Self-injurious behaviour and body site preference

Stress-Induced Auto-Cannibalism in Patients With a History of Moderate Traumatic Brain Injury

A traumatic brain injury (TBI) is a significant factor in injury-related deaths in the United States and may lead to complex psychological disorders. Auto-cannibalism as a sequela of a TBI has yet to be reported in the literature. The current literature regarding such behavior is often associated with psychosis, intellectual disability, or substance use. A 35-year-old male had a past medical history significant for a TBI a decade ago. He was transferred to the emergency department due to a self-inflicted wound. The patient had been scratching his arms and legs for the last few months and displayed an intense new pattern of self-destructive behavior in the past week. He went through surgical wound debridement and psychiatric evaluation before he was discharged home. This case depicts the importance of regular, long-term psychiatric, and neurological follow-up for patients sustaining TBIs, regardless of whether or not they were previously deemed stable. A greater understanding of many factors leading to self-destructive behavior following TBIs is needed to improve patient outcomes.

Behavioral Treatment of Self-Injury: 2001 to 2016

Individuals diagnosed with intellectual and developmental disabilities (IDD) frequently exhibit self-injurious behavior (SIB). Previous research has examined the published literature on behavioral treatments of SIB from 1964-2000. Results suggested that these treatments were highly efficacious at decreasing SIB, particularly when based on the results of a functional assessment. The purpose of this review is to update, replicate, and extend the previous research. The current findings indicate an increase in studies reporting automatically maintained SIB as well as less efficacious treatments overall. Discussion of our conclusions and methods of SIB assessment and treatment are discussed, both as they relate to the previous review and for future directions.

The Pemoline Model of Self-Injurious Behavior: An Update

Neurodevelopmental disorders typically comprise a complex constellation of behavioral symptoms and neurochemical abnormalities. However, many of the symptoms are inconsistently expressed within any one particular patient group or overlap between patient groups. In other words, there is usually heterogeneity of symptoms between diagnostic groups, and there is often partial homogeneity of symptoms across these groups. These include cognitive deficits, emotional lability, and perseverative or aberrant behaviors. Animal models of neurodevelopmental disorders typically reproduce or mimic specific genetic, neurochemical, and/or behavioral sequelae, although they typically fail to replicate the entire spectrum of biological and behavioral characteristics. Indeed, it may be impractical or even impossible to model the entire spectrum of characteristics of a disorder in any single animal model. A focus on one or more specific behavioral characteristics that occur in multiple neurodevelopmental disorders (e.g., self-injury) may be a fruitful strategy. The development of these behaviorally focused models may yield increased understanding of the endogenous and environmental factors that confer vulnerability for aberrant behaviors that commonly occur in these disorders. One such behaviorally focused animal model is the pemoline model of self-injurious behavior.

Classification of injuries observed in functional classes of self-injurious behaviour

BACKGROUND

Limited research has examined how the functions of self-injurious behaviour (SIB) relate to the production of injuries and the location, type or severity of those injuries.

METHODS

Clinical and medical records were coded for 64 individuals hospitalised for SIB. When injuries were present, the physical properties of SIB and injuries were assessed across groups of individuals with automatically and socially maintained SIB.

RESULTS

Injuries were observed for 35 of the individuals who engaged in SIB. Individuals who engaged in a single form of SIB were more likely to have injuries (P < .05). Individuals with SIB maintained by automatic reinforcement had significantly more severe injuries to the head than those in the social group (q < .05, P = .0132, H = 12.54).

CONCLUSION

Although results are preliminary, the results provide evidence that the function of SIB may influence the severity and location of injuries produced.

Does a negative discriminative stimulus function as a punishing consequence?

The study and use of punishment in behavioral treatments has been constrained by ethical concerns. However, there remains a need to reduce harmful behavior unable to be reduced by differential-reinforcement procedures. We investigated whether response-contingent presentation of a negative discriminative stimulus previously correlated with an absence of reinforcers would punish behavior maintained by positive reinforcers. Across four conditions, pigeons were trained to discriminate between a positive discriminative stimulus (S+) signaling the presence of food, and a negative discriminative stimulus (S-) signaling the absence of food. Once learned, every five responses on average to the S+ produced S- for a duration of 1.5 s. S+ response rate decreased for a majority of pigeons when responses produced S-, compared to when they did not, or when a neutral control stimulus was presented. In Condition 5, choice between two concurrently presented S+ alternatives shifted away from the alternative producing S-, despite a 1:1 reinforcer ratio. Therefore, presenting contingent S- stimuli punishes operant behavior maintained on simple schedules and in choice situations. Development of negative discriminative stimuli as punishers of operant behavior could provide an effective approach to behavioral treatments for problem behavior and subverting suboptimal choices involved in addictions.

