Wanted: A vocabulary for talking about involuntary behaviors associated with Lesch-Nyhan disease

Lesch-Nyhan disease (LND) is a rare genetic disorder with an unusual behavioral phenotype that includes severe and involuntary self-injury requiring the near constant use of protective devices and, for some individuals, dental extraction. Often, the person with LND also engages in emotional self-injury in the form of both self-sabotage and behaviors directed toward others that will have a negative social consequence. When these self-destructive behaviors present themselves, it is sometimes challenging for caregivers, professionals, or other observers to fully recognize their lack of volition. It is an even greater challenge to accurately and convincingly convey their involuntary nature to medical students, colleagues, school staff, or even family members who might be unfamiliar with the disorder. It is difficult to find words to clearly and adequately convey the essence of behaviors like those that we find in LND without, in some way, implying intent.

Commentary: defining disability in health care education

According to the 2008 American Community Survey, about 12% of the population of the United States is living with one or more disabling conditions. These conditions impact lives in a variety of ways, some with more or less direct impact on an individual's health and access to health care services. Although it has been 20 years since the passage of the Americans with Disabilities Act, people with disabilities still experience health disparities and a lack of access to the appropriate care. This commentary is part of a collection of articles that describe various aspects of incorporating content into the medical school curriculum to enhance the preparation of today's medical students to meet the needs of people with disabilities. The authors briefly describe the scope of the problem and define the population of people with disabilities that constitutes the focus of the work described in the other articles in this collection.

Teaching medical students about disability: the use of standardized patients

Standardized patients (SPs), now a mainstay of the undergraduate medical education experience, are beginning to play larger roles in helping students build competencies to better serve patients who have disabilities, in educating students about the lived experiences of persons with disabilities, and in testing students' understanding of disability-related issues. In this article, the authors discuss several U.S. training programs that involve SPs who have disabilities or SPs who do not have disabilities but who portray patients who do. The authors review the goals of each program (e.g., to provide students with opportunities to gain experience with patients with disabilities), describe their commonalities (enhancing students' interview skills) and differences (some programs are educational; some are evaluative), and summarize the evaluative data of each. The authors also explore the benefits and challenges of working with SPs with disabilities and of working with SPs without disabilities. Finally, they consider the practical issues (e.g., recruiting SPs) of developing and implementing such programs.

Desired educational outcomes of disability-related training for the generalist physician: knowledge, attitudes, and skills

The problems adults with disabilities face obtaining quality primary care services are persistent and undermine national efforts to improve the health status of this group. Efforts to address this issue by providing disability-related training to physicians are hampered by limited information about what generalist physicians need to know to care for patients with disabilities. The authors consider the desired outcomes of disability-related training for generalists by exploring the contributions of the domains of knowledge, attitudes, and skills to patient-directed behavior and summarizing the empirical data.Because disability reflects a complex interplay among individual, interpersonal, institutional, community, and societal factors, generalist physicians can promote and protect the health of adults with disabilities by interventions at multiple levels. Thus, the authors use the social-ecological framework, an approach to health promotion that recognizes the complex relationships between individuals and their environments, to delineate the recommended knowledge, attitudes, and skills in the context of primary care. The importance of role models who demonstrate the three domains, the interactions among them, and issues in evaluation are also discussed. This clear delineation of the recommended educational outcomes of disability-related training in terms of knowledge, attitudes, and skills will support efforts to better prepare generalist physicians-in training and in practice-to care for adults with disabilities and to evaluate these training strategies.

Identity related to living situation in six individuals with congenital quadriplegia

PURPOSE

This study was a preliminary examination of structural aspects of identity, particularly identity associated with living situation, in individuals who have quadriplegia due to cerebral palsy.

METHOD

A hierarchical classes algorithm (HICLAS) was used to construct idiographic 'identity structure' models for three individuals who are living in an inpatient hospital setting and for three individuals living in community-based group residences.

RESULTS

Indices derived from the models indicate that the identity 'myself as one who has a disability' was structurally superordinate (i.e., resided at a high hierarchical level) for all six participants, suggesting a high level of importance of this identity in participants' sense of self. The models also indicate that while identity associated with one's particular living situation was superordinate for persons living in the hospital, it was not for persons living in community residences.

CONCLUSIONS

While conclusions based on this small sample are necessarily limited, the data suggest that identity associated with living situation might differ in structural centrality, and presumably subjective importance, for persons living in inpatient versus community-based settings.

Delineation of the motor disorder of Lesch-Nyhan disease

Lesch-Nyhan disease (LND) is caused by deficiency of the purine salvage enzyme hypoxanthine-guanine phosphoribosyltransferase (HPRT). Affected individuals exhibit over-production of uric acid, along with a characteristic neurobehavioural syndrome that includes mental retardation, recurrent self-injurious behaviour and motor disability. Prior studies involving relatively small numbers of patients have provided different conclusions on the nature of the motor disorder. The current study includes the results of a multi-centre international prospective study of the motor disorder in the largest cohort of patients studied to date. A total of 44 patients ranging from 2 to 38 years presented a characteristic motor syndrome that involved severe action dystonia superimposed on baseline hypotonia. Although some patients also displayed other extrapyramidal or pyramidal signs, these were always less prominent than dystonia. These results are compared with a comprehensive review of 122 prior reports that included a total of 254 patients. Explanations for the differing observations available in the literature are provided, along with a summary of how the motor disorder of LND relates to current understanding of its pathophysiology involving the basal ganglia.

