Self-injurious behavior: gene-brain-behavior relationships

This paper summarizes a conference held at the National Institute of Child Health and Human Development on December 6-7, 1999, on self-injurious behavior [SIB] in developmental disabilities. Twenty-six of the top researchers in the U.S. from this field representing 13 different disciplines discussed environmental mechanisms, epidemiology, behavioral and pharmacological intervention strategies, neurochemical substrates, genetic syndromes in which SIB is a prominent behavioral phenotype, neurobiological and neurodevelopmental factors affecting SIB in humans as well as a variety of animal models of SIB. Findings over the last decade, especially new discoveries since 1995, were emphasized. SIB is a rapidly growing area of scientific interest to both basic and applied researchers. In many respects it is a model for the study of gene-brain-behavior relationships in developmental disabilities.

Lesion and electrical stimulation of the ventral tegmental area modify persistent nociceptive behavior in the rat

The ventral tegmental area (VTA) has been traditionally related with the control of motor responses. However, some studies show that this area is also involved in the processing of nociceptive information. It has been reported that this nucleus participates in the dissociative analgesia phenomenon. In the few works where electrical stimulation and lesion of the VTA have been performed, evaluated with persistent or chronic pain related behaviors, contradictory results have been obtained. Thus, a more detailed analysis of the role of the VTA in persistent pain is needed. Two series of experiments were performed: lesions of this nucleus were done with radiofrequency, (bilaterally at two points per side using a temperature range from 50 to 80 degrees C), and the VTA was electrically stimulated (10 min daily over 5 days, 2 ms rectangular pulses at 100 Hz during 1 s every 5 s) using two different schemes:10 min before the induction of the nociceptive stimulus and 90 min after the induction of the nociceptive stimulus. The latter allowed us to distinguish if the VTA electrical stimulation had a distinctive antinociceptive effect when applied before or after the induction of the nociceptive stimulus on a persistent pain related behavioral response in the rat, the self injury behavior (SIB). Our results showed that VTA lesions enhanced the occurrence of SIB; while activation of this same nucleus by electrical stimulation after the nociceptive stimulus, but not before, facilitates the analgesic process, expressed as a 1 day delay in SIB onset. These results indicate that the VTA is a brain structure that plays a key role in the processing and modulation of persistent pain information. Data are discussed in terms of the relationship of the VTA with the affective component of pain.

Relationship between 5-HT function and impulsivity and aggression in male offenders with personality disorders

BACKGROUND

Reduced serotonergic (5-HT) function and elevated testosterone have been reported in aggressive populations.

AIMS

To investigate relationships between impulsivity, aggression, 5-HT function and testosterone in male offenders with personality disorders.

METHOD

Sixty male offenders with DSM-III-R personality disorders and 27 healthy staff controls were assessed using the Special Hospital Assessment of Personality and Socialisation (SHAPS), impulsivity and aggression ratings, d-fenfluramine challenge and plasma hormone concentrations.

RESULTS

The SHAPS non-psychopaths and those with schizoid personality disorders had enhanced 5-HT function (prolactin response to d-fenfluramine). Reduced 5-HT function was found in offenders with DSM-III-R borderline personality disorders and those with a history of repeated self-harm or alcohol misuse. The 5-HT function was inversely correlated more strongly with impulsivity than with aggression. Plasma testosterone correlated positively with aggressive acts. The SHAPS primary psychopaths had lower initial cortisol and higher testosterone concentrations than controls.

CONCLUSIONS

Future studies are needed to investigate regional brain 5-HT function.

