, body representation and certain cognitive disorders (learning disorders, problems representing sensations and emotions, problems establishing cause-effect relationships). Additionally, there is a significant relationship between certain self-injurious behaviors and the apparent reduced pain reactivity. Interpretations of this result are presented and the possible role of stress in autism is discussed.

Autistic Disorder↗
PubMed1994

Trauma and the development of borderline personality disorder.

Prolonged and severe trauma, particularly trauma that occurs early in the life cycle, tends to result in a chronic inability to modulate emotions. When this occurs, people can mobilize a range of behaviors that are best understood as attempts at self-soothing. Some of these attempts include clinging and indiscriminate relationships with others in which old traumas are re-enacted over time, as well as more self-directed behaviors such as self-mutilation, eating disorders, and substance abuse. Usually, these behaviors will coexist. Patients with complicated trauma histories often repetitively attempt suicide or engage in chronic self-destructive behavior, and need to address issues of childhood trauma, neglect, and abandonment, both in the past and as re-experienced in current relationships. When treating these patients, therapists must anticipate that painful affects related to interpersonal safety, anger, and emotional needs may give rise to dissociative episodes, which may, in turn, be accompanied by increased self-destructive behavior. The therapy must clarify how current stresses are experienced as a return of past traumas and how small disruptions in present relationships are seen as a repetition of prior abandonment. As part of this, it is essential that the therapist provide validation and support, and avoid participating in a re-enactment of the trauma. Fear needs to be tamed in order for people to be able to think and be conscious of current needs. This bodily response of fear can be mitigated by safety of attachments, security of meaning schemes, and by a body whose reactions to environmental stress can be predicted and controlled. One of the great mysteries of the processing of traumatic experience is that as long as the trauma is experienced as speechless terror, the body continues to keep score and react to conditioned stimuli as a return of the trauma. When the mind is able to create symbolic representations of these past experiences, however, there often seems to be a taming of terror, a desomatization of experience. As Ducey and van der Kolk found in the Rorschachs of Vietnam veterans, patients were unresponsive to outside influences (good or bad) as long as they remained in a state of psychic numbing. Faced with intrusions of past trauma in their current emotional life, patients' initial sense of being overwhelmed was mastered only when a link between past trauma and current perceptions became understood.(ABSTRACT TRUNCATED AT 400 WORDS)

Borderline Personality Disorder↗
PubMed2005

Suicide after deliberate self-harm: a 4-year cohort study.

OBJECTIVE: The purposes of this study were to estimate suicide rates up to 4 years after a deliberate self-harm episode, to investigate time-period effects on the suicide rate over the follow-up period, and to examine potential sociodemographic and clinical predictors of suicide within this cohort. METHOD: This prospective cohort study included 7,968 deliberate self-harm attendees at the emergency departments of four hospital trusts in the neighboring cities of Manchester and Salford, in northwest England, between September 1, 1997, and August 31, 2001. Suicide rates and standardized mortality ratios (SMRs) for the cohort were calculated. Potential risk factors were investigated by using Cox's proportional hazards models. RESULTS: Sixty suicides occurred in the cohort during the follow-up period. An approximately 30-fold increase in risk of suicide, compared with the general population, was observed for the whole cohort. The SMR was substantially higher for female patients than for male patients. Suicide rates were highest within the first 6 months after the index self-harm episode. The independent predictors of subsequent suicide were avoiding discovery at the time of self-harm, not living with a close relative, previous psychiatric treatment, self-mutilation, alcohol misuse, and physical health problems. CONCLUSIONS: The results highlight the importance in a suicide prevention strategy of early intervention after an episode of self-harm. Treatment should include attention to physical illness, alcohol problems, and living circumstances. Self-harm appears to confer a particularly high risk of suicide in female patients.

Adolescent↗
PubMed2004

Clinical forensic medicine and its main fields of activity from the foundation of the German Society of Legal Medicine until today.

The fields mainly covered by clinical forensic medicine are subject to time-related changes which are described on the basis of the German literature of the 20th century. Some fields of forensic sexual medicine (diagnosis of virginity, proof of criminal abortion, potentia coeundi, potentia generandi, potentia concipiendi) have become less important in the daily work of medicolegal institutes, whereas victims of rape and sexual abuse continue to form a major part of the forensic examination material in the German-speaking countries. The evaluation of suspected physical child abuse has grown in importance since the 60s, and it is essentially the merit of Elisabeth Trube-Becker that this problem is now dealt with also in scientific medicine. More recently, medicolegal experts are increasingly confronted with further groups of persons: victims of domestic violence, abused/neglected seniors, refugees from countries where torture is used. A new special field, which established itself only in the 90s, is the estimation of age with regard to the criminal responsibility of suspects who have no identity papers or pretend to have none. A phenomenon frequently observed in the last two decades is the non-accidental self-infliction of injuries. Whereas in the first half of the 20th century the motive for self-mutilation was typically to evade military service, this category of injury was later mainly seen in the context of insurance fraud; more recently most forensically relevant self-inflicted injuries refer to simulated offenses (fictitious sexual offenses and robbery, attacks allegedly having a political background). One of the traditional fields of clinical forensic medicine continues to be the evaluation of victims and suspects following bodily harm and attempted homicides. In the field of civil law medicolegal experts are particularly often concerned with controversial consequences of traffic accidents (e.g. alleged whiplash injuries after rear-end collisions at low velocities).

