Artefactual skin disease in children and adolescents

As in adults, artefactual skin disease in children and adolescents has heterogenous presentations with multifactorial aetiology. We report a series of 32 young patients aged 8-16 years. There were 24 females and 8 males. In over half of the cases the lesions were on the head and neck. The types of lesions encountered included physical injury producing grazing, erosions and deep ulcers, chemical and thermal burns, hair cutting and shaving and skin painting. We discuss the approach that we believe should be taken with these patients, emphasizing the role of dermatology-psychiatry liaison in their management. Of great importance is the avoidance of confrontation of the patient but the clear exposition of the nature of the problem to the parents. The major aim should be to have the family accept the need for expert psychiatric assistance.

[Rectal self-mutilation, rectal bleeding and Prader-Willi syndrome]

Prader-Willi syndrome is a genetic disorder characterized by infantile hypotonia, obesity, hypogonadism and mental retardation. Individuals with Prader-Willi syndrome manifest a severe skin picking behavior, including rectal picking.

CASE REPORT

We report the case of a girl (12 years old) with this syndrome in whom rectal picking resulted in rectal bleeding and solitary rectal ulcer.

CONCLUSION

Caregivers of children with Prader-Willi syndrome should be aware of a potential rectal picking behavior, which results in significant bleeding. Early recognition of such a behavior helps to avoid misdiagnosis.

Dialectical Behavior Therapy for Patients With Borderline Personality Disorder

This study examined the effectiveness of dialectical behavior therapy (DBT) in the treatment of people diagnosed with borderline personality disorder (BPD). The frequency of self-injurious behaviors of 15 women hospitalized on a DBT unit was traced over a 4-week period. Data on self-injurious behaviors and the use of the DBT approach were collected from a review of incident reports and patients' charts. The self-injurious behaviors decreased by almost 50%. In addition, four RNs, who were involved on the DBT unit both before and after the institution of the treatment approach, were interviewed. Semi-structured interviews were conducted to determine the nurses perceptions of the effectiveness of DBT. Their responses were uniformly positive. The most commonly occurring phrase was "it works."

From efficacy to effectiveness: managing organisational change to improve health services for young people with deliberate self harm behaviour

Repeat Deliberate Self Harm is a recognised risk factor for completed suicide and therefore reduction by effective health service response represents a valid contribution to suicide prevention. However, only a small fraction of people with deliberate self harm presentations to general health settings actually reach specialist mental health follow-up appointments. Therefore, even if responses at that point are known to be effective they do not make a significant contribution to reducing repeat self-harm overall. We describe health system organisational change strategies to improve health service engagement for the target group, and present data demonstrating the effectiveness of these strategies.

Obsessive compulsive disorder: a case report

A general dentist often will find the most challenging aspect of dentistry is patient management. In the controlled environment of a dental school, many students are not exposed to certain patient populations. It is likely that their first experience with particular patient pools will be in private practice. One such group of patients is those suffering from Obsessive Compulsive Disorder (OCD). This article reviews the clinical signs and symptoms of this group of patients.

Borderline personality disorder. Suicidality and self-mutilation

Epidemiological and neurobiological perspectives about suicidality in borderline patients are described, highlighting how self-destructive and seemingly suicidal acts are their "behavioral specialty." Principles for management, including the need for a primary clinician to oversee safety, and the pros and cons of both "contracting for safety" and hospitalization are presented. Clinical material is used to illustrate an approach that involves minimal initiative to rescue by therapists, a readiness to comply with patients' wishes for protection (the principle of false submission), and very active interpretation. This approach is contrasted with those advocated by Linehan and Kernberg.

Characterization of self-injurious behaviors in children and adults with Smith-Magenis syndrome

A characteristic pattern of stereotypic and self-injurious behavior (SIB) distinguishes Smith-Magenis syndrome from many other genetic disorders. We examined the prevalence and severity of 11 specific types of SIB in 29 children and adults with Smith-Magenis syndrome. We confirmed the near universal presence of SIB in people with this disorder. The overall prevalence of SIB was found to increase with age as was the number of different types of SIB demonstrated by individuals with Smith-Magenis syndrome. The number of different types of SIB exhibited was also directly correlated with level of intellectual functioning. Our data suggest that with increasing age and ability levels, people with Smith-Magenis syndrome add to their repertoire of SIB from among a small number of specific behaviors.

Complications of an unrecognized cheek biting habit following a dental visit

Cheek biting is a chronic, usually innocuous, self-inflicted injury that is occasionally seen in children. This case report describes the characteristic features of this entity in an 8 year-old girl, including an unfortunate complication following an inferior alveolar mandibular block for restorative dental care.

Self-destructiveness and manic-depressive tendencies

In a sample of 72 undergraduates, scores on Thalbourne, et al.'s measure of manic and depressive tendencies were associated with those on one of general self-destructive tendencies.