Physiological correlates of self-injurious behavior in captive, socially-reared rhesus monkeys

This study examined the relationship between self-injurious behavior (SIB) in rhesus monkeys and several biological variables, including monoamine metabolites in cerebrospinal fluid (CSF) and circulating levels of ACTH, cortisol, and testosterone. Cisternal CSF and blood plasma samples were obtained from 23 individually housed male rhesus macaques, 14 of which had a veterinary record of self-inflicted wounding. CSF samples were analyzed for 5-hydroxyindole-3-acetic acid (5-HIAA), homovanillic acid (HVA) and 3-methoxy-4-hydroxyphenylglycol (MHPG) using isocratic high-performance liquid chromatography with electrochemical detection (HPLC-EC). Plasma samples were analyzed for ACTH, cortisol, and testosterone using commercially available radioimmunoassays (RIAs). Rates of self-directed biting were determined by systematic observation of all monkeys. Monkeys with SIB did not differ from controls in their basal monoamine or gonadal activity. However, the SIB group showed consistently lower mean plasma cortisol levels than the control group. Plasma cortisol was negatively correlated with rates of self-directed biting. These results suggest a persistent dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis in monkeys with SIB. It is not yet clear whether this phenomenon of low cortisol represents chronically reduced adrenocortical secretion under basal conditions or a difference in response to the mild stress of capture and chemical restraint. The implications of these findings will be discussed with respect to SIB in humans as well as post-traumatic stress disorder (PTSD), a condition characterized by pituitary-adrenocortical hypoactivity.

Dopaminergic and glutamatergic interactions in the expression of self-injurious behavior

Self-injurious behavior occurring in persons with severe mental retardation is a clinically significant and poorly understood problem. Multiple neurotransmitter systems have been implicated in the pathogenesis of this behavior, particularly dopaminergic, opioidergic, and serotonergic systems. Pemoline, a central stimulant, administered systemically at high doses reliably produces self-biting behavior in the rat. The systemic bolus of pemoline produces sustained neostriatal levels of pemoline for over 24 h in a continuous infusion paradigm. Studies of the effect of cortical lesions on pemoline-mediated behaviors reveal that cortical damage, as is common in profound mental retardation, lowers the threshold for pemoline-induced self-biting behavior. Data from the corticostriatal slice suggests that sustained exposure to pemoline produces a shift in N-methyl-D-aspartate receptor-mediated responses rendering them more susceptible to dopaminergic enhancement. Thus, dopaminergic and glutamatergic interactions appear to play an important role in the development and expression of self-biting in the pemoline model.

Dopamine transporter binding in Gilles de la Tourette syndrome

Preliminary studies in patients with Gilles de la Tourette syndrome (TS) provided evidence of presynaptic dopaminergic dysfunction, demonstrating increased reuptake sites. Therefore we investigated striatal dopamine transporter binding in 12 TS patients and 9 control subjects using single photon emission computed tomography and 123I-labeled 2beta-carbomethoxy-3beta-(4-iodophenyl)tropane. In TS patients we found significantly higher relative striatal activity ratios (mean +/- SD 12.33 +/- 3.58) than in controls (9.36 +/- 1.35, P< 0.05). Only five patients, however, showed striatum/occipital cortex ratios more than 2 SD above the normal means. Seven patients had activity ratios within the average ratio of the control group plus 2 SD. Regarding the relationship between clinical parameters and striatum/occipital cortex ratios, we found an association between binding ratios and "self-injurious behavior" and "lack of impulse control." This study corroborates previous data suggesting an involvement of the dopaminergic system in TS pathology. Our results demonstrate that an increase in dopamine transporter capacity is a possible but not a necessary alteration, and which appears more likely when self-injurious behavior and lack of impulse control are associated.

EEG theta activity and pain insensitivity in self-injurious borderline patients

The principal aim of this study was to investigate possible neurophysiological underpinnings of self-injurious behavior in women with borderline personality disorder (BPD). Pain report and EEG power spectrum density during a laboratory pain procedure, a 4-min 10 degrees C cold pressor test (CPT), were compared among four groups; female inpatients with BPD who do (BPD-P group, n = 22) and do not (BPD-NP group, n = 19) report pain during self-injury, female inpatients with major depression (n = 15), and normal women (n = 20). The BPD-NP group reported less pain intensity during the CPT compared to the other groups. Total absolute theta power was significantly higher in the BPD-NP group compared to the Depressed (P = 0.0074) and Normal (P = 0.0001) groups, with a trend toward being significantly higher compared to the BPD-P group (P = 0.0936). Dissociative Experience Scale scores were significantly higher in the BPD-NP group compared to the Depressed and Normal groups (maximum P = 0.0004), and significantly higher in the BPD-P group compared to the Normal group (P = 0.0016). Beck Depression Inventory and Sheehan Patient Rated Anxiety Scale scores were significantly lower in the Normal group compared to all patient groups. Theta activity was significantly correlated with pain rating (Pearson partial r = -0.43, P = 0.0001) and Dissociative Experiences Scale score (Pearson partial r = 0.32, P = 0.01).