Unusual devastating self-injurious behaviour in a patient with a severe learning disability: treatment with citalopram

Physicians caring for people with severe learning disabilities are frequently faced with the problem of self-injurious behaviour, which often takes a chronic course. Among neurotransmitter systems the serotonergic system in particular is thought to be involved in the initiation and maintenance of self-injurious behaviour, and pharmacological treatment with serotonin enhancers or serotonin reuptake inhibitors has been shown to reduce impulsive aggressive behaviour.

Potential Risk Factors for the Development of Self-Injurious Behavior among Infants at Risk for Autism Spectrum Disorder

Prevalence of self-injurious behavior (SIB) is as high as 50% among children with autism spectrum disorder (ASD). Identification of risk factors for the development of SIB is critical to early intervention and prevention. However, there is little empirical research utilizing a prospective design to identify early risk factors for SIB. The purpose of this study was to evaluate behavioral characteristics predicting SIB at age 2 years among 235 infants at high familial risk for ASD. Logistic regression results indicated that presence of SIB or proto-SIB and lower developmental functioning at age 12 months significantly predicted SIB at 24 months. A pattern of persistent SIB over this period was associated with a diagnosis of autism and poorer cognitive and adaptive outcomes.

Typical Skin Injuries in Children With Autism Spectrum Disorder

Pediatric skin injuries have primarily been described in typically developing children. Our objectives were to describe the prevalence and pattern of skin injuries of children with autism spectrum disorder (ASD), to describe how this compared with previously demonstrated skin injury locations in typically developing children, and to identify differences in skin injury frequency and locations between autistic children with and without self-injurious behaviors (SIBs). Children with ASD were recruited between September of 2011 and September of 2014. Demographic information was obtained from the caregiver. All skin injuries and their locations were documented. Of the 41 children enrolled, half were reported to have SIBs. The most identified skin injury locations were the legs, knees, and back. Children with autism (1) obtain skin injuries frequently and in similar locations as typically developing children and (2) rarely obtain skin injuries to locations that are considered uncommon for accidental injuries despite reports of SIBs.

Use of the universal pain assessment tool for evaluating pain associated with TMD in youngsters with an intellectual disability

Background

The Universal Pain Assessment Tool (UPAT) was used to assess the level of pain in people with limited communication skills. The UPAT enables clinicians to consult a specialized pain management team more often and lead to earlier interventions. The purpose of this study was to determine, whether the UPAT could be used as an extra tool to collect data on functional TMJ pain and to assess orofacial pain levels related to temporomandibular disorder(s) (TMD) in people with intellectual disabilities (ID).

Material and Methods

Non-down syndrome ID Athletes were screened during the Special Olympics European games in 2014. The clinical scores of possible functional jaw pain were collected using the UPAT, to indicate pain severity on a visual scale during different jaw movements (opening, closing and lateral).

Results

Two hundred and four youngsters were screened by calibrated dentists. The majority (65%) of participants were male (133 male and 71 female athletes); age distribution ranged from 15 to 23 years (mean 19.25 ± 2.53). The results of the UPAT have shown the existence of functional TMJ pain in 32% (n=65) of the athletes without significant prevalence (P > 0.05) in this survey group.

Conclusions

According to the results of the present study, the UPAT demonstrated that it could be a useful tool to detect the existence of functional jaw pain possibly associated with TMD and also a valid instrument to score pain intensity associated with TMD in people with ID.

Key words:Universal pain assessment tool - TMD in ID - TMD in youngsters.

