The structure and correlates of self-injurious behavior in an institutional setting

The prevalence of self-injurious behavior (SIB) in an institution for people with mental retardation was investigated. The relationship between SIB and age, sex, level of retardation, length of institutionalization, adaptive behavior, and probable causes of mental retardation was examined. A factor analysis on the topographies of SIB indicated the existence of two forms of SIB, stereotyped and social. The results are discussed in terms of probable causes of SIB.     

Severe behaviour problems associated with rapid cycling bipolar disorder in two adults with profound mental retardation

ABSTRACT. The authors report the clinical histories of two adults with profound mental retardation, features of rapid cycling bipolar disorder, and periodic maladaptive behaviour. In each case, primary features of mania and depression were identified, operationaliy defined and measured with an ongoing data system, which was used to track SIB and aggression. In the first case, data analysis across days showed that 1-week episodes of depressive features alternated with 2-week episodes of manic features and that SIB was only associated with the depressive features. In the second case, episodes of manic and depressive features alternated every few days, and aggression was only associated with the manic features. These cases suggest that severe behaviour problems can be a state-dependent phenomenon of bipolar disorder. The behaviour monitoring system provided an objective methodology for aiding in the diagnosis of bipolar disorder with profoundly handicapped adults.     

Response covariation of escape-maintained aberrant behavior correlated with sleep deprivation

We examined the relation between sleep deprivation and changes in level and allocation of aberrant behavior (aggression and self-injury) for a child with moderate mental retardation. First, a series of functional analyses identified that self-injury (SIB) and aggression were maintained by escape from demands (i.e., were members of the same response class). Escape from demand conditions were then held constant over time while natural levels of sleep deprivation occurred. This final analysis demonstrated a correlation between sleep deprivation and increases in escape-maintained aberrant behavior. Sleep deprivation seemed to be related to increases in levels of self-injury but did not seem to influence levels of aggression.     

Fluoxetine treatment of depression and associated self-injury in two adults with mental retardation

ABSTRACT. The use of fluoxeiine to treat chronic depression and associated self-injurious behaviour (SIB) in a woman with severe mental retardation and a man with profound mental retardation is reported. In the first case, behavioural monitoring of treatment response revealed a dramatic decrease in SIB and a normalization of the woman's sleep disturbance. In the second case, SIB and the use of mechanical restraint decreased substantially. In both cases, anecdotal reports also indicated a diminution of other depressive symptoms. These cases highlight the need to consider an affective disorder as a cause of SIB in persons with severe and profound developmental disabilities. The behaviour monitoring system proved to be a practical aid in the diagnosis of depression and evaluation of antidepressant treatment in individuals who were incapable of self-report.     

Treatment of previously undiagnosed psychiatric disorders in persons with developmental disabilities decreased or eliminated self-injurious behavior

BACKGROUND: Self-injurious behavior (SIB) is one of the most common challenging behaviors in persons with autistic disorder or severe/profound mental retardation. Many psychotropic drugs have been evaluated for their effectiveness in SIB. Results have varied, and no one psychotropic drug has been indicated for SIB. In this prospective, open clinical study, psychotropic drugs were used to treat the previously undiagnosed psychiatric disorder in persons exhibiting SIB. METHOD: Data were collected from 26 individuals with mental retardation (14 males, 12 females), 7 to 45 years of age (mean = 30.3 years), who exhibited SIB. Psychiatric diagnosis was made according to DSM-III-R and DSM-IV criteria. The Behavior Problem Inventory, Yudofsky's Overt Aggression Scale, repeated direct observation, and information on use of protective devices and Likert scales from log books were used to evaluate degree of SIB. Most of the patients were treated with different psychotropic drugs and behavior modification before they were evaluated for this study, but only 7 of them carried a psychiatric diagnosis. Data were collected between 1987 and 1997. RESULTS: Depressive disorders, impulse-control disorder, and anxiety disorder were the most common final diagnoses. Neuroleptics were discontinued in 5 patients and tapered by 50% to 75% in 14 patients. Antidepressants were added in 12 patients. Treatment of psychiatric disorders produced significant (p < .001) decrease in the severity of SIB in the 26 patients, and SIB was eliminated in 12 patients. The severity of SIB decreased to mild from a moderate, severe, or extreme degree in 11 patients and from an extreme to a severe degree in 3 patients. CONCLUSION: The most effective treatment for SIB that is resistant to environment changes and behavior modification in persons with developmental disabilities is the treatment of their psychiatric disorders with the appropriate psychotropics.     

