Child sexual abuse as a predictor of psychiatric co-morbidity and its implications for drug and alcohol treatment

A study of 180 women in and outside drug and alcohol treatment showed that CSA survivors had higher overall levels of psychological distress, compared with drug and alcohol treatment clients who had not experienced CSA. They reported elevated levels of anxiety, somatisation and dissociation but not depression. Higher rates of self-harm, eating disorders and sexual dysfunction were also reported by CSA survivors. Women with a history of both CSA and substance abuse were more likely to have attempted suicide than other women. The results highlight the need for improved liaison between substance abuse treatment programs and other health services.

Trauma, dissociation, impulsivity, and self-mutilation among substance abuse patients

Among 85 substance abusing or dependent inpatients, it was found that those with histories of distressing traumatic events reported more self-mutilative acts, higher levels of dissociation, and a greater degree of impulsivity than did patients without such histories. Implications of the findings for research and clinical practice are discussed.

Foreign bodies in the bladder: report of four cases

This report presents the author's experience with four cases of foreign bodies in the bladder during a urological practice that spanned three different geographical locations. Relevant clinical aspects of this condition are discussed as well as technical tips given by various authors for the safe retrieval of such objects.

Treatment of multiple sleep problems in children with developmental disabilities: faded bedtime with response cost versus bedtime scheduling

Sleep problems are a common concern for persons with mental retardation and severe behavior problems, yet few empirically validated treatment options exist. In the current investigation, the efficacy of a faded bedtime with response cost treatment was compared with a bedtime scheduling procedure in treating the multiple sleep problems of two groups of children with mental retardation, sleep problems, and other severe behavior problems. Faded bedtime with response cost (FBRC) consisted of systematic delay of bedtime, removal from bed if sleep was not initiated within 15 minutes (response cost), and a fading procedure to gradually advance the bedtime. The bedtime scheduling procedure consisted of a consistent sleep and wake time and prevention of daytime sleep. The sleep of children in the FBRC group improved significantly more than the sleep of children in the bedtime scheduling group. Results are discussed in terms of behavioral and biological mechanisms which may contribute to the efficacy of FBRC.

Affective instability and impulsivity in personality disorder. Results of an experimental study

Affective instability in borderline personality disorder is due to a marked reactivity to environmental events. The present study focused on the relationship between affective instability and impulsivity in personality disorder. It used an experimental approach in the form of an affect-stimulation design based on the presentation of a short story which allowed for an analysis of affective responses in regard to quality, intensity, and alterations over time. Impulsive personalities showed a strong intensity of affective responses us well as a tendency towards rapid affect alterations supporting the theory of poor affect regulation in subjects with impulsive self-harming behaviour. Results suggest that affective instability is a crucial part of impulsive personality functioning.

Autistic traits in adults with learning disabilities

BACKGROUND

Although many adults with learning disabilities show features of autistic syndrome, there have been very few population-based studies. We explored the prevalence of autistic traits and their association with maladaptive behaviours in a geographically defined population of adults with learning disabilities.

METHOD

The carers of 2201 adults with learning disabilities were interviewed, and information was sought concerning aspects of their behaviour and ability. Individuals were scored according to the number of core autistic traits displayed. The prevalence of autistic traits was examined in respect of aspects of behaviour and ability.

RESULTS

Autistic traits were common among adults with learning disabilities. Those with a higher number of autistic traits were more likely to be profoundly learning disabled and demonstrate a wide range of challenging behaviours.

CONCLUSION

Many adults with learning disabilities demonstrate autistic traits. The relationship of autistic traits with challenging behaviour has major implications in service planning and delivery.

Pseudoseizure "status"

Psychogenic pain, disturbances of gait and stance, sensory symptoms, dizziness, and psychogenic seizures have been found to be the most common conversion symptoms in neurology clinics. A retrospective analysis of 18 patients suffering from pseudoseizure "status" is presented in this study. All of the patients fulfilled the DSM-III-R criteria of conversion disorder. However, 5 of them had concomitant major depression, 6 suffered from bulimia nervosa, and 7 met the criteria for substance abuse. On Axis II, 10 cases of borderline personality disorder, 2 cases of antisocial personality disorder, and 3 cases of histrionic personality disorder were diagnosed. The majority of the patients had attempted suicide and other forms of self-destructive behavior. The findings suggest that patients with pseudoseizure "status" suffer from severe affective imbalances and disturbed impulse control.