Naltrexone treatment reverses astrocyte atrophy and immune dysfunction in self-harming macaques

The role of glia in the development and treatment of behavioral abnormalities is understudied. Recent reports have observed glial activation in several disorders, including depression, autism spectrum disorders and self-injurious behaviors (SIB). In the current study, we examined SIB in the physiologically and anatomically relevant nonhuman primate (NHP) model. At the Tulane National Primate Research Center (TNPRC), approximately 5% of singly housed macaques develop symptoms of SIB. We have previously demonstrated that naltrexone hydrochloride can be effective in reducing SIB. We have also demonstrated that the astrocytes of animals with SIB are distinctly atrophic and display heightened innate immune activation compared with control animals. We have added a third group of animals (five macaques identified with SIB and treated with oral naltrexone at a dose of 3.2mg/kg) to the previous cohort (six macaques with a history of SIB but not treated, and nine animals with no history of SIB) for this study. Gray and white matter astrocytes from frontal cortical tissue were examined following necropsy. Innate immune activation of astrocytes, which was increased in SIB animals, was markedly decreased in animals receiving naltrexone, as was atrophy of both grey and white matter astrocytes. This was concomitant with improved behavioral correlates. Preventing astrocyte activation in select areas of the brain to reduce injurious behavior is an innovative concept with implications for mental health studies. Differences in multiple areas of primate brain would help determine how self-injurious behavior develops. These studies suggest a stronger role for astrocytes in the cellular events associated with self-injurious behaviors.

Delineating subtypes of self-injurious behavior maintained by automatic reinforcement

Self-injurious behavior (SIB) is maintained by automatic reinforcement in roughly 25% of cases. Automatically reinforced SIB typically has been considered a single functional category, and is less understood than socially reinforced SIB. Subtyping automatically reinforced SIB into functional categories has the potential to guide the development of more targeted interventions and increase our understanding of its biological underpinnings. The current study involved an analysis of 39 individuals with automatically reinforced SIB and a comparison group of 13 individuals with socially reinforced SIB. Automatically reinforced SIB was categorized into 3 subtypes based on patterns of responding in the functional analysis and the presence of self-restraint. These response features were selected as the basis for subtyping on the premise that they could reflect functional properties of SIB unique to each subtype. Analysis of treatment data revealed important differences across subtypes and provides preliminary support to warrant additional research on this proposed subtyping model.

Experimental functional analysis of severe skin-picking behavior in Prader-Willi syndrome

Skin picking is an extremely distressing and treatment resistant behavior commonly shown by individuals with Prader-Willi syndrome (PWS). However, with the exception of a limited number of published single-case and survey studies, little is known about the environmental determinants of skin picking in this population. In this study, functional analyses were conducted with thirteen individuals with PWS, aged 6-23 years, who engaged in severe skin-picking behavior. In addition to the conditions typically employed in a functional analysis (i.e., alone, attention, play, demand), we included an ignore condition to examine potential effects of stimulus control by the presence of an adult. Twelve participants engaged in skin picking during the functional analysis, with the highest levels occurring in the alone and ignore conditions for eight participants, suggesting that skin picking in these participants was maintained by automatic reinforcement. For the remaining four participants, an undifferentiated pattern of low-rate skin picking was observed across conditions. These data confirm previous studies indicating that skin picking in PWS may be maintained most often by automatically produced sensory consequences. There were no associations between demographic characteristics of the participants (e.g., sex, age, IQ or BMI) and levels of skin picking observed in the functional analysis. Additional investigations are needed to identify the nature of the sensory consequences produced during episodes of skin picking in PWS. Behavioral interventions designed to extinguish or compete with the potential sensory consequences arising from skin picking in PWS are also warranted.

Auto cannibalism in mental retardation

Mental retardation (MR) deems an individual more vulnerable to psychopathologies. The individual may develop an array of behavioral disturbances manifesting themselves in the form of aggressive and destructive conduct, violent fits of anger, stereotyped, or self-injuring behavior. Self-injurious behavior is heterogeneous in nature ranging from mild to severe variant. We report a case of a 7-year-old boy with MR with self-inflicted severe oral injuries of cannibalistic nature presenting as cleft lip and palate. A more extensive research is needed on the problem behaviors in mentally retarded patients for early detection and effective and timely intervention leading to a better outcome.