Accidents, Traffic↗
PubMed1989

The study of suicidal behavior in the schools.

The studies reviewed indicate that suicidal behavior is infrequent among school children (12%), but increases progressively among junior high (35%), high school (65%), and college students (50-65%). Though considerable, these values are lower than those of similar-age psychiatric populations. Estimates of the rate of actual attempts were 3% for elementary students, 11% for high school students, and 15-18% for college students. Most were low-lethality attempts for which medical or other attention was not sought. Accordingly, the vast majority of suicide attempts will not be uncovered by investigations dealing solely with clinical or medically identified populations. The most commonly identified correlates of suicidal behaviors included depressive symptoms, social problems, family disorganization and problems, life stress, and poor problem-solving skills. Academic problems were not as important. These findings must be interpreted in light of methodological constraints. Response rates have been low, samples have been small, minorities have been underrepresented, nonstudents have been ignored, and volunteers of unreported characteristics have predominated. The representativeness of such groups is questionable. The definition and categorization of behaviors have varied considerably, making between-study comparisons difficult. The differences among thoughts, threats, and attempts (the most frequently used categories) have often not been taken into account. Rather, in analyses, these behaviors have been treated as if they were homogeneous entities and grouped together. Where attempters have been separated from ideators, they too have been treated as a single entity. Many deliberately survived attempts are manipulative and oriented toward the benefits the individual survivors expect. Such attempts probably differ substantially in nature from those attempts where survival is not intended. Understanding of this phenomenon could be enhanced by a comparison of the characteristics of those with high- and low-lethality attempts. Similarly, a third group of behaviors--that of chronic behavior patterns that potentially hasten death (alcoholism, drug abuse, self-mutilation, and risk taking)--has not been adequately addressed in terms of its relationship to more discrete suicidal events. Data have generally been obtained via anonymous self-administered questionnaires. The accuracy of retrospective self-reports on emotionally laden events is suspect. Only in two instances have self-reported questionnaire data been validated via interviews with subjects alone or subjects and their families. The time frames on which the referent behaviors has been collected have included "last week", "last month", "last year", "lifetime", and not specified. The longer the interval between the occurrence of the behavior and the report, the greater the likelihood that some reporting inaccuracies may occur.(ABSTRACT TRUNCATED AT 400 WORDS)

Adolescent↗
PubMed1994

Multiple personality: self-rape.

Multiple personality disorder is the classification given a person for whom two or more distinct personalities are diagnosed. The personalities can be different and vary in character from aggressive to submissive (victimized). The victim alters can be abused and abuse or mutilate self to relieve anxiety or guilt (deserving punishment) or to exert control. Alters may provide a means of expressing anger or other feelings. Aggression towards the body may be sexually oriented, so one may ask whether aggression could make self-rape possible. If so, such expression of self-injuries may be observed in a person with multiple personality as when one alter may injure another. Clinical case material is presented on this concept for a woman who had been formally diagnosed with multiple personality disorder.

Adult↗
PubMedDate not supplied

Autoextraction in an autistic dental patient: a case report.

This is a case report of a 21-year-old male patient with autism who sought treatment at a General Practice Residency clinic for dental treatment following the autoextraction of several teeth. A review of autism and self-mutilation is presented.

Adult↗
PubMed2000

Self-surgery: removal of ankle surgical implants--A case report.

Self-surgery is rare, but numerous cases of self-mutilation are reported in the literature (eg, castration, enucleation of an eye, and amputation of a limb).[1] We have found no previous reports in the literature of a patient who has performed self-surgery to remove fracture fixation implants.

Adult↗
PubMed2006

Lesch-Nyhan disease in a 20-year- old man incorrectly described as developing 'cerebral palsy' after general anaesthesia in infancy.

