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It is estimated that over 6600 children under the age of 16 years are sexually abused each year in England and Wales (NSPCC, 1990). Of these incidents, 78% involve female children and 22% male children. The effects on the child range from self-mutilating behaviour and dissociative disorders to suicide. Consequently, nurses caring for victims of sexual abuse need to be aware of the trauma involved.
BACKGROUND: A paucity of information exists in the dental literature about autism and its dental implications. TYPES OF STUDIES REVIEWED: The authors conducted a MEDLINE search for the period 2000 through 2006, using the term "autism," with the aim of defining the condition's clinical manifestations, dental and medical treatment and dental implications. RESULTS: Autism is a severe developmental brain disorder that appears in infancy, persists throughout life, and is characterized by impaired social interaction, abnormalities in communication (both verbal and nonverbal) and restricted interests. Often accompanying the disorder are behavioral disturbances - such as self-mutilation, aggression, psychiatric symptoms and seizures - that necessitate the administration of multiple medications to help the affected person participate effectively in the educational and rehabilitative process. CLINICAL IMPLICATIONS: Dentists caring for people with autism must be familiar with the manifestations of the disease and its associated features so that they can garner the maximum level of patient cooperation. They also must be familiar with the medications used to treat the associated features of the disorder because many of them cause untoward orofacial and systemic reactions and may precipitate adverse interactions with dental therapeutic agents.
The purpose of this paper was to characterize adolescent borderline personality disorder (BPD) and compare it to adult BPD. A retrospective chart review of 20 adolescent and 20 adult BPD patients was conducted. The retrieved data included demographics, history features, symptoms, observations made during hospitalization and treatments. There were many similarities between the two groups. The differences included the number of report pages during hospitalization (p<0.05), of current self-mutilation (p=0.051), of past and present obsessive-compulsive symptoms (p=0.02 and p=0.03) and of past escapes (p=0.006). Adults had more alcohol abuse (p=0.02). There was a correlation between the number of anti-psychotic drug trials and the length of hospitalization among adolescents, and a correlation between the number of antidepressant and anxiolytic drug trials and the length of hospitalization among adults. Our findings support the general similarity of BPD between adolescents and adults. The differences in pharmacotherapy and several clinical observations warrant further study.
The McLean Study of Adult Development (MSAD) began 12 years ago. It is the first NIMH-funded prospective study of the course and outcome of borderline personality disorder (BPD). After careful analysis of the first six years of follow-up, 5 main findings concerning the symptomatic and psychosocial course of BPD have emerged from this study. The first finding is that remissions are far more common than previously recognized (about 74%). The second is that these remissions are quite stable and thus, recurrences are quite rare (about 6%). The third finding is that completed suicides are far more rare than anticipated (about 4% vs. 10%). The fourth finding is that a "complex" model of borderline psychopathology best describes BPD. In this model, some symptoms resolve relatively quickly, are the best markers for the disorder, and are often the immediate reason for needing costly forms of treatment, such as psychiatric hospitalizations. We termed these symptoms (e.g., self-mutilation, help-seeking suicide threats or attempts) acute symptoms. Other symptoms resolve more slowly, are not specific to BPD, and are closely associated with ongoing psychosocial impairment. We termed such symptoms (e.g., chronic feelings of intense anger, profound abandonment concerns) temperamental symptoms. Fifth, it was also found that borderline patients were improving psychosocially over time, particularly remitted borderline patients; psychosocial functioning of remitted patients continued to improve as time progressed, suggesting that they were somewhat belatedly achieving the milestones of young adulthood and not simply returning to a prodromal level of functioning. Taken together, these results suggest that the prognosis for BPD is better than previously recognized.
Report of a girl with the epileptic, hydrocephalic and encephalitic form of neurocysticercosis, diagnosed by cerebrospinal fluid and computed tomography exams, during her second year of life and an evolution with multiple types of seizures, prolonged periods of intracranial hypertension due to obstruction in the ventriculoperitoneal shunt, psychomotor regression and blindness until she was 10 years old, when the Lennox-Gastaut syndrome was diagnosed. Nowadays the patient is 16 years old and presents complex partial seizures with automatism not completely controlled with clobazan and oxcarbazepine, associated to left spastic hemiparesis, universal hyperreflexia, psychomotor agitation, self-mutilation, amaurosis and severe mental retardation. The association between neurocysticercosis and Lennox-Gastaut syndrome was first described in 1973 by Frochtengarten & Scarante in a Brazilian girl with a similar clinical picture.