Aggressive behaviour and its prevalence within five typologies

Crucial to understanding an individual, presenting with intellectual disability and the management of their challenging behaviours, is the knowledge of the types of those specific behaviours. The term aggressive behaviour is a universal term that embraces many aspects of behaviour that vary in terms of severity, frequency and seriousness for the individual and those around them. Hence, greater consideration regarding intervention, management, person-centred strategies and prevalence and frequency rates are required in service provision for individuals with intellectual disability and aggressive behaviour. This review presents the context of aggressive behaviour and its prevalence within the five typologies of aggressive behaviour: verbal aggression, aggression against others, sexually inappropriate behaviour, self-injurious behaviour and aggression against property, as identified by Crocker et al. (2007). The focus of this review is to report on the prevalence of aggressive behaviour reported for individuals with intellectual disability and consider the ambiguity in defining aggressive behaviour.

An analysis of the topography, severity, potential sources of reinforcement, and treatments utilized for skin picking in Prader-Willi syndrome

We examined the topography, severity, potential sources of reinforcement, and treatments utilized for skin-picking behavior shown by individuals with Prader-Willi syndrome (PWS). The parents of 55 individuals with PWS, aged 6-25 years, were interviewed about their child's skin-picking behavior using the Self-Injury Trauma Scale (SIT; Iwata, Pace, Kissel, Nau, & Farber, 1990) and the Functional Analysis Screening Tool (FAST; Iwata, DeLeon, & Roscoe, 2013). Results showed that skin picking in PWS occurred on the extremities (i.e., arms, legs, hands, and feet) for 75% of cases and resulted in bodily injury for 83.7% cases. Skin picking posed a high risk to the individual concerned in 41.8% of cases. Automatic sensory stimulation was identified as a potential source of reinforcement in the majority of cases (52.7%) followed by access to social attention or preferred items (36.4%). Treatments utilized by parents were primarily behavioral strategies (56.3%) followed by basic first aid (54.5%). There were no differences in the topography, severity or potential source of reinforcement between those with the deletion (DEL) subtype and those with the uniparental disomy (UPD) subtype. Taken together, these data indicate that skin picking shown by individuals with PWS is a particularly severe and intractable behavioral issue that may be maintained by (as yet unknown) sensory consequences. Further studies to identify the determinants of skin picking in PWS are therefore needed. The implications for interventions are discussed.

The pemoline model of self-injurious behaviour

Traditional models of neuropsychiatric disorders consist of attempts to replicate the broad spectrum of behavioural and neurochemical sequelae that characterize a specific disorder. However, these disorders comprise complex constellations of symptoms, including emotional instability, perseverative thoughts, and aberrant behaviours. Close examination often reveals heterogeneity of symptom expression within patient groups and homogeneity in expression of specific symptoms across diagnostic categories. Accordingly, it may not be possible to model the entire spectrum of characteristics for any one of these disorders in any single animal model. A focus on one or more specific behavioural characteristics (e.g. self-injury) may be a more fruitful strategy. Development of behaviourally focused models yields increased understanding of the genetic basis and biochemical abnormalities that underlie specific psychiatric dysfunctions. Furthermore, by revealing pathophysiology that underlies specific disease characteristics, behaviourally focused models improve translational power and help to identify targets for effective pharmacotherapies. One such behaviourally focused animal model is the pemoline model of self-injurious behaviour.

Evidence-based behavioral interventions for repetitive behaviors in autism

Restricted and repetitive behaviors (RRBs) are a core symptom of autism spectrum disorders (ASD). There has been an increased research emphasis on repetitive behaviors; however, this research primarily has focused on phenomenology and mechanisms. Thus, the knowledge base on interventions is lagging behind other areas of research. The literature suggests there are evidence-based practices to treat "lower order" RRBs in ASD (e.g., stereotypies); yet, there is a lack of a focused program of intervention research for "higher order" behaviors (e.g., insistence on sameness). This paper will (a) discuss barriers to intervention development for RRBs; (b) review evidence-based interventions to treat RRBs in ASD, with a focus on higher order behaviors; and (c) conclude with recommendations for practice and research.

Self-injurious behaviour: limbic dysregulation and stress effects in an animal model

BACKGROUND

Self-injurious behaviour (SIB) is prevalent in neurodevelopmental disorders, but its expression is highly variable within, and between diagnostic categories. This raises questions about the factors that contribute to aetiology and expression of SIB. Expression of SIB is generally described in relation to social reinforcement. However, variables that predispose vulnerability have not been as clearly characterised. This study reports the aetiology and expression of self-injury in an animal model of pemoline-induced SIB. It describes changes in gross neuronal activity in selected brain regions after chronic treatment with pemoline, and it describes the impact that a history of social defeat stress has on the subsequent expression of SIB during pemoline treatment.

