Repair of scleral rupture and total retinal detachment in a self-injuring psychotic patient under local anesthesia: a case report

PURPOSE

Ocular self-injury by psychotic patients is an uncommon cause of ocular morbidity that poses peculiar problems. This report describes a schizophrenic self-injuring patient with scleral rupture and retinal detachment (RD), treated under loco-regional anesthesia.

CASE REPORT

A 65-year-old man presented with scleral rupture, hyphema, traumatic lens luxation, vitreous prolapse, vitreous hemorrhage and total RD after deliberately hitting his head. The fellow eye had been successfully operated with scleral buckle surgery for the same reason two years earlier. The patient underwent a two-step surgical procedure under local anesthesia, with repositioning and resection of the uveal prolapse and scleral rupture repair and, separately, lens removal pars plana vitrectomy (PPV), membrane peeling, retinotomy, laser treatment and SiO tamponade.

RESULTS

Twelve months after PPV, the cornea was clear, IOP was 16 mmHg, the retina was attached and VA was 20/200. The fellow eye maintained 20/30 VA.

CONCLUSIONS

In psychotic patients the intrinsic difficulty of a traumatic RD is combined with systemic illness, no compliance and the risk of recurrence. Although ocular traumas usually require general anesthesia, this patient underwent both interventions under local anesthesia with sedation, because of his psychotic condition and chronic liver failure. Local anesthesia and sedation proved effective in controlling pain and intra-operative compliance even in such a difficult patient. Although it is reasonable to question operating on such patients, we nonetheless believe that every attempt should always be made at gaining useful vision in both eyes since these patients are at a high risk of recurrent ocular trauma.

Identification of early self-injurious behaviour in young children with intellectual disability

Very little is known about the early stages of self-injurious behaviour (SIB) in young children with developmental disabilities, even though there has been a great deal of research into the prevalence, assessment and treatment of well-established SIB in older individuals. In the present initial study, teachers in special schools for children under II years of age with severe intellectual disability and/or autism were asked to identify children who were beginning to show early self-injury (the index group). These children were then matched to classroom controls (of the same ability level and mobility), and teachers were interviewed about the children's behaviours and skills. The index children showed significantly more potential SIB than the control group children, but there was overlap between the groups in terms of percentage duration of potential SIB, suggesting that teachers do not find it easy to identify children with 'early' SIB. The index children's skills and problem behaviours, their sensory impairments and degree of autism did not differ significantly from those of the control group. When all the children showing any potential SIB were pooled together, it transpired that developmental age and degree of mobility were significantly correlated with percentage duration of SIB, suggesting that these characteristics may be important risk markers. The index children were also observed at 3-month intervals at school over the following 18 months and self-injury clearly escalated for some of the index children, while it did not do so for others. Using regression analysis, increases in SIB were shown to be associated only with the degree of concern expressed about the child's behaviour at time I by the teacher, no other variables predicting increases in SIB.

An evaluation of functional variables affecting severe problem behaviors in adults with mental retardation by using the Questions about Behavioral Function Scale (QABF)

We examined the functions of five severe problem behaviors in a sample of 417 institutionalized persons with mental retardation by using the Questions About Behavior Function Scale. The behaviors we examined included self-injurious behavior, aggression, stereotypies, pica, and rumination. The most common function for all behaviors except aggression was nonsocial. Aggression, however, was maintained by external environmental contingencies. Particular items of the Questions About Behavior Function Scale were identified as more frequently occurring and critical in ascertaining behavioral function. Implications of these results for developing more effective treatment plans are discussed.

Effect of divalproex sodium on aggression and self-injurious behaviour in adults with intellectual disability: a retrospective review

The aim of the present study was to evaluate the efficacy of divalproex sodium treatment in adults with intellectual disability, and aggressive or self-injurious behaviour. Twenty-eight adults aged between 20 and 63 years of age with severe, long-lasting behavioural problems were treated with divalproex sodium (dosage 500-4000 mg day(-1)). Clinical changes were assessed at 2-73 months into the pharmacological treatment utilizing the Clinical Global Impression Severity (CGI-S) scale, and monthly behavioural counts of aggressive and self-injurious acts. Seventy-one percent of subjects demonstrated a moderate or marked improvement on the CGI-S; another 21% demonstrated mild benefits. Among the patients for whom objective prospective behavioural counts were available, 88% showed a significant reduction in aggression and self-injurious behaviour, 46% had other psychotropic medications discontinued, and another 39% had psychotropic medications decreased. One patient had serious thrombocytopenia which required the discontinuation of divalproex sodium, and one other had vomiting and worsened aggression. The present preliminary, uncontrolled study suggests that adults with intellectual disability, and aggressive or self-injurious behaviour may respond to divalproex sodium, and that this drug is well-tolerated in the majority of subjects.