An adult, captive-born Sumatran tiger (Panthera tigris sumatrae) had been ataxic for approximately 3 mo and had been self-mutilating after an acute onset of unilateral paresis and Homer's syndrome. Histologic lesions in the cervical spinal cord were consistent with fibrocartilaginous embolic myelopathy (FCEM), and they included the presence of cartilaginous occlusion of spinal blood vessels. This is the first reported case of FCEM in a large felid and specifically a Sumatran tiger.
Some determinants of the reinforcing and punishing properties of timeout were investigated in two experiments. Experiment I began as an attempt to reduce the frequency of tantrums in a 6-yr-old autistic girl by using timeout. Unexpectedly, the result was a substantial increase in the frequency of tantrums. Using a reversal design, subsequent manipulations showed that the opportunity to engage in self-stimulatory behavior during the timeout period was largely responsible for the increase in tantrums. Experiment II was initiated following the failure of timeout to reduce the spitting and self-injurious behavior of a 16-yr-old retarded boy. Using a multiple-baseline design, the nature of the timein environment was shown to be an important determinant of the effects of timeout. When the timein environment was "enriched", timeout was effective as a punisher. A conception of timeout in terms of the relative reinforcing properties of timein and timeout and their clinical implications are discussed.
This report details the experience of two people who suffered a unique type of periodontal atrophy following trigeminal sensory rhizotomy. The cause is unknown but it may be the result of unintentional self-mutilation.
A major depressive episode can be categorised as severe based on depressive symptoms, scores on depression rating scales, the need for hospitalisation, depressive subtypes, functional capacity, level of suicidality and the impact that the depression has on the patient. Several biological, psychological and social factors, and the presence of comorbid psychiatric or medical illnesses, impact on depression severity. A number of factors are reported to influence outcome in severe depression, including duration of illness before treatment, severity of the index episode, treatment modality used, and dosage and duration of and compliance with treatment. Potential complications of untreated severe depression include suicide, self-mutilation and refusal to eat, and treatment resistance. Several antidepressants have been studied in the treatment of severe depression. These include tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), serotonin-noradrenaline (norepinephrine) reuptake inhibitors, noradrenergic and specific serotonergic antidepressants, serotonin 5-HT(2) receptor antagonists, monoamine oxidase inhibitors, and amfebutamone (bupropion). More recently, atypical antipsychotics have shown some utility in the management of severe and resistant depression. Data on the differential efficacy of TCAs versus SSRIs and the newer antidepressants in severe depression are mixed. Some studies have reported that TCAs are more efficacious than SSRIs; however, more recent studies have shown that TCAs and SSRIs have equivalent efficacy. There are reports that some of the newer antidepressants may be more effective than SSRIs in the treatment of severe depression, although the sample sizes in some of these studies were small. Combination therapy has been reported to be effective. The use of an SSRI-TCA combination, while somewhat controversial, may rapidly reduce depressive symptoms in some patients with severe depression. The combination of an antidepressant and an antipsychotic drug is promising and may be considered for severe depression with psychotic features. Although the role of cognitive behaviour therapy (CBT) in severe depression has not been adequately studied, a trial of CBT may be considered in severely depressed patients whose symptoms respond poorly to an adequate antidepressant trial, who are intolerant of antidepressants, have contraindications to pharmacotherapy, and who refuse medication or other somatic therapy. A combination of CBT and antidepressants may also be beneficial in some patients. Electroconvulsive therapy (ECT) may be indicated in severe psychotic depression, severe melancholic depression, resistant depression, and in patients intolerant of antidepressant medications and those with medical illnesses which contraindicate the use of antidepressants (e.g. renal, cardiac or hepatic disease).
