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PubMed2006

Management of borderline personality disorder: a review of psychotherapeutic approaches.

There are currently three major psychotherapeutic approaches to the management of borderline personality disorder (BPD): the psychodynamic, the cognitive-behavioral, and the supportive. There are special varieties within each: e.g., transference-focused psychotherapy (psychodynamic) or dialectic behavioral therapy (cognitive-behavioral). Though differing in basic conceptions and in methodology, all approaches aim at the amelioration of both the symptom-aspects that dominate the clinical picture at the outset, and the personality difficulties that remain apparent after the symptoms have been alleviated. The term "management" implies a focus on the more serious aspects of the borderline picture. These can be pictured hierarchically as to their level of seriousness, and there is universal agreement about the nature of this hierarchy. Therapists must pay attention first to suicidal and self-mutilative behaviors. Next, one deals with any threats to interrupt therapy prematurely. Third in order of seriousness: non-suicidal symptoms such as (mild to moderate) depression, substance abuse, panic and other anxiety manifestations, or dissociation. Psychopharmacological treatment will often be used adjunctively to help control any target symptoms, which usually fall into such categories as cognitive-perceptual, affect dysregulation, or impulsive/ behavioral dyscontrol. Therapists must then be alert to any signs of withholding, dishonesty, or antisocial tendencies, since these have an adverse effect on prognosis. When all these disruptive influences are (to the extent possible) dealt with, therapists will next take up milder symptoms such as social anxiety or lability of mood. Throughout this initial process, the personality-disorder attributes of BPD will become more apparent, and will usually emerge with greater clarity, once the serious symptoms have been dealt with. The management issues will gradually be supplanted with the overlapping and enduring personality issues: inappropriate anger, abrasiveness, manipulativeness, demandingness, jealousy, "all-or-none" thinking and the extreme attitudes (idealization/devaluation) that accompany such thinking, masochistic traits, etc. Under ideal circumstances, the borderline patient will have "graduated" toward a higher level of function, where (acute) management issues have been adequately dealt with or have receded into the background. Psychotherapy, individual and group, becomes the dominant intervention, with such goals as psychic integration, skills training, and the fostering of long-range ambitions relating to friendships, partner choice, and work.

Journal Article↗
PubMed2006

[Penetrating wound of the abdomen. Profile of the suffering patient at Dakar teaching hospital].

INTRODUCTION: In Senegal, the rate of penetrating wound of the abdomen seems to be in great progression. The purpose of this study was to make a descriptive analysis of the epidemiological data on the patient suffering from a penetrating wound of the abdomen. MATERIAL AND METHOD: It is about a retrospective study performed on a 5 years period from January 1997 to January 2002. This study covered 90 cases of penetrating wounds of the abdomen listed at the emergency department of Dakar teaching hospital. The rate, age, sex, responsible agent, circumstances of the wound, place of the injury, evacuation mode, time of admission and check-up injury were studied. RESULTS: The average absolute rate of the penetrating wounds of the abdomen was 18 cases per year. The average age was about 27 +/- 10 years with 88 men for 2 women. The responsible agent was a knife (87%), a firearm (6%), a broken glass (4%), a bullock horn (2%) and a piece of iron (1%). Circumstances of the injury was aggression (91%), accident (6%), self-mutilation (2%), suicide attempt (1%). Evacuation was done by firemen (60%), by the ambulances of the medical structures (22%), and by private individuals (18%). The average time of admission was 5 hours. Nearly 61% of the wounds were located in the umbilical, epigastric, left hypochondre and left side areas. Wound was single in 93,4% of cases and linear in 71,8% of cases. We noted an exit of epiploon (38 cases), peritoneal signs (13 cases) and a small bowel evisceration (9 cases). The treatment was a systematic laparotomy (68%) and a simple closure of the wound with a good follow-up for any further aggravation (32%). CONCLUSION: The patient admitted at the surgical emergency unit of Dakar teaching hospital for penetrating wound of the abdomen is generally a young man, victim of aggression by knife, evacuated by firemen within 5 hours, which present a single and linearwound in perish-umbilical area with exit of epiploon and/or small bowel evisceration, which would undertaken a surgical operation in 68% of cases.

Abdominal Injuries↗
PubMedDate not supplied

Orthopaedic manifestations in congenitally insensate patients.