Dermatologic findings in anorexia and bulimia nervosa of childhood and adolescence

The cutaneous signs of anorexia nervosa (AN) and bulimia nervosa (BN) have been described previously in adult patients. For the first time, we present here dermatologic findings in children and adolescents suffering from eating disorders. Thirty consecutive young anorexic and bulimic inpatients (8 to 17 years of age, mean 15.1 years) underwent a standardized dermatologic examination. Patients were checked for abnormalities of the skin including atopic stigmata, dermographism, hair, nails, and oral cavity. Serum was obtained for hemoglobin, iron, zinc, GPT, thyroid, and sex-hormone levels. In 13 patients, the total serum IgE was determined, and a prick test was carried out with defined type I allergens. Findings in order of frequency included xerosis of the skin, white dermographism, diffuse hypertrichosis, acrocyanosis, scars, diffuse effluvium, artifacts, brittle nails, and onychophagia. Significant co-relations were found between the presence of hypertrichosis and the existence of amenorrhea or a body mass index of less than 16. In 22 patients a low T3 level was found. In summary, children and adolescents suffering from AN or BN show dermatologic features similar to those reported in older patients. Special findings in this age group are extensive lanugo hair and signs of autoaggressive behavior.

Clarifying an ambiguous functional analysis with matched and mismatched extinction procedures

Results of functional analysis were ambiguous in suggesting that self-injurious behavior (SIB) was maintained by escape, sensory reinforcement, or both. To help clarify these results, we compared escape extinction, sensory extinction, and the combined treatments. Sensory extinction proved to be a necessary and sufficient treatment, whereas escape extinction failed to decrease SIB. These analyses helped to clarify the function of SIB and to identify an effective and efficient treatment.

Different types of self-injurious behavior in bulimia nervosa

In a previous study, we demonstrated the validity of the distinction, in bulimia nervosa (BN), between compulsive self-injurious behavior (SIB), such as hair pulling and onycophagia, and impulsive SIB, such as skin cutting and burning. The aim of the present study is to investigate the clinical and psychological correlates of these two categories of SIB in BN. The sample consisted of 175 consecutive patients with BN, diagnosed according to DSM-IV criteria. Subjects were assessed by means of a semistructured interview and self-reported questionnaires (Eating Disorders Inventory [EDI] and Hopkins Symptom Checklist [SCL-90]). In our sample, impulsive SIB appeared to be associated with suicide attempts, a history of sexual abuse, and depression. On the other hand, compulsive SIB seemed to be related to a lack of awareness towards emotions and body sensations, greater obsessionality, and a shorter duration of illness.

Decreasing signs of negative affect and correlated self-injury in an individual with mental retardation and mood disturbances

We evaluated the effects of an enriched environment, based on a paired-choice preference assessment, on both rates of self-injurious behavior (SIB) and percentage of session intervals during which signs of negative affect were displayed by a woman with mental retardation and a mood disorder. Results suggested that SIB and signs of negative affect were highly correlated and that the enriched environment effectively reduced both.

The relationship between self-induced water intoxication and severity of psychiatric symptoms

The purpose of this study was to test a theoretical framework that proposed a relationship between severe psychiatric symptoms and self-induced water intoxication (SIWI) by using reliable and valid measures. Twenty of 28 community-dwelling individuals with severe mental illness (SMI) in the sample exhibited excess fluid consumption as reflected by a mean urine specific gravity of 1.003 mEq/L. The psychometric measures included the Positive and Negative Syndrome Scale (PANSS), the Self Deficit Syndrome Scale (SDSS), and the Spielberger State-trait Anxiety Scale (STAI From X-1). A significant relationship was found at p .01 between severity of psychotic symptoms and severity of SIWI and between severity of SIWI and psychopathology symptoms within the PANSS. Anxiety was higher in those with SIWI before fluid loading compared with those with less excess fluid intake (i.e., USG < 1.010), and anxiety decreased from morning to evening in those with SIWI compared with those who did not exhibit excess fluid intake. The findings revealed a strong relationship between SIWI and severe psychiatric symptoms, including psychosis and a broad range of psychiatric symptoms. The findings provided initial support for the proposed theory, and consideration needs to be given to the development of interventions to augment existing treatment of fluid control.