METHODS

Experiment 1--Male Long-Evans rats were injected on each of five consecutive days with pemoline or vehicle, and the expression of SIB was evaluated using a rating scale. The brains were harvested on the morning of the sixth day, and were assayed for expression of cytochrome oxidase, an index of sustained neuronal metabolic activity. Experiment 2--Male Long-Evans rats were exposed to a regimen of 12 daily sessions of social defeat stress or 12 daily sessions of handling (i.e. controls). Starting on the day after completion of the social defeat or handling regimen, each rat was given five daily injections of pemoline. The durations of self-injurious oral contact and other stereotyped behaviours were monitored, and the areas of tissue injury were quantified.

RESULTS

Experiment 1--Neuronal metabolic activity was significantly lower in a variety of limbic and limbic-associated brain structures in the pemoline-treated rats, when compared with activity in the same regions of vehicle-treated controls. In addition, neuronal activity was low in the caudate-putamen, and in subfields of the hypothalamus, but did not differ between groups for a variety of other brain regions, including nucleus accumbens, substantia nigra, ventral tegmentum, thalamus, amygdala, and cortical regions. Experiment 2--All the pemoline-treated rats exhibited SIB, and whereas the social defeat regimen did not alter the total amount of self-injurious oral contact or other stereotyped behaviours, it significantly increased the severity of tissue injury.

CONCLUSIONS

A broad sampling of regional metabolic activity indicates that the pemoline regimen produces enduring changes that are localised to specific limbic, hypothalamic and striatal structures. The potential role of limbic function in aetiology of SIB is further supported by the finding that pemoline-induced self-injury is exacerbated by prior exposure to social defeat stress. Overall, the results suggest brain targets that should be investigated further, and increase our understanding of the putative role that stress plays in the pathophysiology of SIB.

Recent research on aetiology, development and phenomenology of self-injurious behaviour in people with intellectual disabilities: a systematic review and implications for treatment

BACKGROUND

Behavioural interventions conceptualise self-injurious behaviour (SIB) as developing from early repetitive behaviours through acquisition of homeostatic functions in regulating stimulation and subsequent shaping into SIB through socially mediated or automatic operant reinforcement. Despite high success rates, such interventions rarely completely eliminate SIB, and overall effectiveness has not increased since the 1960s.

METHODS

Research (excluding studies of single genetic syndromes) on the early development, functional properties and phenomenology of SIB in persons with intellectual disabilities (IDs) published from 1999 to 2010 inclusive is reviewed.

RESULTS

Despite evidence to support the operant shaping hypothesis, in some cases tissue-damaging SIB, especially head-banging, emerges at a similar or younger age than stereotyped behaviours or 'proto-SIB', often associated with tantrums following frustrative non-reward and/or abrupt situational transitions. Many young children show undifferentiated patterns of responding in functional analyses of SIB, and SIB is associated with aggression and impulsivity as well as with repetitive behaviour.

CONCLUSIONS

One dynamic in the development of SIB may be Pavlovian conditioning of aggression, originally elicited by aversive events or frustrative non-reward, to stimuli associated with such situations. Integration into operant technology of interventions based on Pavlovian principles such as graduated exposure (with or without counterconditioning) to aversive stimuli may enhance the effectiveness of behavioural interventions.

Self-injury in people with intellectual disability and epilepsy: a matched controlled study

We aimed to identify the presence of self-injurious behavior in a sample of 158 people with intellectual disability and epilepsy as compared with a control sample consisting of 195 people with intellectual disability without epilepsy. The Italian Scale for the Assessment of self-injurious behaviors was used to describe self-injurious behavior in both groups. The groups were matched for ID degree: mild/moderate (20 and 20 respectively), severe/profound (45 in both samples) and unknown (4 in both samples). Seventy-four percent of the first sample were diagnosed with symptomatic partial epilepsy. The prevalence of self-injurious behaviors was 44% in the group with intellectual disability and epilepsy and 46.5% in the group with intellectual disability without epilepsy (difference not significant). The areas most affected by self-injurious behaviors in both samples were the hands, the mouth and the head. The most frequent types of self-injurious behaviors were self-biting, self-hitting with hands and with objects. Self-injurious behavior is frequently observed in individuals with epilepsy and intellectual disability. Our study does not suggest that the presence of epilepsy is a risk factor for self-injurious behavior in this patient group.