Disgust with "fatness" and a consequent preoccupation with body weight, coupled with an inability to reduce it to or sustain it at the desired low level, characterizes the abnormal normal weight control syndrome. Individuals remain sexually active in a biological sense and often also socially. Indeed their sexual behaviour may be as impulse ridden as is their eating behaviour, which often comprises phases of massive bingeing coupled with vomiting and/or purgation. The syndrome is unlike frank anorexia nervosa in that the latter involves a regression to a position of phobic avoidance of normal body weight and consequent low body weight control with inhibition of both biological and social sexual activity. In abnormal normal weight control there is a strong and sometimes desperate hedonistic and extrovert element that will often not be denied so long as body weight does not get too low. Individuals nevertheless feel desperately "out of control" and insecure beneath their bravura. The syndrome is much more common in females than in males. There is a clinical overlap with anorexia nervosa and obesity in many cases as the disorder evolves. Depression, stealing, drug dependence (including alcohol) and acute self-poisoning and self-mutilation are common complications. Clinic cases probably only represent the tip of the iceberg of the much more widespread morbidity within the general population. Like anorexia nervosa and for the same reasons the disorder is probably more common than it used to be.
OBJECTIVE: To assess the use of a caudal external thoracic artery axial pattern flap to treat sternal cutaneous wounds in birds. ANIMALS: 16 adult Japanese quail. PROCEDURE: A cutaneous defect in the region of the mid-sternum was surgically created in all quail. In 6 quail (group I), an axial pattern flap was created from the skin of the lateral aspect of the thorax and advanced over the sternal defect. In 8 quail (group II), a flap was similarly created and advanced but the flap vasculature was ligated. All quail were euthanatized at 14 days after surgery and had necropsies performed. Sections of the flap and the surrounding tissue were examined histologically to assess flap viability. RESULTS: All axial pattern flaps in group-I quail had 100% survival. In group II, mean percentage area of flap survival was 62.5%; mean area of necrosis and dermal fibrosis of flaps were significantly greater than that detected in group I. In flaps of group-II quail, neovascularization in the deep dermis and profound necrosis of the vascular plexus in the superficial dermis were observed. CONCLUSIONS AND CLINICAL RELEVANCE: Results indicated that the caudal external thoracic artery axial pattern flap could be used successfully in the treatment of surgically created sternal cutaneous defects in quail with no signs of tissue necrosis or adverse effects overall. Use of this technique to treat self-mutilation syndromes or application after surgical debulking of tumors or other masses might be beneficial in many avian species.
OBJECTIVE: To determine whether cats develop clinical signs typical of separation anxiety syndrome (SAS) and the type and frequency of applicable clinical signs in affected cats. DESIGN: Retrospective study. ANIMALS: 136 cats with clinical signs typical of SAS in dogs. Subjects were evaluated during home visits. PROCEDURE: Medical records of pet cats evaluated for behavior problems during a 10-year period were reviewed. Medical records of cats that displayed behaviors typical of dogs with SAS (eg, inappropriate elimination, excessive vocalization, destructiveness, or self-mutilation) were more extensively examined, and cats that displayed these behaviors only when separated from an apparent attachment figure were included in the study. RESULTS: Behavior problems triggered by separation anxiety included inappropriate urination (96 cats), inappropriate defecation (48), excessive vocalization (16), destructiveness (12), and psychogenic grooming (8). Inappropriate defecation was identified in a significantly higher percentage of the neutered females in the study than in the neutered males. Seventy-five percent of the cats that urinated inappropriately urinated exclusively on the owner's bed. Psychogenic grooming was identified in 8 of the 40 neutered females but in none of the neutered males, whereas destructiveness was observed in 12 of the 92 neutered males but in none of the neutered females. CONCLUSIONS AND CLINICAL RELEVANCE: Results suggest that cats can develop SAS. Sex and breed differences in the frequency of particular signs of SAS in cats may exist. Feline SAS should be considered in the differential diagnosis of anxiety-related misbehavior in cats.