The effects of noncontingent and contingent attention for self-injury, manding, and collateral responses

To date, most functional analysis studies have focused on the effects of treatment contingencies on specific targeted aberrant and alternative responses. In the current investigation, the main and collateral effects of the assessment and treatment of attention-maintained self-injury were assessed. Specifically, we evaluated the effects of noncontingent and contingent social attention on four categories of behavior: self-injury, a novel mand, preexisting prosocial responses (e.g., babbling and reaching out), and other aberrant responses (i.e., aggression and destruction). Results suggested that self-injury, prosocial responses, and other aberrant behaviors were within the same functional response class. Possible impact of these results when selecting mands for functional communication training is discussed.

'Pfropfschizophrenie' revisited. Schizophrenia in people with mild learning disability

BACKGROUND

It is reported that people with mild learning disability have a higher point prevalence of schizophrenia than the normal population, the reasons for which are unclear.

METHOD

Thirty-nine subjects with mild learning disability and schizophrenia, 34 control subjects with schizophrenia and 28 control subjects with mild learning disability were seen. Interviews with relatives and carers were also conducted. Assessments were made of clinical variables, psychopathology, neurological 'soft' signs, IQ, memory and family history. Blood was taken for karyotypic analysis from comorbid subjects.

RESULTS

The comorbid group had more negative symptoms, episodic memory deficits, soft neurological signs, epilepsy and receive more community supports than control subjects with schizophrenia. Comorbid subjects had a tendency to belong to multiply affected families and show high rates of chromosomal variants on routine karyotypic testing.

CONCLUSIONS

Future work on the generality of schizophrenia should include people with premorbid learning disability, as a discrete subtype from whom valuable genetic aetiological clues may be obtained.

Inadequate response to therapy as a predictor of suicide

The role of response to cognitive therapy as a predictor of suicide was investigated by comparing 17 outpatients with mood disorders who committed suicide with 17 matched patients who did not commit suicide. The suiciders attended significantly fewer sessions of cognitive therapy and dropped out of therapy more frequently: 88% of the suiciders, compared to 53% of the controls, were rated by their therapists as requiring more treatment at termination. They also had higher levels of hopelessness at the termination of therapy. The results suggest that premature termination of therapy and inadequate response to treatment have unfavorable prognostic significance for eventual suicide.

Causes of ear trauma in Kenyan patients

Ear trauma is one of the most important epidemiological factors in causation of deafness. The causation of otologic trauma in eighty three patients is analysed. The triad of pain, hearing loss and tinnitus comprised the most frequent presenting complaints. Physical assault was the most common causation in 49.4% of the cases, road traffic accidents in 19.3% and self-inflicted injury in 15.6%. Law enforcement agencies constituted the most prominent factor in assault cases. Iatrogenic trauma was confined to 13.3% who were all below ten years of age. Road traffic accidents and violence from law enforcers were significant contributors to severe otologic damage as defined by dead ears and cerebrospinal otorrhoea.

Thegosis--a critical review

The evidence for tooth sharpening has been examined and it has been concluded that there is no evidence for a posterior tooth sharpening mechanism which is independent of masticatory function and improves the efficiency of that function. Anterior tooth sharpening may occur in some species as behavioural activity but it is not accepted that this sharpening is directed towards the production of new incisiform weapons as distinct from the improvement of existing caniniform weapons, or more efficient tools for the manipulation of food. Thegosis (from the Greek, thego to whet or sharpen) is a term which could be used to describe the sharpening of anterior teeth under specific often socially context driven situation. Stress is accepted as a cause of non-masticatory tooth to tooth contact as is the suggestion that excessive tooth grinding and clenching is pathological and stress related. Bruxism and pathological thegosis are suggested synonymous terms for this activity.