Severe self-injurious behavior associated with treatment-resistant schizophrenia: treatment with maintenance electroconvulsive therapy

A 35-year-old man with schizophrenia associated with a 10-year history of repetitive and often severe self-injurious behaviors was treated successfully with maintenance electroconvulsive therapy. Initially his condition did not respond to multiple psychotropic agents (including a year-long trial of clozapine), 27 hospitalizations, two courses of bilateral electroconvulsive therapy, and supportive psychotherapy with partial hospitalization. After the initiation of maintenance electroconvulsive therapy, this patient was able to tolerate residential placement and begin a work therapy program with only one instance of self-injurious behavior in the past 17 months.

Another idea for the treatment of patients with borderline personality disorder

We are not suggesting that casting is appropriate for all patients with BPD, nor are we suggesting that patients need be casted for prolonged periods of time. In the 3 stated cases, the patients were desperate to have some behaviour modification introduced into their lives and welcomed the procedure. In all these cases, comorbidity existed. Because marked skin damage and open wounds often occur, other specialists with expertise in wound healing and joint mobility maintenance need to be involved. We were fortunate to have the services of a plastic surgeon with a special interest in psychiatric disorders. We believe that psychiatrists should be aware of this technique as a possible strategy to be used in very specific circumstances. It appears, in our short series of 3 cases, to have benefits in very specific cases. If it appears that casting may be helpful, our recommendations are as follows: 1. The behaviours should be thoroughly evaluated, and all alternative managements should be reviewed. 2. Reasonable rapport needs to be established between the patient and the major therapists so that compliance can be assured. 3. Other specialists should be consulted, such as plastic surgeons, who have the expertise to manage prolonged casting. 4. Along with casting, appropriate medications and psychotherapy must be in place for a balanced approach to management.

Patterns of self-harm behavior among women with borderline personality symptomatology: psychiatric versus primary care samples

The current study investigated differences in self-harm behavior among individuals with borderline personality symptomatology from two different clinical settings. Participants were women, between the ages of 18 and 45, from an outpatient mental health setting or a primary care setting. Each participant completed the Self-Harm Inventory (SHI) and the borderline personality scale of the Personality Diagnostic Questionnaire-Revised (PDQ-R). Using a predetermined cut-off for substantial borderline personality symptomatology on the SHI, group comparisons with chi(2) analyses indicated that "overdosed" and "hit self" were significantly more common in the mental health subsample whereas "abused laxatives" was significantly more common in the primary care subsample. Using a predetermined cut-off for borderline personality on the PDQ-R, chi-square analyses indicated that "overdosed" and "hit self" remained significantly more common in the mental health subsample. Despite these differences, there was remarkable similarity of symptoms between groups. The implications of these findings are discussed.

Further analysis of idiosyncratic antecedent influences during the assessment and treatment of problem behavior

Recent research findings suggest that idiosyncratic variables can influence the outcomes of functional analyses (E. G. Carr, Yarbrough, & Langdon, 1997). In the present study, we examined idiosyncratic environment-behavior relations more precisely after identifying stimuli (i.e., a particular toy and social interaction) associated with increased levels of problem behavior. Two children, an 8-year-old boy with moderate mental retardation and a 5-year-old boy with no developmental delays, participated. Results of functional analyses for both children indicated that idiosyncratic antecedent stimuli set the occasion for occurrences of problem behavior (hand biting or hand flapping) and that problem behavior persisted in the absence of social contingencies. Further analyses were conducted to identify specific components of the stimuli that occasioned problem behavior. Treatments based on results of the analyses successfully reduced self-injury and hand flapping.

[Psychopharmacological therapy of self-injurious behavior in mentally retarded individuals]

Neurobiological research has implicated the dopamine and serotonin system in the pathogenesis of self-injurious behavior. The efficacy of antipsychotic drugs has been questioned. Opened and controlled investigations have shown risperidone is effective for reducing self-injurious behaviour in mentally retardation. We report about 3 mentally retarded patients which were given open-label risperidone for 12 weeks. They participated in a detailed assessment of behaviour symptoms at baseline and the repetitive behaviour was weekly rated with the disability assessment schedule (DAS). All three patients responded.

Small bowel and mesenteric injury following traditional treatment and self-inflicted trauma to inguinal hernia

Inguinal hernia is a common indication for emergency surgery in our environment after intestinal obstruction. Occasionally other rare indications may be seen. Recently, two patients with such unusual presentation were managed in this institution. One had his hernia incised, by a traditional barber with evisceration and the other incised his hernia himself with evisceration and laceration of the small bowel. Both patients were successfully managed. The menace of traditional barbers and medical ignorance in tropical Africa are reported.