The spectrum of orthopaedic problems in eight congenitally insensate patients was reviewed. The conditions included congenital insensitivity to pain, Riley-Day syndrome, and Lesch-Nyhan syndrome. In each of these conditions, the patient has an abnormality of interpretation of painful stimuli or lacks normal pain avoidance, leading to self-inflicted damage. The orthopaedic problems and complications included fracture, self-mutilation, autoamputation, osteomyelitis, septic arthritis, Charcot joints, scoliosis, and dislocation. Effective management consists of early diagnosis and patient/parent education to prevent as many complications as possible. Fractures may be treated conservatively, while progressive scoliosis requires operative intervention. Osteomyelitis, septic arthritis, and Charcot joints require appropriate operative treatment.

Adolescent↗
PubMed2006

A retrospective study of idiopathic ulcerative dermatitis in mice with a C57BL/6 background.

Idiopathic ulcerative dermatitis is a well-recognized disease in C57BL mice and related strains. This disease manifests as a pruritic dermatitis with resulting self-mutilation, dermal ulceration, necrosis, and fibrosis. Ulcerative dermatitis has the ability to confound ongoing research by causing systemic pathologic changes, such as lymphadenopathy and splenomegaly. Although various treatments have been described, none has been curative consistently; therefore, minimizing negative effects on research through prevention of disease is ideal. To identify etiologic factors, we conducted a 2-y retrospective study of 1352 mice with a C57BL/6 genetic background; these mice demonstrated an overall prevalence of 4.1% and a seasonal effect with a peak incidence during midsummer. Corroborating previous studies, our study revealed a disease predilection for female mice. In contrast to prior reports, the disease prevalence was greatest in 10- to 16-mo-old mice. In addition, mice with a C57BL/6 background that were deficient in the gene for inducible nitric oxide synthase had a 50% disease incidence, suggesting a potential animal model for further characterizing the pathogenesis, prevention, and treatment of ulcerative dermatitis.

Animals↗
PubMed1991

Emergence and maintenance of stereotypy and self-injury.

A three-level model was used to explain the emergence and maintenance of rhythmic stereotypy and self-injury. Level I represents rhythmic behaviors as internally regulated and common in normally developing infants, but delayed in onset among children with handicapping conditions. Consistent with homeostasis theory, Level II considers stereotypy and self-injury as adaptive responses to under- or overstimulating environments. Level III represents stereotypy and self-injury as learned behaviors emitted to control the behavior of others. The model includes fluid transitions between the levels. Implications for assessment intervention and prevention were discussed and further research suggested.

Arousal↗
PubMed1991

Multiple personality and forensic issues.

As clinicians become more sophisticated regarding MPD, we can expect many more cases to come to the court's attention, especially among violent offenders. This is because violence and MPD have very similar origins in early extraordinary physical and sexual abuse. As offenders become more knowledgeable, we can also expect to encounter more and better malingering. At this time, however, we are far more likely to overlook the problem than we are to overdiagnose it. Why is it that MPD is recognized so infrequently in the offender population? Probably because so many of its characteristics are similar to the symptoms associated with antisocial personality. For example, amnesia for behaviors is dismissed as lying, fugue states appear to be attempts to evade justice; finding things in one's possession looks like stealing; self-mutilation and suicide attempts seem manipulative; and the use of different names at different times and in different circumstances is interpreted as the conscious use of aliases in order to evade the law. Even the dramatic, at times heart-wrenching emotional catharses relating to abuse revealed during hypnosis are so painful that the average person has difficulty accepting that they happened and, therefore, dismisses them as exaggeration or total fabrication. Most often, the diagnosis is missed because the clinician does not even consider it a possibility. In this article we have reviewed some of the ways in which courts have approached the issue of MPD and some of the problems specific to its diagnosis in forensic settings. The clinician must keep in mind that in cases in which issues of mental illness are raised, the law reflects that which it is taught by alleged experts. The case law on multiple personality is still sparse, leaving much room for new data and new interpretations of these data. The current tendency to treat each alternate as though it were a whole and responsible individual as opposed to an imaginary construct, a symptom of a mental illness, reflects the confusion among clinicians as well as attorneys regarding the phenomenon of MPD. As we continue to learn more about the disorder and its forensic implications, we must be careful to avoid presenting to the court clinical impression as fact or mythology as truth.

Diagnosis, Differential↗
PubMed1990

Pharmacological evaluation of SCH-12679: evidence for an in vivo antagonism of D1-dopamine receptors.