Self-trephination of the skull with an electric power drill

There is extensive archaeological evidence of the practice of trephination of the skull in many ancient cultures in different parts of the world. We report a case of self-trephination of the skull by a patient using an electrical power drill subsequently requiring neurosurgical intervention.

A study of cognitive development and behavior problems in mentally retarded children

Cognitive development in seventy-one mentally retarded children (19 autistic, 52 non-autistic; aged 7-19 years) from a school for handicapped children was studied, using Ohta's scale for evaluating cognitive development level based on language comprehension (Ohta's stage), and other developmental scales. Behavior problems were also examined. The present study reports on the utility of Ohta's stage in non-autistic children, and the relationship between cognitive development level and behavior problems in mentally retarded children. In non-autistic children, there were temporal correlations between Ohta's stage and other development scales (a standard developmental test, speech development, symbolic play development, imitation development), suggesting that in non-autistic children as well, Ohta's stage may serve well as a scale for cognitive development, and reflect symbolic representational functioning. In non-autistic children, most behavior problems in feeding, elimination and sleeping, hyperkinesis, hypokinesis, stereotyped behaviors, self-injurious behavior and licking were closely associated with cognitive development level, and were more often noted in children of lower cognitive development level rather than only in the severely mentally retarded children. Some behavior problems may often occur in the sensorimotor period and hardly occur in the symbolic representational period.

Serotonergic function and self-injurious behavior in personality disorder patients

Self-directed aggression, whether in the form of non-suicidal self-mutilation or suicidal behavior, is a prominent feature of personality disorders. We hypothesized that self-injurious behavior, like suicidal behavior, represents a form of self-directed aggression, and may, like suicidal behavior and impulsive aggression, be associated with a decrease in central serotonin function in personality disorder patients. Ninety-seven patients with DSM-III personality disorder underwent D,L-fenfluramine challenge as an assessment of serotonergic activity. Patients with a history of self-mutilation or suicide had blunted prolactin and cortisol responses to D,L-fenfluramine compared to those with neither, and those with both had the most blunted responses to fenfluramine. These data raise the possibility that the central 5-HT abnormality, previously associated with suicidal behavior, may be associated with self-directed violence and not necessarily specifically with suicidal intent.

Characteristics of children and adolescents with mental retardation and frequent outwardly directed aggressive behavior

Two interrelated cross-sectional studies were conducted to expand earlier findings about correlates of outwardly directed aggressive behavior in children with mental retardation. In Study 1 we compared children with mental retardation, 27 with and 23 without aggression. Aggression was best predicted by concurrent self-injurious behavior (SIB). In Study 2 we examined the likelihood that aggression was predicted by concurrent SIB and other nondestructive maladaptive behaviors in an archival cohort of 701 children younger than 21 with IQs below 70. Self-injurious behavior significantly predicted outwardly directed aggression for all children regardless of age. Additional predictors besides SIB showed only minimal improvements in model R2 values. Results were discussed in light of recent research proposing a common basis for aggression and SIB.

Self-injury in trauma survivors: 1. functions and meanings

Self-injury is increasingly linked to traumatic childhood experiences, and is identified in this paper as a means by which some trauma survivors cope with post-traumatic effects. It is proposed that self-injury serves a number of functions, organized here into four categories: re-enactment of the original trauma, expression of feelings and needs, reorganization of the self, and management of dissociative process.

Self-injury in trauma survivors: 2. levels of clinical response

Responding effectively to trauma survivors who engage in self-injury can be challenging, even for experienced therapists. This paper outlines therapeutic goals and appropriate clinical responses, including remaining present at and open to communication about disclosures of self-injury, helping clients to intervene in their own process of self-injury, and working with clients to resolve underlying issues. Alternatives to self-injury are discussed and cautions are offered about common therapeutic responses likely to be particularly unhelpful.

Open trial lamotrigine in the treatment of self-injurious behavior in an adolescent with profound mental retardation

This single case reports an open trial of lamotrigine in the treatment of self-injurious behavior (SIB) and epilepsy in an 18-year-old female diagnosed with generalized seizure disorder, stereotypic movement disorder, and compulsive SIB in the context of profound mental retardation. Animal models of SIB suggest that the glutamate neurotransmitter systems, involved in the generation of epileptic seizures, may also have a role in the pathophysiology of SIB. Data suggesting that lamotrigine may decrease glutamate release encouraged an empirical trial of lamotrigine for treatment of SIB. After 4 weeks of treatment of lamotrigine 200 mg daily, decreases in agitation and fearfulness were clinically observed, along with a 50% reduction in the frequency of SIB as measured by standardized scales. Good seizure control was maintained throughout the trial. No significant adverse effects were observed. Positive effects persisted at 1-year follow-up. Symptoms of stereotypic movement disorder appeared unchanged. Because these findings are preliminary, no clinical recommendations for the treatment of SIB with lamotrigine can be made until controlled studies have been completed.