Lesch-Nyhan disease (LND) is a rare X-linked recessive genetic disorder caused by a deficiency of hypoxanthine-guanine phosphoribosyltransferase (HPRT) enzyme. The classic clinical condition is characterized by cognitive impairment, hypotonia at rest, choreoathetosis, hyperuricaemia and the hallmark symptom of severe and involuntary self-mutilation. We describe a man with LND who was initially thought to have suffered from a dyskinetic cerebral palsy after an uncomplicated inguinal herniorrhaphy under general anaesthesia at 5 1/2 months of age. In the absence of overt self-injurious behaviour, the diagnosis was not considered for nearly two decades. The diagnosis of LND was established at 20 years of age through clinical review, biochemical examinations and molecular analysis. HPRT haemolysate activity was 7.6% of the normal control, suggesting that he had a milder variant of the disease. Mutation analysis of the HPRT gene revealed a novel missense mutation, c.449T > G in exon 6 (p.V150G). Cascade testing of family members revealed that the mother was heterozygous for the mutation but two siblings (a brother and a sister) did not carry the sequence mutation. Whether the onset of neurological abnormalities in this particular case can be attributed to the general anaesthesia is discussed.

Adult↗
PubMed2005

The implications of attachment theory and research for understanding borderline personality disorder.

Borderline personality disorder (BPD) is a highly prevalent, chronic, and debilitating psychiatric problem characterized by a pattern of chaotic and self-defeating interpersonal relationships, emotional lability, poor impulse control, angry outbursts, frequent suicidality, and self-mutilation. Recently, psychopathology researchers and theorists have begun to understand fundamental aspects of BPD such as unstable, intense interpersonal relationships, feelings of emptiness, bursts of rage, chronic fears of abandonment and intolerance for aloneness, and lack of a stable sense of self as stemming from impairments in the underlying attachment organization. These investigators have noted that the impulsivity, affective lability, and self-damaging actions that are the hallmark of borderline personality occur in an interpersonal context and are often precipitated by real or imagined events in relationships. This article reviews attachment theory and research as a means of providing a developmental psychopathology perspective on BPD. Following a brief review of Bowlby's theory of attachment, and an overview of the evidence with respect to the major claims of attachment theory, I discuss individual differences, the evidence that these differences are rooted in patterns of interaction with caregivers, and how these patterns have important implications for evolving adaptations and development. Following this discussion, I present recent work linking attachment theory and BPD, focusing on the implications for understanding the etiology and treatment of BPD. In conclusion, I address some of the salient issues that point to the direction for future research efforts.

Adolescent↗
PubMed1993

Futility of muscle flaps for self-inflicted wounds.

Unacceptable forms of self-mutilation usually are resistant to surgical intervention and have a basis in psychopathology. Establishing this diagnosis may be as difficult as is the treatment, frequently involving a prolonged process of exclusion of other known disease entities. Management of these chronic self-inflicted wounds demands flexibility by the surgeon who must be aware of this possibility and willing to deviate from the normal approach to wound healing. Simplicity is of paramount importance. The use of vascularized tissues and, in particular, the sacrifice of scarce muscle flaps probably is unwarranted except as a last resort because these wounds nevertheless remain recalcitrant to permanent healing. Instead, a nonconfrontational approach with long-term psychotherapy should be a major part of the initial therapy with surgery considered only important in an adjunctive role.

Adolescent↗
PubMed2007

[Psychotherapeutic day treatment of patients with severe personality disorders. Results from the first two years].

INTRODUCTION: A psychotherapeutic day treatment (DT) for patients with severe personality disorders (PD) was established in January 2003, consisting of five months of intensive psychodynamic based integrated therapy for 14 patients. This paper presents results from the first two years. MATERIAL AND METHODS: 53 patients were included in a five month combined group psychotherapeutic DT, including psychoeducation, cognitive, body, music/drawing and individual therapy. Semi-structured interviews were used to assess diagnosis (PSE, SCID-II). SCL-90-R, self-rating scales and GAF rating (s/f) were used before and after therapy. The design was naturalistic. RESULTS: 40 patients (34 women) completed the DT. Eight dropped out and five received another treatment. Before treatment: Average age 27(SD 6,5), mean GAF= 43 corresponding with unemployment, singles and social dysfunctions, high degree of self mutilation, suicide attempts, earlier hospitalisations and substance abuse. The most frequent diagnosis was borderline disorder 63%. There were co-morbidity with anxiety disorder 48% and depression 22%. Most importantly, we found a significant reduction in symptoms, significant increase in the level of function, reduction in self destructive behaviour, a pronounced reduction in hospitalisations and a relatively high degree of satisfaction with the treatment programme. CONCLUSION: According to literature, effective treatment of patients with severe PD has to be long term, integrated, theoretical coherent and focused on compliance. Our study indicates that the intensive DT is effective and a good introduction to long term psychotherapy.