Evaluation of an evolutionary model of self-preservation and self-destruction

According to deCatanzaro's mathematical model of self-preservation and self-destruction, staying alive actually may reduce inclusive fitness for an individual who is low in reproductive potential and, at the same time, poses such a burden to close kin that it costs them opportunities for reproduction. Predictions generated from this model were tested using 175 university students as subjects and variables constructed from a 164-item questionnaire. The criterion variables were separate measures of depression, hopelessness, and suicide ideation and behavior. The predictor variables derived from the model were separate measures of reproductive potential of the individual, the individual's perceived benefit or cost to kin, and reproductive potential of the individual's kin. As predicted, there were negative and significant bivariate correlations between each of the model-generated predictor variables and one or more of the criterion variables. Multiple regression analyses showed that benefit to kin was the best predictor of both depression and hopelessness. Discriminant analysis showed that reproductive potential of kin significantly differentiated suicide attempters from nonattempters. Overall, our results support and extend deCatanzaro's model and empirical findings.

The self-mutilative nature of severe onychophagia: a comparison with self-cutting

OBJECTIVE

To investigate the psychophysiological pattern associated with severe and mild onychophagia, and to compare this pattern with that demonstrated by previous research on self-cutting.

METHOD

Comparisons between the psychophysiological responses accompanying 3 behaviours were made using a guided imagery methodology. Imagery of nail-related, skin-cutting, and neutral events were presented in 4 stages.

RESULTS

Experiment I distinguished participants exhibiting severe and mild onychophagia by the severity and frequency of nail-biting and by the pattern of psychophysiological response across the stages. Experiment II indicated that the change in psychophysiological arousal accompanying severe onychophagia was not as dramatic as that demonstrated for skin-cutting. The behaviour seems to be less effective in reducing tension.

CONCLUSION

Severe onychophagia appears to manage the level of tension experienced by an individual, instead of dramatically reducing it in times of crisis. Such a process is consistent with that demonstrated in individuals with obsessive-compulsive disorder.

Cortical damage enhances pemoline-induced self-injurious behavior in prepubertal rats

Self-injurious behavior (SIB) is a devastating characteristic of several developmental disorders including a number of mental retardation syndromes. The functional neuroanatomy and neuropharmacology of SIB is not well understood. Self-biting behavior (SBB) can be induced in rats by a high dose, systemic injection of pemoline (250 mg/kg, SC). This animal model allows for the investigation of anatomical and pharmacological aspects of SIB. Cortical pathology is a common occurrence in human disorders with SIB, and may be a fundamental pathological factor in producing the behavior. The present experiment was designed to investigate the effects of cortical damage on pemoline-induced SBB in prepubertal rats. Bilateral cortical aspirations were performed in 3-5-week-old rats. One week postsurgery, a pemoline challenge was administered. Behavioral comparisons were completed between the lesion group and an anesthetized-only control group. Results indicated that cortical damage significantly enhanced pemoline-induced SBB, along with some of the other pemoline-induced stereotypical behaviors. These results support the hypothesis that cortical damage influences the expression of stimulant-induced self-injury, and potential mechanisms for this influence are suggested.

Dynamics of self-injurious behaviors

Self-injurious behavior was examined in a case study of head-banging by an 8-year-old girl with profound mental retardation and an autistic disorder. Trajectories of the arm movements and impact forces of the head blows were determined from a dynamic analysis of videotapes. Results revealed a high degree of cycle-to-cycle consistency in the qualitative dynamics of the limb motions, with one hand motions being faster than those with two hands (inphase and antiphase) and the motions with the helmet about 25% faster than those without the helmet. The impact force of SIBs as a percentage of body weights are near the low end of forces generated in boxing blows and karate hits.