Correlates of interventions with self-injurious behaviour

ABSTRACT. A review was conducted of published intervention research on the self-injurious behaviour (SIB) of individuals with severe or profound mental retardation. The review comprised articles published between 1980 and 1990. Thirty-eight biodemographic and environmental variables were investigated, with type of SIB and intervention type considered primary variable classes. Efficacy was also investigated as an additional variable. Cross-tabulations were performed on selected variables with 24 significant and five marginally significant results obtained. These results indicated that there were possible biases in treatment approaches, problems in compliance with standards of practice, and differential efficacy levels related to certain variable types. Findings were discussed in relation to establishing a prototype for successful SIB interventions.     

Risperidone for Aggression and Self-Injurious Behavior in Adults with Mental Retardation

Risperidone has proven efficacy with reduced likelihood of causing extrapyramidal symptoms in the treatment of schizophrenia. Initial work suggests its utility in the management of aggression and self injury in patients with mental retardation. The use of risperidone in eight adult patients with moderate to profound mental retardation is described. Risperidone in these individuals was associated with significant reduction in aggression and self injurious behavior. Side effects were primarily those of sedation and restlessness. These cases illustrate the possible utility of risperidone in the treatment of aggression and self injury in adult patients with moderate to profound mental retardation.     

Naltrexone attenuates self-injurious behavior in mentally retarded subjects

The effect of naltrexone on the frequency of self-injurious behavior (SIB) was investigated in 6 male subjects with profound mental retardation. Following a double-blind placebo-controlled crossover design, naltrexone was administered in a dose of 50 mg once daily for 3 consecutive weeks. In 2 of 5 subjects, a significant decrease of SIB frequency could be demonstrated, and in 1, a tendency to a reduction was found. No effect on duration of restrain time was found in 3 subjects. These data suggest that disturbances of the endogenous opioid systems may be involved in the pathophysiology of SIB of certain patients.     

Effects of a topical anesthetic on non-socially maintained self-injurious behavior

In the present study we hypothesized that the self-injurious behavior (SIB) of a 12-year-old male diagnosed as having autism and severe mental retardation was maintained by automatic reinforcement. Further, we hypothesized SIB served a sensory reinforcement function related to sensation at the skin surface. The participant engaged in high rates of SIB in the form of self-slapping. A functional analysis resulted in undifferentiated findings. Additional observations indicated that SIB occurred only to exposed skin surfaces. To test for a sensory function, we applied a topical anesthetic to the participant's skin. SIB was reduced by 20 to 60% after application of the dermal anesthetic. These results support an automatic reinforcement hypothesis. Implications for treatment are discussed.     

Naltrexone as a treatment of self-injurious behavior--a case report

OBJECTIVE: Self-injurious (SIB) is a phenomenon associated with different psychopathological conditions such as psychosis, mental retardation and especially severe personality disorders--mainly of the borderline subtype. It has been suggested that a blockade of the endogenous opoid system might lead to a reduction of the urge to SIB. METHOD: The case and successful treatment of SIB with naltrexone in a patient with borderline personality disorder and dysthymia is described. RESULTS: After treatment trials with neuroleptics, antidepressants and valproate the patient was treated with naltrexone in a dosis of 50 mg/day and did not show SIB over a follow-up period of 32 weeks. CONCLUSION: Naltrexone could be effective in reducing SIB in patients with psychiatric disorders by blocking the positive reinforcement of SIB, which is released by the release of endogenous opoides. Placebo-controlled studies of the efficacy of naltrexone in treating SIB should be undertaken.     

A review of behavioral treatments used for Lesch-Nyhan syndrome

Lesch-Nyhan syndrome is a genetic disorder resulting in hyperuricemia, choreoathetosis, mental retardation, and self-mutilation. The most salient feature of this disorder is the self-injurious behavior (SIB). Although the utility of behavioral interventions with SIB has been well documented, behavioral interventions with Lesch-Nyhan syndrome have been limited in number and long-term success. This article reviews the behavioral treatments that have been used in treating individuals with Lesch-Nyhan syndrome and discusses the strengths and weaknesses of these methods. Suggestions for future directions in the use of behavioral interventions for controlling SIB in Lesch-Nyhan syndrome are provided.     