Adult↗
PubMed1979

Effects of food deprivation on etonitazene consumption in rats.

One group of free-feeding rats was given a 5 microgram/ml etonitazene HCl solution as their sole liquid. This group increased their drug intake by 100% when they were partially food-deprived during a 23-day period. Another group that remained food-satiated and received etonitazene for an equal number of days did not show similar increases in drug intake. However, this group drank greater volumes of the etonitazene solution than a food-satiated control group drank of water. These results are contrasted with a fourth group showing a 50% decrement in water intake during similar food-deprived conditions. The food-deprived group drinking etonitazene showed highly erratic drinking patterns compared to all the other groups. Daily liquid intake ranged from 30 to 250 ml in this group, and volumes oscillated from high to low on alternating days. When the food-deprived/food-satiated conditions were replicated in this experimental group, corresponding increases and decreases in drinking reliably occurred. However, during the second food-deprived phase, the large increases occurred almost immediately as contrasted with a gradual increase over 17 days during the first food-deprived phase. This would suggest a learning mechanism may be involved. Self-mutilation and other forms of stereotypy were noted only in food-deprived rats consuming etonitazene.

Animals↗
PubMed1996

HPRT-APRT-deficient mice are not a model for lesch-nyhan syndrome.

Complete hypoxanthine-guanine phosphoribosyl-transferase (HPRT) deficiency in humans results in the Lesch-Nyhan syndrome which is characterized, among other features, by compulsive self-injurious behavior. HPRT-deficient mice generated using mouse embryonic stem cells exhibit none of the behavioral symptoms associated with the Lesch-Nyhan syndrome. Administration of drugs that inhibit adenine phosphoribosyltransferase (APRT) in HPRT-deficient mice has produced the suggestion that deficiency of APRT in combination with HPRT-deficiency in mice may lead to self-mutilation behavior [C.L. Wu and D.W. Melton (1993) Nature Genet. 3, 235-240]. To test this proposition, we bred HPRT-APRT-deficient mice. Although the doubly-deficient mice excrete adenine and its highly insoluble derivative, 2,8-dihydroxyadenine, which are also associated with human APRT deficiency, additional abnormalities or any self-injurious behavior were not detected. Thus, APRT-HPRT-deficient mice, which are devoid of any purine salvage pathways, show no novel phenotype and are not a model for the behavioral abnormalities associated with the Lesch-Nyhan syndrome as previously suggested.

Adenine Phosphoribosyltransferase↗
PubMed1993

Naltrexone and fluoxetine in Prader-Willi syndrome.

The case discussed is of a 9-year-old boy with a diagnosis of Prader-Willi, compulsive eating, severe skin picking, mild mental retardation, and behavioral problems. Prehospital, hospital, and posthospital course is reviewed. An approach using fluoxetine and naltrexone shows a marked improvement in weight control, skin picking, and behavior. Obesity and self-mutilation are discussed with regard to the use of fluoxetine and naltrexone.

Child↗
PubMed1994

Harakiri: a clinical study of deliberate self-stabbing.

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.

Adolescent↗
PubMed2006

The relationship of suicide attempt history with childhood abuse and neglect, alexithymia and temperament and character dimensions of personality in substance dependents.

The aim of this study was to evaluate the prevalence of suicide in Turkish male substance dependents, and to investigate the relationship of suicide attempt history with childhood abuse and neglect, alexithymia, and temperament and character dimensions of personality. Participants were 154 consecutively admitted male substance dependents. Patients were investigated with the Childhood Abuse and Neglect Questionnaire, Toronto Alexithymia Scale (TAS-20) and Temperament and Character Inventory (TCI). Among substance-dependent patients, 28.6% was considered a group with suicide attempt history (SAH). Current age was lower and rate of being single was higher in the group with SAH. There were no significant differences between groups in terms of employment, educational status and duration of education. Rates of physical, emotional abuse and neglect, self-mutilation and being alexithymic were higher and ages at first substance use and regular substance use were lower in the group with SAH. Mean scores of "difficulty in identifying feelings" (DIF) and "difficulty in describing feelings" (DDF) subscale EOT of the TAS-20 were higher in the SAH group. Among temperament and character dimensions of the TCI, only "Self-directedness" and "Cooperativeness" were lower in SAH and there were no significant differences between groups in terms of other subscales. Age and Self-directedness score of TCI were determinants for suicide attempt. In particular, young drug users with low Self-directedness scores could be the target population in order to prevent suicidal behavior. This study also suggests that in substance-dependent patients, in the background of all suicidal behavior, childhood abuse and neglect must be evaluated.

Adult↗