The last two decades have seen rapid changes in many facets of Aboriginal society, including morbidity and mortality. The same period has witnessed a dramatic increase in writing about and by Aborigines and this has necessitated a re-examination of the national "history" to include the indigenous people of Australia. Medical workers in Aboriginal Australia should be alert to the historical forces determining patterns of ill-health. Psychiatry in particular must develop this perspective if it is to participate with Aborigines in addressing emergent patterns of behavioural distress including suicide, parasuicide, ludic behaviour and self-mutilation. This paper demonstrates the importance of the socio-historical frame in the examination of these behaviours from one discrete region in isolated Aboriginal Australia: the Kimberley.
A 22 year old female-to-male half-Aboriginal transsexual had been exposed to gross neglect and violence, separation and inconsistent cultural supports during childhood. Her mother had also been convicted of homicide in a context of alcohol and violence. Transsexual identification, antisocial behaviours, self mutilation, substance abuse and unmet dependency needs were evident from childhood or early adolescence. The killing was a confrontational peer group stabbing in a brawl under influence of alcohol--the male mode of homicide. This is the first known case in world literature of a female-to-male transsexual guilty of homicide.
OBJECTIVE: The present study investigated the relationship of characteristics of childhood sexual abuse and subsequent psychopathology. METHOD: Referrals to a female psychiatrist in private practice in an urban working class area provided 73 adult female subjects who reported having been sexually abused in childhood. Data were collected on age at onset, duration, physical invasiveness of the abuse, violence, and the number and relationship of abusers. RESULTS: Having had multiple abusers in childhood was significantly (p < 0.01) associated with every outcome measure of severe psychopathology: an initial Global Assessment Functioning score of 50 or below; both single and repeated incidents of deliberate self-harm; overdose; self-mutilation; and psychiatric hospital admission. CONCLUSIONS: Notably, having had multiple abusers was the only characteristic showing a reliable independent association with any of these measures. Subjects who had had multiple abusers were significantly more likely to have an earlier age of onset and longer duration of abuse, and to have experienced violent abuse.
A small group of patients is reported in whom amputation or re-amputation of the upper or lower limb has been performed at increasingly higher levels in an unsuccessful attempt to relieve the patients' unrecognized chronic pain syndrome. The possibility of self mutilation should also be considered. The etiological factors and management of this uncommon but difficult problem are discussed. It is hoped that members of an experienced amputee team will recognize this rare problem and help to avoid multiple surgical procedures, which are harmful to the patient and costly to society.
Affective dysregulation, impulsivity and cognitive-perceptual difficulties are the psychopathological nuclear dimensions of Borderline Personality Disorder (BPD). Psychopharmacological treatment may become necessary during episodes of acute decompensation in which suicidal or self-destructive behaviour erupts. Some classes of psychotropic drugs have demonstrated efficacy in diminishing symptom severity and optimising functioning, such as antidepressants, mood stabilizers, benzodiazepines, opiate antagonists and antipsychotics. Conventional antipsychotics are the best-studied psychotropic medications for BPD, but nonadherence is often due to their severe side effects. Preliminary data reveal efficacy of atypical antipsychotics in BPD. We describe the impact of the novel antipsychotic drug quetiapine on severe self-mutilation in two female patients with the diagnoses of BPD. In both cases, monotherapeutic treatment with quetiapine was well tolerated and resulted in a marked improvement of impulsive behaviour and, over time, overall level of function. Though promising, our findings have to be regarded as preliminary. Due to the overall paucity of data there still is insufficient evidence to make a strong recommendation concerning continuation and maintenance therapy with atypical antipsychotics in BPD. Thus, there is a clear need for further controlled studies to evaluate pharmacological treatment options for this disorder.
Simple continuous closure of scrotal urethrostomy in 20 dogs is described. Mean duration of postoperative active bleeding and mean duration of bleeding only associated with urination were 0.2 day and 3.1 days, respectively. Long-term complications were minimal; intermittent urine scald (n = 2), recurrent urinary tract infections (n = 2), and recurrent obstruction due to struvite stones (n = 2) developed after surgery. All complications resolved with medical therapy (n = 4) or by cystotomy (n = 2). None of the dogs had complications due to wound dehiscence, stricture, incisional infections, self-mutilation, or incontinence. Follow-up ranged from two to 52 months (mean, 25.2 months). This technique is a viable alternative to previously reported closure methods.