Self-injurious behavior in neurodevelopmental disorders: relevance of nociceptive and immune mechanisms

Self-injurious behavior (SIB) among individuals with intellectual and related neurodevelopmental disorders (IDD) is a clinical challenge and scientific puzzle. The physiological mechanisms regulating the sensory components of SIB remain a mystery with no clear understanding of the underlying pathophysiology. The central dogma regarding sensory processing in general and pain in particular among individuals with IDD and chronic SIB is that sensory processing is reduced and pain is absent or blunted. In this paper, recent findings challenging some of the conventional wisdom regarding pain and sensory function among individuals with IDD and SIB are reviewed. It seems that at least a subgroup of individuals with IDD and chronic SIB may be in a physiological state similar to neuropathic pain in which hyperalgesia is mediated by plasticity mechanisms regulating inflammatory, immune, and nociceptive systems. In response to repeated tissue damage associated with chronic self-injury, innate immune cells may be producing pro-inflammatory and pro-nociceptive cytokines that act on the brain to cause sickness-like behavior and sensitize primary sensory nerve afferents contributing to pain hypersensitivity (i.e., hyperalgesia).

Reviewing risk for individuals with developmental disabilities

There are many categories of risky behaviors that are of interest to individuals, agencies, and institutions interested in care for developmentally disabled persons. These include challenging behaviors such as aggression and self-injury, psychiatric diagnoses, medical problems, criminal behaviors, and victimization. The literature in this area is difficult to digest due to a number of methodological problems. This paper reviews the research on one of these behaviors, self-injury, and provides a framework that can be applied to other research on predicting risk. Additionally, it attempts to organize the findings in such a way as to maximize the utility to providers and suggest useful directions for future research.

[Autism and pain - a literature review]

The purpose of the present article was to assess the available literature concerning pain and autism. First, authors summarized the published articles on pain reactivity in people with autism. Second, the hypotheses envisaged to explain the presence of expressive particularities in people with autism spectrum disorders were reviewed; these included endogenous opioid excess theory, sensorial abnormalities and sociocommunicative deficit. Finally, the present review dealt with the tools available to assess and manage pain in people with autism. In conclusion, the authors revealed the need for more research to obtain more consensual data and provided some recommendations in this domain that were under exploited by the scientific community. From a clinical point of view, more knowledge about pain in people with autism should enable the development of specific assessment tools and, consequently, better pain management in daily care.

Degranulated mast cells in the skin of adults with self-injurious behavior and neurodevelopmental disorders

The role of nociceptive processes in relation to chronic, tissue-damaging self-injury among individuals with neurodevelopmental disorders is poorly understood. Scientific investigation has been limited, in part, by the clinical reality that the majority of individuals with severe intellectual impairments have co-morbid communicative impairments making it difficult to ascertain information regarding pain. Recently, we found abnormal patterns of peripheral epidermal nerve fiber (ENF) innervation and increased neuropeptide (substance P; SP) content among a subset of individuals with chronic self-injury. Here, we provide initial evidence for peripheral neuro-immune activity specific to self-injury. Skin samples from non-injury body-matched sites were compared between non-verbal adults with and without self-injury matched on gender and disability level. Relative to disability-matched controls, individuals with chronic self-injury had significantly more degranulated mast cells and were more responsive to tactile stimulation during a sensory testing procedure. Thus, nociceptive mechanisms and peripheral afferent sensitization may play a part in mediating and maintaining chronic self-injury.

The role of endogenous opioids in the pathophysiology of self-injurious and suicidal behavior

Multiple lines of evidence suggest that endogenous opioids are involved in the pathogenesis of non-suicidal self-injury (NSSI). Evidence for such a role is based on the partial success of opioid antagonist treatment to ameliorate NSSI, reports of altered pain sensitivity during episodes of NSSI, and findings of altered endogenous opioid levels in individuals with NSSI. While suicidal behavior (SB) and NSSI are distinct behaviors, NSSI is a significant risk factor for suicide attempts and suicide. The high co-occurrence of SB and NSSI suggests that they may share a common biology. Available data indicate that endogenous opioids may be involved in the pathophysiology of SB. Future studies of the role of opioids in the biological mechanisms of NSSI and SB are merited and may lead to the development of new treatment modalities.