Self-injurious behavior and tuberous sclerosis complex: frequency and possible associations in a population of 257 patients

Self-injurious behavior (SIB) has been observed in people with tuberous sclerosis complex (TSC), although the frequency of SIB in TSC is largely unknown. SIB is associated with intellectual and developmental disabilities, but there is no single cause of SIB. We retrospectively examined the frequency of SIB in a population of 257 patients with TSC and determined possible associations with SIB. We found a 10% frequency of SIB in our TSC population. When compared with patients without psychiatric symptoms, we identified a significantly higher rate of electroencephalographic interictal spikes in the left frontal lobe and a significantly lower number of tubers in the left occipital, parietal, and posterior temporal lobes. We also found that frequency of TSC2 mutation, history of infantile spasms, history of seizures, mental retardation, and autism are significantly associated with SIB.     

Self-injurious behavior among Greek male prisoners: Prevalence and risk factors

BackgroundSelf-harm among prisoners is a common phenomenon. This study aims to estimate the prevalence of self-injurious behavior (SIB) among Greek male prisoners, record their motives and determine independent risk factors.MethodsA self-administered, anonymous questionnaire was administered to 173 male prisoners in the Chalkida prison, Greece. The questionnaire included items on self-harm/SIB, demographic parameters, childhood history, family history, physical and mental disease, lifestyle and smoking habits, alcohol dependence (CAGE questionnaire), illicit substance use, aggression (Buss–Perry Aggression Questionnaire [BPAQ] and Lifetime History of Aggression [LTHA]), impulsivity (Barrat Impulsivity Scale-11) and suicidal ideation (Spectrum of Suicidal Behavior Scale). Univariate nonparametric statistics and multivariate ordinal logistic regression were performed.ResultsOf all the participants, 49.4% (95% CI: 41.5–57.3%) disclosed self-harm (direct or indirect). The prevalence of SIB was equal to 34.8% (95% CI: 27.5–42.6%). Most frequently, SIB coexisted with indirect self-harm (80.7%). The most common underlying motives were to obtain emotional release (31.6%) and to release anger (21.1%). At the univariate analysis, SIB was positively associated with a host of closely related factors: low education, physical/sexual abuse in childhood, parental neglect, parental divorce, alcoholism in family, psychiatric condition in family, recidivism, age, sentence already served, impulsivity, aggression, alcohol dependence, self-reported diagnosed psychiatric condition and illicit substance use. Childhood variables were particularly associated with the presence of diagnosed psychiatric condition. At the multivariate analysis, however, only three parameters were proven independent risk factors: self-reported diagnosed psychiatric condition, illicit substance use and aggression (BPAQ scale).ConclusionThe prevalence of SIB is particularly high. Psychiatric condition, illicit substance use and aggression seem to be the most meaningful risk factors; childhood events seem only to act indirectly.     

Self-injurious behavior and tuberous sclerosis complex: Frequency and possible associations in a population of 257 patients

Self-injurious behavior (SIB) has been observed in people with tuberous sclerosis complex (TSC), although the frequency of SIB in TSC is largely unknown. SIB is associated with intellectual and developmental disabilities, but there is no single cause of SIB. We retrospectively examined the frequency of SIB in a population of 257 patients with TSC and determined possible associations with SIB. We found a 10% frequency of SIB in our TSC population. When compared with patients without psychiatric symptoms, we identified a significantly higher rate of electroencephalographic interictal spikes in the left frontal lobe and a significantly lower number of tubers in the left occipital, parietal, and posterior temporal lobes. We also found that frequency of TSC2 mutation, history of infantile spasms, history of seizures, mental retardation, and autism are significantly associated with SIB.     

Psychosurgery for self-injurious behavior in Tourette's disorder

One of the most serious and difficult-to-treat conditions in child and adolescent psychiatry is self-injurious behavior (SIB). SIB can be associated with a number of psychiatric disorders, including mental retardation, schizophrenia, borderline personality disorder, pervasive developmental disorders, stereotypic movement disorder, and Tourette's Disorder. A variety of neurosurgical procedures have been used to treat both intractable SIB and severe Tourette's Disorder. Understandably, there are few reports concerning psychosurgery in children and adolescents for any condition or disorder. This report describes the use of cingulotomy and subsequent limbic leucotomy in an adolescent boy with Tourette's Disorder for SIB. His repetitive and medically serious SIB and failure of all other treatments prompted this intervention after careful, comprehensive review and discussion. Following the second surgery, the severity and frequency of his SIB were reduced.     