Considering the culture of disability in cultural competence education

Cultural competence extends beyond understanding those values, beliefs, and needs that are associated with patients' age or gender or with their racial, ethnic, or religious backgrounds. People hold many simultaneous cultural associations, and each have implications for the care process. The "culture of disability" is a pan-ethnic culture for which a set of physician competencies are required to ensure appropriate, culturally sensitive care to persons with congenital or acquired disabilities. Such competencies include communicating with patients who have deficits in verbal communication and avoidance of infantilizing speech; understanding the values and needs of persons with disabilities; the ability to encourage self-advocacy skills of patients and families; acknowledging the core values of disability culture including the emphasis on interdependence rather than independence; and feeling comfortable with patients with complex disabilities. Medical schools have developed programs to increase students' exposure to persons with disabilities and it is suggested that such programs are most effective when they are the result of collaboration with community-based facilities or organizations that serve persons with disabilities in the natural environment. Combining lecture-based instruction and structured experiences with the opportunity for students to interact with patients in their natural environments may facilitate development of competencies with respect to patients with disabilities. The culture of disability should be included as one of the many cultures addressed in cultural competence initiatives in medical school and residency curricula.

Modes and patterns of self-mutilation in persons with Lesch-Nyhan disease

Lesch-Nyhan disease (LND) is a rare X-linked recessive genetic disorder associated with cognitive impairment, choreoathetosis, hyperuricemia, and the hallmark symptom of severe and involuntary self-mutilation. This study examines data gathered from a survey of 64 families in the USA and abroad regarding the self-injury of their family members who have LND. The individuals with LND ranged in age from 1 to 40 years (mean 16 years 7 months, SD 11 years 2 months) and, with the exception of one, were males. The most common initial mode of self-mutilation, and the most frequently cited past or current behavior, was biting of lips and/or fingers. Other behaviors, in order of frequency, included head banging, extension of arms when being wheeled through doorways, tipping of wheelchairs, eye-poking, fingers in wheelchair spokes, and rubbing behaviors. Hierarchical cluster analysis identified patterns of association among the types of self-mutilation. Modes of self-mutilation in which external surfaces (such as a wheelchair component) served as instruments of self-injury tended to co-occur, as did biting of lips and fingers.

Group home residents' identities as patients and as community members

OBJECTIVE

The study examined the extent to which group home residents identified with the roles of psychiatric patient and community member. It was hypothesized that a longer history of hospitalization and a lower level of functioning would be associated with a stronger patient identity and that longer community tenure would be related to a less pronounced identification with the patient role.

METHODS

Fifty-seven group home residents were given a list of 50 features, or words describing thoughts, feelings, and personal characteristics. They were asked which features they would attribute to each of two identities--"myself as a psychiatric patient" and "myself as a community member." Correlations with hospitalization history, community tenure, and level of functioning were determined.

RESULTS

Residents with greater cumulative time spent hospitalized attributed more features to their identity as a patient than to their identity as a community member, indicating a greater elaboration of patient identity. Residents with long community tenures were no more likely than those recently hospitalized to have a more extensively elaborated identity as a community member. Global functioning scores were not related to strength of identification with the patient role.

CONCLUSIONS

Identification with the patient role persists among group home residents even after relatively long tenure in the community. Providers of residential services may find it more helpful to promote positive associations with community membership rather than to attempt to reduce identification with the patient role.

Use of formal assessments among providers of residential services for the seriously mentally ill

A survey of use of formal scales in assessment was sent to 1381 agencies that provide residential services to the seriously mentally ill. 271 residential agencies responded. A majority of respondents who used formal assessments used in-house measures. Scales were used most often in client care decisions. A substantial minority of respondents reported being somewhat or very dissatisfied with existing scales. Lack of predictive ability and staff time required were the most frequently cited difficulties. The study indicates a need for better assessments to aid client-care planning, and promote interagency communication.

Self-structure in schizophrenia

This study used a set-theoretical model to construct self-perception structures and person-perception structures for 10 recently hospitalized schizophrenic patients, 10 nonschizophrenic patients recently hospitalized for depression, and 10 nonpsychiatric subjects. Overall self-perception structures were significantly less elaborated in the schizophrenic patients when compared with either the psychiatric or the nonpsychiatric comparison group. No comparable differences were found for measures taken from the person-perception structures. The degree of elaboration of self in the particular context of self as psychiatric patient was found to be correlated (r = .74, p less than .01) with Global Assessment Scale ratings of current functional level in the schizophrenic group.

Self-structure in schizophrenia

This study used a set-theoretical model to construct self-perception structures and person-perception structures for 10 recently hospitalized schizophrenic patients, 10 nonschizophrenic patients recently hospitalized for depression, and 10 nonpsychiatric subjects. Overall self-perception structures were significantly less elaborated in the schizophrenic patients when compared with either the psychiatric or the nonpsychiatric comparison group. No comparable differences were found for measures taken from the person-perception structures. The degree of elaboration of self in the particular context of self as psychiatric patient was found to be correlated (r = .74, p less than .01) with Global Assessment Scale ratings of current functional level in the schizophrenic group.