Glutamate-mediated neuroplasticity in an animal model of self-injurious behaviour

Self-injurious behaviour (SIB) is exhibited by individuals with a broad variety of developmental disorders and genetic abnormalities, including autism and Lesch-Nyhan, Prader-Willi and Rett syndromes. Most research has focused on environmental factors that reinforce SIB, and less is known about the biological basis of this behaviour disorder. However, animal models have been developed to study the neurochemical pathology that underlies SIB. In one model, rats exhibit self-biting after repeated daily administration of moderately high doses of pemoline (100-200mg/kg). Dopaminergic and glutamatergic neurotransmission have been implicated in this model. Accordingly, we investigated the role of glutamatergic neurotransmission in pemoline-induced SIB, using the N-methyl-d-aspartate (NMDA) receptor antagonists MK-801 and memantine. MK-801 is a high affinity antagonist which blocks glutamate-mediated neuroplasticity and behavioural sensitization to other psychostimulants. It lessened the incidence of SIB, the time spent self-injuring, and the area of tissue damage in the pemoline model. Memantine, on the other hand, is a low affinity antagonist which does not disrupt glutamate-mediated neuroplasticity, and it had little if any effect on any measure of pemoline-induced SIB. These results suggest that repeated pemoline administration induces glutamate-mediated neuroplastic changes that lead to the eventual expression of SIB. Further investigation of these changes may reveal specific neurochemical factors that contribute to SIB in this animal model of self-injury.

Evidence of altered epidermal nerve fiber morphology in adults with self-injurious behavior and neurodevelopmental disorders

The purpose of this preliminary study was to examine the morphology and neuropeptide density of epidermal nerve fibers quantified through skin biopsy samples from three adults with neurodevelopmental disorders and chronic self-injurious behavior (SIB) secondary to mental retardation compared with non-SIB normal IQ controls. A cross-sectional design was used with 3mm punch skin biopsies collected from each participant from non-self-injurious body sites and compared with site-matched existing normal control skin samples. The study was conducted at an outpatient clinic. The primary dependent measure for the morphology analyses was the coefficient of variation (CV) to quantify the mean gap length between epidermal nerve fibers for each subject. Visual microscopic examination and quantitative analysis of the microscopy images suggested there were morphological abnormalities (increased CV) in the epidermal nerve fibers among the chronic SIB cases. Substance P (SP) fiber density was increased with 2-3 times as many fibers in SIB subjects as control subjects. Additional empirical work is needed to clarify the relation between sensory innervation of the skin and self-injury to improve assessment and treatment outcomes.

Self-injurious behavior to the lower extremities among children with atypical development: a diagnostic and treatment algorithm

Self-injurious behavior is a devastating and persistent condition that results in severe tissue damage, permanent impairment, or, occasionally, death. This aberrant behavior seen in specific childhood syndromes is compounded when the lower limbs are injured. Secondary complications are more frequent, depending on the site of the injury, resulting in significant morbidity and depletion of hospital resources. A substantial body of empirical evidence indicates that this deviant behavior is partly learned and partly of biologic origin. Therefore, this article presents a case study and reviews the components of a biopsychosocial paradigm of treatment for self-inflicted wounds to the lower extremity and formulates a prototypical algorithm for its diagnosis and management.

Relation between pain and self-injurious behavior in nonverbal children with severe cognitive impairments

OBJECTIVES

To explore whether self-injurious behavior (SIB) alters pain expression in children with severe cognitive impairments and the relation between SIB and chronic pain.

STUDY DESIGN

Caregivers of 101 nonverbal children 3 to 18 years of age (55% boys) completed the Non-Communicating Children's Pain Checklist-Revised (NCCPC-R) retrospectively and for an observed pain episode. Caregivers of children with SIB (n = 44) completed the Behavior Problems Inventory, the Self-Injury Grid, and the Self-Injury and Self-Restraint Checklist.