Self-injurious behaviour: a kindling phenomenon?

Self-injurious behaviour continues to be a drain on the resources for rehabilitation of the children with developmental disabilities. Pathogenesis and therapy seems fragmentary, with virtually every major neurotransmitter system being identified as the putative substrate for self-injurious behaviour. This phenomenon as it cuts across the diagnostic boundaries, although it is suggestive of a heterogeneous neurochemical basis, should call for the exploration of the biological event preceding the neurochemical cascade resulting in the behaviour. The authors argue that kindling is the preceding neurophysiological event resulting in self-injurious behaviour and, thus, can be effectively prevented pharmacologically.

Impaired peripheral somatosensory function in children with Prader-Willi syndrome

The Prader-Willi syndrome (PWS) is associated with a tendency to self-injury and a reduced sensitivity to painful stimuli. Somatosensory functions were studied in 5 children aged 11-13 years with PWS. Tactual perception in the hands (stereognosis) was apparently normal in 4 of them. Sensory nerve conduction velocities in the median nerve and latencies for sensory evoked potentials were similar in the PWS subjects and in 10 healthy controls indicating a preserved myelinisation of sensory nerve fibers in PWS. Sensory nerve action potential amplitudes in the PWS group were on an average only 40-50% of normal size (p = 0.03), suggesting a reduced number of normal axons in the median nerve. The results may be relevant for the impaired pain sensitivity in PWS because similar neurographic findings and a low density of peripheral nerve fibers have been reported in patients with hereditary or congenital insensitivity to pain.

Nocturnal wandering and violence: review of a sleep clinic population

Sleep consists of two complex states--NREM and REM sleep--and disturbances of the boundaries between the states of sleep and wakefulness may result in violence. We investigated our population for reports of violence associated with sleep. REM behavior disorder is rarely associated with injury to the sufferer or others. NREM sleep related nocturnal wandering associated with self-inflicted injuries has variable etiologies. In the elderly, it is associated with dementia. In young individuals, it may be associated with mesio-temporal or mesio-frontal foci and an indication of a complex partial seizure. It also may be related to abnormal alertness and is associated with excessive daytime sleepiness, micro-sleeps, and hypnagogic hallucinations in sleep disorders such as narcolepsy or sleep disordered breathing.

The behavioral neurobiology of self-injurious behavior in rhesus monkeys. Current concepts and relations to impulsive behavior in humans

The objective of this report is to critically review past reports and present new data on the psychobiology of self-injurious behavior (SIB) and/or "risky" or "impulsive" behavior in primates (human and nonhuman). One aim was to reexamine how early social deprivation and neurobiological changes caused by deprivation might contribute to SIB in monkeys, and how the causes of SIB in monkeys might inform us about the psychobiology of suicide in humans. A second aim was to examine the evidence that social deprivation in monkeys produces reductions in brain 5-HT system function that are causal or coincident factors associated with self-injurious or impulsive behavior. Prior studies and new data indicate that the environmental causes of SIB and unusual aggression in rhesus monkeys do not produce reductions in brain 5-HT system activity and that experimental production of low levels of brain 5-HT system activity does not reliably promote either SIB or unusual other-directed aggression in monkeys. A third and final aim was to suggest that in severe cases of environmentally induced SIB and/or aggression in monkeys, having relatively high or low levels of 5-HT system activity may not be related to ongoing behavior because the 5-HT system may not interact with other neurotransmitter systems in the usual way. Overall, the contention is that primates exhibiting SIB and unusual aggression may have altered 5-HT system function, but this may be but one aspect of a more profound disorganization of brain function involving many neurohormonal and transmitter systems. Contemporary theorizing and experimentation tends to be restricted to the idea that altered function in one key system might be the cause of a specific form of psychopathology. In the future, research examining the probable change interactions of neurotransmitter and neuroendocrine systems as underlying causes of behavioral disorders should have a high priority.