Self-induced pneumoparotitis

Pneumoparotitis is a rare cause of enlargement of the parotid gland; it is often misdiagnosed and therefore incorrectly treated. We report three pediatric cases of self-induced pneumoparotitis and detail the clinical presentation, pathogenesis, radiographic findings, and treatment options. We also review the literature on the subject. In children, inflammatory swelling of the parotid gland is usually due to acute viral or bacterial infection, juvenile recurrent parotitis, or allergic, autoimmune, or systemic disease. Infrequently, swelling may result from air being forced through Stensen's duct, resulting in pneumoparotitis. This may occur as a transient or recurrent phenomenon. Recurrent parotid insufflation is not entirely benign and may predispose to sialectasias, recurrent parotitis, and even subcutaneous emphysema.

[Keratitis punctata superficialis caused by self-injury]

PATIENT

A 57-year-old patient with diabetes mellitus presented with therapy-resistant superficial punctate keratitis in his only eye. Finally self-injury was suspected. After unsuccessful medical treatment of three weeks' duration the disease could be healed promptly after application of an eyepad: the patient admitted self-manipulation.

CONCLUSION

In all patients with ocular pathology of uncertain origin, especially in corneal lesions, self-inflicted injury should be part of the diagnostic consideration.

Facial swelling: an unusual case

Facial swelling is a common presenting sign of the dental emergency patient. The most common etiology of the swelling is odontogenic infection, whereupon the dental practitioner begins his intraoral examination in order to assess, diagnose and ultimately treat the source of the swelling. In many cases the examination is academic, as the causative tooth sticks out like the proverbial 'sore thumb.' Other times the source of the swelling is not so clear cut, and the practitioner must formulate a differential diagnosis in order to accurately deal with the pathology. It is vital that all information be accurately assessed prior to diagnosis and treatment. The etiology of facial swelling may be infectious, traumatic or neoplastic.

Staffing and staff performance in services for people with severe or profound learning disability and serious challenging behaviour

Eighteen people with severe or profound learning disability and very serious challenging behaviour were tracked for four and a half years. Thirteen subjects moved to staffed houses in the community. A multiple time-series design and direct observation were used to evaluate whether there was any change in staffing and staff contact. The houses had higher staff ratios and proportionately even higher levels of assistance and other contact with clients, who showed significant improvement in engagement in meaningful activity without overall increase in major problem behaviour.

Self-mutilation, anorexia, and dysmenorrhea in obsessive compulsive disorder

This report described 19 female patients (M = 23.5) diagnosed as obsessive compulsive disorder (OCD; DSM-III-R) who exhibited additional symptoms of self-mutilation, dysmenorrhea, and dysorexia. A biphasic pattern related to menstruation during the course of OCD emerged: Phase 1, amenorrheic--characterized by anorexia nervosa, amenorrhea, and aggressive behavior, and Phase 2, postamenorrheic--characterized by self-mutilation following the return of the menstrual cycle, dysorexia, and aggressive behavior. All mutilative acts were reported by the patients to be painless and consisted of slashes. Seventy percent of the patients were sexually abused during childhood. All patients underwent an open trial of clomipramine (M = 200 mg/day) for 6 months, and intensive behavior therapy for 8 weeks. Based on clinical observations and self-reports, there was a decrease in self-harm and OCD symptoms. The emergence of OCD, self-mutilation, dysorexia, and dysmenorrhea in a sequential manner may suggest a specific clinical syndrome or the presence of an OCD subset. A biological working hypothesis of a hypothalamic dysfunction with serotonergic participation was suggested.

Review of the gentle teaching data

The gentle teaching philosophy has been accepted by some providers of services for people with severe problem behaviors and mental retardation without independent empirical verification of its procedures and effects. Proponents have made spectacular claims for gentle teaching, citing, for example, success in 540 consecutive referrals. These claims were reviewed and doubts about their accuracy raised. Review of independent studies of gentle teaching shows that the methods have been unsuccessful with seven of nine individuals; however, advocates for this approach have dismissed these attempts at replication. Specific suggestions for further research were provided. Critical review indicates that gentle teaching still cannot be considered an ethically defensible treatment alternative.