The benzazepine compound SCH-12679 has been shown to have clinical efficacy against aggressive behavior in mentally deficient patients. The purpose of the present investigation was to evaluate the potential mechanism of action of SCH-12679. Because of the structural similarity of SCH-12679 to compounds influencing D1-dopamine receptors, even though in vitro studies indicated no direct action on this receptor, investigations focused on the possibility that in vivo SCH-12679 antagonizes the function of this dopamine receptor subtype. After i.p. administration to neonatal-6-hydroxydopamine (6-OHDA)-lesioned rats, SCH-12679 reduced, dose-dependently, the locomotor activity induced by SKF-38393, a D1-dopamine agonist. A dose of SCH-12679 that antagonized the activity induced by SKF-38393 in neonatally lesioned rats also blocked various behaviors observed after administration of this D1-dopamine agonist. SCH-12679 did not alter the activity or behavioral responses induced by quinpirole, a D2-dopamine agonist, when administered to 6-OHDA-lesioned rats. SCH-12679 antagonized the self-mutilation behavior and behavioral responses induced by L-dihydroxyphenylalanine in neonatal-6-OHDA lesioned rats in a manner similar to the prototypic D1-dopamine antagonist SCH-23390 and, like SCH-23390, produced a deficit in avoidance responding in unlesioned rats. SCH-12679 produced a small, transient activation of locomotor activity immediately after administration to neonatal-6-OHDA-lesioned rats that was not observed in unlesioned or adult-6-OHDA-lesioned rats.(ABSTRACT TRUNCATED AT 250 WORDS)

2,3,4,5-Tetrahydro-7,8-dihydroxy-1-phenyl-1H-3-ben↗
PubMed1990

Heterozygous expression of Lesch-Nyhan syndrome clinical and ultrastructural studies.

The study comprised two cases (male & female sibs) from one family, with Lesch-Nyhan Syndrome. They were subjected to clinical evaluation, pedigree construction, uric acid estimation in blood, urates in urine, metabolic screening of blood and urine for amino acids, examination of oral cavity, histological studies of the gingiva by light and electron microscopy as well as buccal smear for Barr & Y bodies (for the female). The proband, a six years old female presented with self-mutilation, mental retardation, hyperactivity and aggression. She had bitten her index finger causing amputation of its distal phalanx. On family study her younger brother (9 months) was found to have increased uric acid and less severe neurologic involvement. The serum uric acid level of the affected female was higher. Her Barr body showed normal pattern. Oral cavity examination showed no abnormalities. Histological examination of the gingiva showed macrophages around the blood vessels. Ultrastructural studies showed more or less normal epithelium. There was collection of macrophages around the blood vessels in the sub-epithelial layer, the cytoplasm of these macrophages contained stippled cytoplasmic inclusions. The surrounding connective tissue showed thin collagen fibers with sharp delineation between the epithelial and connective tissue layers indicating poor quality of collagen. There was no histological difference between the hemizygous male and the heterozygous female. The present study indicates heterozygous expression of Lesch-Nyhan Syndrome at both the clinical and the ultrastructural levels in favour of extreme lyonization or X-chromosome deletion in the affected female. Our findings also indicate that ultrastructural studies could be sensitive indicators of abnormal uric acid metabolism. Further studies are needed to compare the phenotypic expression of hemizygotes and heterozygotes with Lesch-Nyhan Syndrome at both the clinical and ultrastructural levels.

Child↗
PubMed1990

A severe form of breakdown in communication in the psychoanalysis of an ill adolescent.

The paper focuses on a particularly severe kind of breakdown in communication that can arise in the psychoanalysis of ill adolescents who have experienced a real breakdown in functioning, such as a severe suicide attempt or one or more psychotic breakdowns. Clinical material is presented from the analysis of a suicidal and self-mutilating adolescent as an illustration of the theme. Included is a discussion of different types of breakdown in communication.

Adolescent↗
PubMed1986

[Cornelia de Lange syndrome (I) with analgesia].

The case of a boy, observed from 9-17 years of age, with de Lange syndrome is described. The typical symptoms of the de Lange syndrome (brachymicrocephalie, characteristic face, hypertrichosis, typical form of the hand, debility and proportioned shortening) were combined with intensivity to pain and psychomotoric epilepsy. He showed a strikingly aggressive behaviour and simultaneous masochism with self-mutilation as it is typical for analgesia congenita. The autopsy showed cortical heterotopias of the brain and slight microgyria.

Adolescent↗
PubMed1989

[Effects of muscimol on aggressive behaviors induced by clonidine in mice].