Effects of REM sleep deprivation on the d-amphetamine-induced self-mutilating behavior

It is well known that self-mutilating behavior (SMB) is developed in rats and humans during the daily treatment with d-amphetamine. Accordingly, in this work it was found that the daily treatment with 7.5 mg/kg d-amphetamine induced in rats a progressive appearance of SMB. Lower doses (5.0 mg/kg) were uneffective and higher doses (10 mg/kg) produced a pattern of SMB in which the mutilation induced at the beginning of the d-amphetamine administration disappears completely as the treatment progresses. Interestingly, it was also found that REM sleep deprivation (48 h) potentiated significantly the SMB induced by the daily administration of 7.5 mg/kg d-amphetamine, and to lesser extent, the SMB induced by the daily treatment with 10 mg/kg d-amphetamine. R(+)-SCH-23390 a D1 dopamine (DA) receptor antagonist blocked completely or abolished the SMB induced by 7.5 mg/kg d-amphetamine in REM sleep deprived rats while (+/-)-sulpiride a D2 DA receptor antagonist had only a partial blocking effect. Haloperidol a D1/D2 DA receptor antagonist behaved as a D1 antagonist. Our results indicate that REM sleep deprivation enhances the SMB induced by the daily administration of d-amphetamine and suggest the involvement of D1 DA receptors in the mechanism underlying the SMB. A role of REM sleep deprivation is also suggested in the appearance of self-mutilating episodes in d-amphetamine addicts.

Plasma beta-endorphin concentrations in people with learning disability and self-injurious and/or autistic behaviour

BACKGROUND

It has been suggested that the key variable in reduced plasma immunoreactive beta-endorphin concentrations in autistic subjects may be concomitant self-injurious behaviour.

METHOD

We studied morning levels of plasma beta-endorphin in 33 learning disabled people with self-injurious and/or autistic behaviour.

RESULTS

The beta-endorphin level of the subjects with severe self-injurious behaviour proved to be significantly lower than of autistic subjects without severe self-injurious behaviour (3.6 (1.4) pmol/l v. 5.8 (4.3) pmol/l; t-test: P = 0.045. Replication: 3.7 (1.1) pmol/l v. 5.7 (3.8) pmol/l; t-test: P = 0.043). Individuals with mild and occasional self-injurious behaviour were found to have beta-endorphin levels comparable to those without self-injurious behaviour. Further, subjects being treated with neuroleptics and lower beta-endorphin levels than untreated subjects.

CONCLUSIONS

These results stress that in any study of opioid systems of learning disabled people, it is very important to differentiate between people with and without severe self-injurious behaviour. The results support the idea that severe self-injurious behaviour may be related to functional disturbances in the endogenous opioid system.

Self-injurious behavior: pathophysiology and implications for treatment

BACKGROUND

Self-injurious behavior (SIB) is a common clinical problem that affects a diverse group of patients and populations. Little is known about the underlying pathophysiology and pharmacologic treatment of SIB.

METHOD

The authors selectively reviewed the clinical literature on SIB and related aggressive/impulsive behaviors, with the aim of formulating provisional guidelines for pharmacotherapy.

RESULTS

The serotonergic system is most directly implicated in the pathophysiology of SIB and related behaviors. While there is no well-established "drug of choice" for SIB, the identification of specific subgroups of SIB patients and associated symptoms such as psychosis permits the rational selection of medication. Serotonin selective reuptake inhibitors, other serotonergic agents, antipsychotics, beta-blockers, and opiate antagonists all play a role in the treatment of SIB.

CONCLUSION

SIB is not a single entity and may have different pharmacologic treatments, depending on the associated symptoms and target population. Medications that act on the serotonergic system appear to be the most promising.