RESULTS

Multivariate analysis of variance indicated that NCCPC-R scores did not differ between children with and those without SIB. However, t tests indicated that children with chronic pain (n = 13) self-injured less body surface (P =.01) and fewer body sites (P =.04) than did children without (n = 31). Multiple Correspondence Analysis generated 2 dimensions (49% variance), suggesting a distinction between two SIB forms: (1) high frequency of SIB to the head/hand and absence of chronic pain and (2) less frequent SIB near the site of pain.

CONCLUSIONS

Children with severe cognitive impairments who display SIB do not have reduced pain expression, and chronic pain may influence the frequency and location of SIB. Further research should examine the usefulness of these findings for management of SIB and pain.

Self-injurious behavior in young boys with fragile X syndrome

In this study, we distributed surveys to 67 families of young boys with fragile X syndrome to determine the prevalence, onset, form, function, location, and correlates of self-injurious behavior. Fifty-five surveys were completed (82%). The mean age of the boys at the time of the survey was 80 months (range = 20-144). Self-injurious behavior (SIB) was reported for 58% of the participants with a mean age of onset of 31 months. The mean number of forms of self-injury was 2 per participant. Biting was the most commonly reported form of self-injury with the fingers and back of the hand disproportionately targeted as the most prevalent self-injury body site. There was no linear increase in risk of SIB with age past 25 months. SIB was reported as most likely to occur following the presentation of difficult task demands or changes in routine. Significant group differences were found between overall ratings of problem behavior for boys with self-injury compared to those without self-injury. Groups did not differ on measures of fragile X mental retardation protein (FMRP), autism status, adaptive behavior, or age first medicated. Results are discussed in terms of future research designed to further elucidate the behavioral phenotype of fragile X syndrome.

Effects of single and repeated shock on perceived pain and startle response in healthy volunteers

Contingent shock (CS) has been used in a number of studies to suppress health-threatening self-injurious behavior of individuals with mental retardation and autism. As sustained suppression is an issue of concern, research into procedural variables of CS is needed. In this study, clinical evidence was used to infer a variable that might be of relevance for the application of clinical contingent shock, that is, to assess the effect of single versus repeated shock at a specific location on the body. With pain intensity and startle response as dependent variables, shocks were administered to 48 healthy volunteers. Electric shocks were identical to those that used in clinical practice. The second shock in succession to the same location of the body produced higher pain intensity ratings than the first shock and that the third shock in succession to the same location of the body produced higher pain intensity ratings than the second shock in succession. Startle responses, however, failed to be affected in this direction. The latter result is consistent with a previous study. Our data suggest that repeated shock to the same location is likely to be more effective to establish suppression than repeated shock to different locations.

A survey of the prevalence of stereotypy, self-injury and aggression in children and young adults with Cri du Chat syndrome

The aim of the present study was to determine the prevalence and frequency of stereotypy, self-injurious behaviour (SIB), and aggression in children and adults with Cri du Chat syndrome (CCS), and to investigate the relationship between SIB, aggressive behaviour and stereotypy in these individuals. Sixty-six families of children and adults diagnosed with CCS completed the Behaviour Problems Inventory. Additional information relating to gender, chronological age, type of school/post-school occupation and medication was also included in the survey. Stereotyped behaviour was reported for 82% of subjects, more than half the sample displaying it on a daily basis. The occurrence percentage of 15 topographies of SIB suggested that head banging, hitting the head against body parts, self-biting and rumination are the most frequently occurring behaviours in CCS. Aggressive behaviour was reported for 88%, with a statistically significant negative correlation between age and the number of aggressive behaviours reported. The present findings suggest that specific types of stereotypy and SIB are observed frequently in CCS.

Predicting the persistence of severe self-injurious behavior

Information was collected on 95 people with mental retardation who had been identified seven years previously as showing severe self-injurious behavior. At follow up 71% of participants were still showing self-injurious behavior of a severity which presented a management problem for care staff. The occurrence of specific topographies of self-injury was extremely stable among the group showing persistent self-injury. Finally, self-injury status at follow-up was predicted with 76% accuracy by a logistic regression model containing three variables: site of injury (higher persistence being shown by people exhibiting head directed self-injury); reported (greater) stability of self-injury when first identified; and (younger) age.

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.