A behavioral study was carried out to clarify a relationship between the GABAergic and purinergic central system in aggressive behaviors induced by clonidine in mice. Mice administered a high dose of clonidine (20 mg/kg, i.p.) exhibited aggressive behaviors such as biting and attacking. These behaviors are inhibited by L-PIA (N6-L-phenylisopropyl adenosine) and stimulated by caffeine, which suggest that a blockade of adenosine receptors is involved in these behaviors. Muscimol (0.5-2 mg/kg, i.p.), a GABA-a receptor agonist, not only markedly potentiated clonidine (20 mg/kg i.p.)-induced aggressive behaviors but also elicited characteristic behaviors such as gnawing, reinforced irritability, and self-mutilation. Bicuculline (1, 2 mg/kg, i.p.), a GABA-a receptor antagonist, or picrotoxin (1 mg/kg, i.p.), a chloride channel blocker, did not significantly affect clonidine (20 mg/kg, i.p.)-induced aggressive behaviors. The potentiating effects of muscimol (0.5, 1 mg/kg, i.p.) on clonidine-induced aggressive behaviors were antagonized by bicuculline (1, 2 mg/kg, i.p.), but not affected significantly by picrotoxin (1 mg/kg, i.p.). L-PIA (0.2 mg/kg, i.p.) reduced clonidine-induced aggressive behaviors and also reversed the potentiating effects of muscimol. Stereotyped gnawing behaviors induced by combined treatment of muscimol (0.5, 1 mg/kg, i.p.) and clonidine (20 mg/kg, i.p.) were not affected by bicuculline (2 mg/kg, i.p.). The results suggest that the potentiating effects of muscimol on clonidine-induced aggressive behaviors may be induced via the stimulation of GABA-a receptors, although not necessarily associated with chloride channel functions, and may involve certain interactions between the stimulation of GABA-a receptors and the inhibition of adenosine receptors.(ABSTRACT TRUNCATED AT 250 WORDS)

Aggression↗
PubMedDate not supplied

Alcohol intoxication in teenagers using inhalant stupefacients.

The study was carried out 11 boys, 12-17 years old, treated in the Therapeutic-Educational Guidance Center for the Young because of using inhalant stupefacients and incliniation to alcohol abuse. The inhalant stupefacients were taken for a period of 6 months to three years, of alcohol--from 6 months to 2 years. The most common inhalant stupefacients were "Butapren" glue, trichlorethylene and "Roxy" fluid; wine and vodka were the alcohols used. No one patient displayed the full dependence syndrome, most of them (83%) had organic CNS damage, in 63% pathological EEG changes were recorded. The alcohol inebriation was accompanied by marked psychomotor excitation with cognitive disturbances, aggressiveness, anxiety, self-mutilation. One patient developed visual illusions and hallucinations. The findings suggest that the consequences of abuse of inhalant stupefacients significantly influence the syndrome of alcohol intoxication, potentiating the psychopathological signs.

Adolescent↗
PubMed1989

[A neurologic model of early infantile autism].

Based on the abnormalities in sleep-wakefulness cycle of early infantile autism, the author discussed its pathophysiology focusing on its main lesion in the raphe nuclei. These neurons, located in the midline portion of the brainstem send their axons to various neurons of the upper and lower nervous systems, including the locus coeruleus and the dopamine neurons of the tegmentum, the former having a broad innervation and the latter a restricted area in the central nervous system. These monoaminergic neurons modulate the functions of the involved neurons and regulate their functional and structural maturation in the early developmental course. The early lesion of the raphe nuclei causes poor adaptation to environment which develops as abnormal circadian oscillation and pervasive lack of responsiveness. Combined hypofunction of the locus ceruleus, particularly of its dorsal bundle, results in the failure of extinction of acquired memory in mice which relates clinically to the excellent memory and resistance to change peculiar interests and attachments in humans. From early childhood, the disturbance of dopaminergic neurons becomes apparent clinically, and causes hyperkinesia and stereotyped activities. With the other two monoaminergic neurons, dopaminergic neurons cause occasional aggressiveness or self-mutilation. The latter behaviors are like those of pampered children and are simulated to "muricide" and "friendliness" observed in rats with these monoaminergic lesions. The particular language disturbance with echolalia is due to the right hemispheric dominance, which might have been caused by a delayed functional lateralization of the hemisphere resulting also from the delayed development of the circadian oscillation in infancy. The motor disturbances consisting of hypotonia and impaired locomotion might be due to decreased tonic innervations of the locus ceruleus and the raphe nuclei to the spinal locomotion center. CT examination of symptomatic autism showed the amygdala as one of the causative nuclei for the autistic behavior.

Animals↗
PubMed1977

The Lesch-Nyhan syndrome: a family study.

Two brothers were found to have athetoid cerebral palsy, mental and growth retardation and evidence of self mutilation. One had passed a renal calculus and both had high serum uric acid levels. The diagnosis of Lesch-Nyhan syndrome was confirmed by the finding of low levels of hypoxanthine-guanine phosphoribosyl transferase in erythrocytes and by autoradiography of fibriblasts. The mother, maternal grandmother, a female sibling and a maternal aunt were identified as carriers of the X-linked mutation which was responsible for the enzyme deficiency in the two male siblings.