The spasmodic upper-body squeeze: a characteristic behavior in Smith-Magenis syndrome

The authors have observed a hand- and arm-squeezing behavior that seems to be highly characteristic of Smith-Magenis syndrome (SMS). This behavior serves as a useful diagnostic marker for SMS, a disorder in which the physical phenotype is often subtle. The squeezing behavior appears to be part of a complex upper-body tic which is exacerbated by happiness, excitement or overstimulation. The tic most often manifests as a 'self-hug', and is frequently associated with facial grimacing. Fleeting arm- and hand-squeezing movements may be repeated hundreds of times over the course of a day, but they do not significantly interfere with other hand functions. The excitable self-hugging in people with SMS may be one of the more benign and appealing aspects of their behavioral phenotype.

Positive side effects in the treatment of SIB using the Self-Injurious Behavior Inhibiting System (SIBIS): implications for operant and biochemical explanations of SIB

The rate of self-injurious head hitting was reduced using contingent electric shock delivered via the Self-Injurious Behavior Inhibiting System (SIBIS). Positive side effects indicating an improved affective state and increased interaction with the environment were documented. Treatment gains were maintained at a 1-year follow-up assessment. The consistent reports of positive affective side effects from successful treatment studies using SIBIS and contingent electric shock are noted. Implications for current operant-based theories of SIB based on the communication function of SIB and endogenous opiate mechanisms are discussed.

Self-injury by people with mental retardation: a compulsive behavior hypothesis

Self-injury is a significant problem for many individuals with developmental disabilities, particularly those with severe or profound mental retardation. Many hypotheses have been suggested to account for self-injury, but none has been comprehensive. In this paper hypotheses suggesting psychological, behavioral, physiological, or neurochemical factors as causes of self-injury were critically reviewed. A compulsive behavior hypothesis was then introduced, which allows for alternative interpretations of some existing data and suggests several readily testable predictions.

[Aggression and autoaggression]

This paper attempts to describe the relationship between violence and suicidality according to phenomenological, biological and psychodynamic aspects. In bringing together these aspects a model of human aggressive behaviour is represented.

Anatomy of self-injurious, stereotypic, and aggressive movements: evidence for involuntary explanation

Self-injurious movements, common in persons diagnosed with Tourette syndrome, or mental retardation, are typically difficult to eliminate. The author considers the possibility that certain self-injurious movements are involuntary phenomena. An anatomical analysis of high-frequency movements in a patient with severe head slapping is presented by tracing the muscles and nerves involved. The median nerve innervates muscles that bring the hand/arm to the head and also muscles that control this patient's other frequent movements, viz., pill-rolling, thumb-gouging, wrist-flapping, and pinching the neck or cheek. Other patients underwent similar investigation: one who headbangs, one who hits out repetitively, and one with non-injurious stereotypic movements. An anatomical explanation suggests that certain self-injurious, aggressive, and stereotypic movements are involuntary muscle contractions that reflect abnormal innervation along specific nerves.

Effects of linear vestibular stimulation on body-rocking behavior in adults with profound mental retardation

The effects of linear vestibular stimulation on body-rocking behaviors in adults with profound mental retardation were studied. A single-system multiple base-line design across 3 subjects was used. The design included three phases spread over a period of 9 weeks. An interval time sampling procedure was used to collect data. Data from the 3 subjects were graphed and interpreted through visual inspection. Trend lines were computed with the celeration line approach to supplement the visual inspection of the data. The results demonstrated a decrease in body-rocking behaviors during the treatment and follow-up phases for Subject 2 but no obvious change in performance for Subjects 1 and 3. A lengthier treatment period and selection of subjects with similar body-rocking frequencies are suggested for further research.

Inherited propensity for neuropathic pain is mediated by sensitivity to injury discharge

We reported previously that injury discharge (ID), a burst of impulses fired following nerve injury, plays a role in triggering autotomy, a neuropathic pain-related behavior in rats. Here we affirm this link using two lines of rats, derived by selective breeding from the Sabra strain to express high (HA) or low (LA) levels of autotomy following hindpaw denervation. Blocking ID in HA rats before injury suppressed autotomy. Correspondingly, artificial prolongation of ID in LA rats just prior to neurectomy, increased autotomy. The autotomy in these HA and LA rats was like that of their Sabra ancestors. This suggests that the underlying basis for selection of these lines was differential sensitivity of the CNS to the effects of ID.