Self-injurious behaviour as part of genetic syndromes

BACKGROUND

The purpose of this paper is to review the association between genetic syndromes and self-injurious behaviour.

METHOD

The information available from the literature on the subject of self-injurious behaviours and genetic syndromes was collated and presented with a critical appraisal.

RESULTS

Self-injurious behaviours are associated with some genetic syndromes. However, the causal relationship between the genetic syndromes and the self-injurious behaviour remains far from clear.

CONCLUSIONS

Although self-injurious behaviour has been shown to be the part of a broader phenotype in many genetic disorders, the specificity and sensitivity of these behaviours in this context remain unclear.

Case report: tooth wear associated with an unusual habit

Pathological tooth wear is an increasing problem affecting a significant proportion of the population. Although different wear mechanisms have been described, most reports in the literature concentrate on cases in which the predominant mechanisms were erosion and attrition. This article presents an unusual case of abrasive tooth wear caused by a sand eating habit which the patient had adopted as a child. Different causes of "abrasive" wear are discussed and the difficulties in management of this case are also presented.

Joint care admissions to a psychiatric unit: a prospective analysis

Despite developments in general hospital liaison psychiatry over the past 20 years, joint care still remains underdeveloped in Europe. Psychiatry continues to move from the mental hospital to the general hospital unit without the parallel evolution of combined medical and psychiatric. An inpatient unit that provides both medical and psychiatric care may provide an essential integration of care that can benefit a select group of patients. The aims of this study were to prospectively evaluate the profile, treatment, and follow-up of patients admitted to the joint-care unit, and to examine the difficulties associated with the treatment of these patients on a joint unit. Eighty-nine patients were admitted to the joint care unit over a 6-month period. Their median length of stay was 2 days (range 1-52 days). Fifty-six (50%) were female. The majority (68) (76%) of the group were admitted following acts of deliberate self-harm. The overall predominant psychiatric diagnosis was depression (41) (46%). During admission, 23 (26%) patients were found to have behavioral and psychiatric problems that were difficult to manage on the ward. Eleven patients caused difficulties for staff relating to the management of their physical illness. Thirty-six (33%) patients were referred for further psychiatric inpatient care from the joint-care unit. The extra burden of these patients' care was felt to fall on the staff working on the psychiatric unit. The joint care unit provided a combined psychiatric and medical service. It was used predominantly by patients following acts of deliberate self-harm. Joint care allowed a comprehensive assessment and initiation of treatment of this patient group as well as a learning experience for medical and nursing staff. The inclusion of such a unit is a worthwhile consideration in any general hospital psychiatric service, with advanced planning easing staff workload.

Self-inflicted intramyocardial injury with a sewing needle: a rare cause of pneumothorax

An unusual case of a self-inflicted intracardiac injury with a sewing needle caused a pneumothorax. Fewer than ten cases of needles in the heart have been reported in the recent medical literature; none of these cases was associated with presence of a pneumothorax. The literature regarding self-inflicted injury with needles in the heart is reviewed.

Deliberate self-inflicted trauma: population demographics, the nature of injury and a comparison with patients who overdose

Self-inflicted harm, whether by trauma or drug overdose, is not uncommon, and has important social consequences. This study was a retrospective record analysis of patients who presented to an emergency department after deliberate self-inflicted harm. Over the two-year study period, there were 175 self-inflicted trauma and 441 overdose presentations. The self-inflicted trauma patients were a heterogeneous group and included patients who displayed suicide-related behaviour and behaviour not related to suicide. The self-inflicted traumatic injuries tended to be either relatively minor or potentially very serious. Lacerations to the upper limb were seen most frequently. The trauma and overdose groups were almost mutually exclusive populations and showed some significant differences. The trauma group was smaller, contained a significantly greater proportion of younger patients and males, presented more commonly in the late evening and early morning hours and ultimately received less psychiatric counselling. Research of this type has problems of underreporting and data bias. Prospective studies of self-inflicted trauma would improve the identification of patients after self-harm and improve the understanding of the relationship between the patterns of injury psychiatric diagnosis and the long-term risk of future self-harm.