Allopurinol↗
PubMed1986

The role of the HPRT gene in human disease.

Human HPRT deficiency leads to two major forms of human disease. Partial enzyme deficiency results in gouty arthritis, while an almost complete deficiency leads to the Lesch-Nyhan disease. The latter is characterized by severe neurological dysfunction in addition to gouty arthritis, including retardation, choreoathetosis and aggressive and compulsive self-mutilation. The biochemical basis for the neurological symptoms is not understood. The human and mouse cDNA (RNA copy) genes have been isolated and sequenced. In addition, the amino acid sequence of the human protein has been directly determined. The human and mouse proteins differ at 7 amino acids out of the total, (including the N terminal methionine, which is processed off during maturation) of 218. There are 42 out of 654 nucleotide differences between the human and mouse genes in the amino acid coding region. The mouse genomic structure has been determined. It has 9 exons and 8 introns with a total size of approximately 36 kb. The human gene is very similar with identical intron-exon junction points and approximately the same total gene size. Both mouse and human presumed promotor region at the 5' end, lack a recognizable promotor in the form of a "TATAA" box and are very G-C rich, though not the same. This may be a feature of most "housekeeping" genes. HPRT gene point mutations in three gouty arthritis and one Lesch-Nyhan patient have been identified by peptide sequencing. Six gross gene rearrangements have been identified in Lesch-Nyhan HPRT genes. However it is likely that most mutations are point mutations or small deletions. So far all gene mutations identified are different from all others. The gene has been engineered into retrovirus vehicles which allows its efficient introduction into a wide variety of cells, including mouse marrow stem cells. This may allow treatment of Lesch-Nyhan patients as a model of gene therapy.

Amino Acid Sequence↗
PubMed1989

[Who is left in the institutions? Some problems in connection with the process of deinstitutionalization].

The medical and psychiatric diagnoses of 168 clients aged 16 to 65 years in a Norwegian institution for the mentally retarded were registered together with medication, level of functioning, and types of problem behavior. Most of these clients (64.9%) were profoundly or deeply retarded, and only 6.5% were independent of continuous supervision or help. Medical diagnoses were found in 87.5%, psychiatric diagnoses in 89.1% (DSM-III, axis I). Daily use of medication was found in 81.0% of the clients, and 48.9% used psychotropic drugs on a daily schedule. 58.3% of the clients had exhibited violent behavior during the last year, defined as assaults on persons, self-mutilation or destructiveness. The article discusses the implications of these observations for primary health care, which is expected to supply the necessary service to these clients after 1991.

Adolescent↗
PubMed1988

Assessment of purine-dopamine interactions in 6-hydroxydopamine-lesioned rats: evidence for pre- and postsynaptic influences by adenosine.

Lesch-Nyhan syndrome involves disorders of both purine and dopamine metabolism. Neonatal lesioning of dopaminergic neurons with 6-hydroxydopamine (6-OHDA) has been proposed as a rodent model of the dopamine deficiency in this childhood disorder. In the present studies, the functional interaction between purines and dopamine was examined in adult rats which received 6-OHDA lesions either as neonates or as adults. Even though dopamine levels were decreased by at least 92%, both neonatal- and adult-6-OHDA-lesioned rats had normal hypoxanthine-guanine phosphoribosyltransferase function and purine nucleotide levels (adenosine, ADP, ATP and AMP), indicating that hypoxanthine-guanine phosphoribosyltransferase is not localized only to dopaminergic neurons in striatum. However, the 6-OHDA-lesioned animals were supersensitive to the locomotor activating effects of the adenosine antagonist, theophylline, with the response being greater in adult-6-OHDA-lesioned rats. This effect was presynaptic to dopaminergic neurons as indicated by alpha-methyltyrosine blockade of the theophylline response and its reinstatement by L-dopa. The presynaptic nature of this action of theophylline was supported further by a lack of interaction between theophylline and the direct acting D1- and D2-dopamine agonists, SKF-38393 and LY-171555, respectively. After systemic administration of SKF-38393 or L-dopa, central microinjection of the adenosine agonists, 2-chloroadenosine or 5'-N-ethylcarboxamide adenosine, were effective in preventing self mutilation induced by these dopamine agonists in neonatally lesioned rats. Relative potencies of the adenosine agonists for A1 and A2-adenosine receptors suggested involvement of an A2-adenosine receptor in this action.(ABSTRACT TRUNCATED AT 250 WORDS)

Adenosine↗