A review of treatment research for aggressive and disruptive behavior in the mentally retarded

This study reviews current treatment research on aggression of mentally retarded persons. Twenty-seven studies meet methodological criteria from an initial pool of 47. All the studies reviewed were empirical and had been published in national and internationally recognized journals. Treatments were behavioral and level of mental retardation and ages of the persons studied varied widely. Age and level of mental retardation proved to be significant factors in predicting treatment outcome. Also, it was found that some types of behaviors were treated more frequently than others, with inappropriate verbal responses being the most common, followed by aggression toward others and noncompliance. The implications of these findings are discussed.     

Cessation of long-term naltrexone administration: longitudinal follow-ups

Longitudinal follow-ups of the cessation of long-term Naltrexone administration (1 year of drug therapy) were conducted with a young woman (in her early 30s) with profound mental retardation who had previously displayed dramatic decreases in her self-injurious behaviors (SIB) both during, and for a period of at least 6 months following termination of drug treatment. After 2 and 4 years, post-Naltrexone therapy, the subject continued to exhibit near-zero rates of SIB episodes despite significant turnovers in her direct care staff by the 2-year follow-up, and changes in her physical/living environment and fellow residents by 4-year follow-up. These findings provide further support to the idea that long-term Naltrexone administration may result in highly durable reductions in SIB long after treatment ends and argue against certain aspects of the subject’s environment affecting her rates of SIB significantly. These results are discussed in light of the endogenous opiate system theories of SIB. A functional analysis and discussion of the effectiveness of behavioral treatments for her few remaining SIB episodes are also provided.     

Effects of Snoezelen room, Activities of Daily Living skills training, and Vocational skills training on aggression and self-injury by adults with mental retardation and mental illness

Multi-sensory stimulation provided in a Snoezelen room is being used increasingly for individuals with mental retardation and mental illness to facilitate relaxation, provide enjoyment, and inhibit behavioral challenges. We observed aggressive and self-injurious behavior in three groups of 15 individuals with severe or profound mental retardation and mental illness before, during, and after being in a Snoezelen room. All participants were receiving psychotropic medication for their mental illness and function-derived behavioral interventions for aggression, self-injury, or both. Using a repeated measures counterbalanced design, each group of participants was rotated through three experimental conditions: Activities of Daily Living (ADL) skills training, Snoezelen, and Vocational skills training. All other treatment and training activities specified in each individual's person-centered plan were continued during the 10-week observational period. Both aggression and self-injury were lowest when the individuals were in a Snoezelen room, followed by Vocational skills training and ADL skills training. The levels in the Snoezelen room were significantly lower than in both the other conditions for aggression but only in ADL skills training for self-injury. The difference in levels before and after Snoezelen were statistically significant with self-injury but not with aggression. The order of conditions showed no significant effect on either behavior. Snoezelen may provide an effective context for reducing the occurrence of self-injury and aggression.     

Behavioral treatment of self-injury, 1964 to 2000

A quantitative analysis of behavioral research on the treatment of self-injurious behavior (SIB) over the past 35 years is provided. A literature search covering the period from 1964 to 2000 yielded 396 articles (706 participants) on the treatment of SIB. Most research participants have been male and diagnosed with severe/profound mental retardation. The use of reinforcement-based interventions has increased during the past decade, whereas the use of punishment-based interventions has decreased slightly; both of these trends coincide with the increase in the use of functional assessments. Most treatments have been highly effective in reducing SIB; nevertheless, the disorder persists in spite of an abundance of research, suggesting that a greater emphasis should be placed on prevention.     

Self-injurious behavior in frontotemporal dementia

Abstract

Frontotemporal dementia (FTD) may be one of the most common neurodegenerative dementias with onset before age 65. Investigators have only recently characterized FTD, which encompasses Pick's disease as well as non-specific degeneration of the frontal lobes. Neuropsychiatric symptoms are the main features of FTD and include disinhibition, apathy, obsessive-compulsive behavior, and the Kluver-Bucy syndrome. We report a patient with FTD who developed prominent self-injurious behavior (SIB) consisting of persistent self-biting and hair-pulling. Stereotypical, repetitive SIB usually occurs in patients with autism or mental retardation; SIB is rarely discussed in patients with dementia. This report extends the neuropsychiatric spectrum of FTD to encompass SIB and discusses the potential mechanisms for SIB in these patients. The most likely contributing source for their self-injury is the development of obsessive-compulsive behaviors in the presence of coincident self-directed behaviors. Hyperorality from anterior temporal Involvement and the release of primitive grooming behavior from frontal degeneration are self-directed behaviors that contribute to the specific manifestations of SIB among FTD patients. The pharmacological management of SIB emphasizes drugs that work through opioid, serotonergic, or dopaminergic systems.