Self-injurious behavior

Additionally, an opioid antagonist, naltrexone, has been used to treat children with autism. The results from these studies have been mixed, with some studies showing a mild decrease in hyperactivity and self-injurious behavior, and improved attention (Gillberg, 1995). The children who respond best to this medication appear to have more severe abnormalities in their beta endorphin levels (Bouvard et al., 1995). Overall, the research suggests that the endogenous opioid system, which is important in the reward aspects of affiliation, may also play a role in the neurobiology of autism. 

Griffin, J.C., Williams, D.E., Stark, M.T., Altmeyer, H.K., and Mason, M. (1986) Self-injurious behavior a state-wide prevalence survey of the extent and circumstances. Appl Res Ment Retard 7 105-16. 

There are two main hypotheses about the involvement of endogenous opioid systems in the maintenance of self-injurious behaviors (Sandman, 1988 Buitelaar, 1993). The pain hypothesis suggests that in some subjects self-injury does not induce pain because excessive basal activity of opioid systems in the CNS has led to an opioid analgesic state. The addiction hypothesis posits that particularly repetitive and stereotyped forms of self-injury stimulate the production and release of en-dogeneous opioids. Therefore, chronic maintenance of self-injury may be due to addiction to endogenous opioids or to positive reinforcement by a central release of opioids triggered by the self-injurious behavior. Irrespective of which hypothesis one favors, treatment with opiate antagonists seems to be a rational approach. 

Buitelaar, J.K. (1993) Self-Injurious behavior in retarded children, clinical phenomena and biological mechanisms. Acta Paedopsy-chiatr 56 105-111. 

Herman, B.H. (1990) A possible role of proopiomelanocortin peptides in self-injurious behavior. Prog Neuropsychopharmacol Biol Psychiatry 14 S109—S139. 

Lang, C. and Remington, D. (1994) Treatment with propranolol of severe self-injurious behavior in a blind, deaf, retarded adolescent. / Am Acad Child Adolesc Psychiatry 33 265—269. 

Sandman, C.A. (1988) Beta-endorphin disregulation in autisric and self-injurious behavior a neurodevelopmental hypothesis. Synapse 2 193-199. 

Plasma P-endorphin levels in patients with self-injurious behavior and stereotypy. Am / Ment Retard 95 84-92. 

Sandman, C.A., Hetrick, W, Taylor, D.V., Marion, S.D., Touchette, R, Barron, J.L., Martinezzi, V., Steinberg, R.M., and Crinella, EM. (2000) Long-term effects of naltrexone on self-injurious behavior. Am J Ment Retard 105 103-117. 

Verhoeven, W.M., Tuinier, S., van den Berg, Y.W., Coppus, A.M., Fekkes, D., Pepplinkhuizen, L., and Thijssen, J.H. (1999) Stress and self-injurious behavior hormonal and serotonergic parameters in mentally retarded subjects. Pharmacopsychiatry 32 13-20. 

In a retrospective case analysis, fluoxetine (20 to 80 mg daily) and paroxetine (20 to 40 mg daily) were found to be effective in approximately one-quarter of adults (mean age, 39 years) with intellectual disability and autistic traits (Branford et al., 1998). The sample consisted of all intellectually disabled subjects who had been treated with a SSRI over a 5-year period within a health-care service in Great Britain. The mean duration of treatment was 13 months. Target symptoms were perseverative behaviors, aggression, and self-injurious behavior. Six of 25 subjects treated with fluoxetine and 3 of 12 subjects given paroxetine were rated as much improved or very much improved on the CGI. 

Paroxetine. Only a few reports, none of them controlled, have appeared on the use of paroxetine in autistic disorder. Paroxetine at 20 mg/day decreased self-injurious behavior in a 15-year-old boy with high-functioning autistic disorder (Snead et al., 1994). In another report, paroxetine s effectiveness for a broader range of symptoms, including irritability, temper tantrums, and interfering preoccupations, was reported in a 7-year-old boy with autistic disorder (Posey et al., 1999). The optimal dose of paroxetine was 10 mg daily an increase of paroxetine to 15 mg/day was associated with agitation and insomnia. As described earlier, a retrospective case analysis found paroxetine to be effective in approximately 25 % of adults with PDD NOS (Branford et al., 1998). 

Lamotrigine is an anticonvulsant drug that attenuates some forms of cortical glutamate release via inhibition of sodium, calcium, and potassium channels. An open-label case series (Uvebrant and Bauziene, 1994) and a case report (Davanzo and King, 1996) described improvement in autistic symptoms and self-injurious behavior, irritability, disturbed sleep, and social impairment in autistic children and an 18-year-old female with profound mental retardation, respectively, who were treated for epilepsy. 

Davanzo, P.A. and King, B.H. (1996) Open trial of lamotrigine in the treatment of self-injurious behavior in an adolescent with profound mental retardation. 1 Child Adolesc Psychopharmacol 6 273-279. 

Snead, R.W., Boon, E, and Presberg, J. (1994) Paroxetine for self-injurious behavior./ Am Acad Child Adolesc Psychiatry 33 909-910. 

FIGURE 43.1 Pharmacologic treatment algorithm for full syndrome pediatric PTSD. Based on a snythesis of consensus data and clinical reports in the adult and child literature. The author hers no responsibility for the use of this guideline by third parties. SSRI, selective serotonin reuptake inhibitor NEE, nefaza-done SIB, self injurious behavior VLF, venlafaxine VPA, valproic acid. 

Aman, M.G. (1993) Efficacy of psychotropic drugs for reducing self-injurious behavior in the developmental disabilities. Ann Clin Psychiatry 5 171-188. 

Rojahn, J. (1994) Epidemiology and topographic taxonomy of self-injurious behavior. In Thompson, T. and Gray, D.B., eds. Destructive Behavior in Developmental Disabilities Diagnosis and Treatment. Thousand Oaks, CA Sage pp. 49-67. 

Ruedrich, S., Swales, T.P., Fossaeeca, C., Toliver, J., and Rutkowski, A. (1999) Effect of divalproex sodium on aggression and self-injurious behavior in adults with intellectual disability a retrospective review. / Intellect Disabil Res 43 105-111. 

The clinical implications of such data point to a relationship between abnormalities in the central serotonin system and self-injurious behavior. These findings have led to an interest in developing specific drugs that alter 5-HT activity to treat suicidality, impulsivity, and aggressivity independent of any specific psychiatric disorder. Central serotonin function can be enhanced by agents such as lithium and various serotonin reuptake inhibitors. Recent studies have found that the use of such agents is associated with reductions in the likelihood of suicide attempts and completions in both patients with major depression and those with cluster... 

ECT should be considered for more severe forms of depression (e.g., those associated with melancholic and psychotic features, particularly when the patient exhibits an increased risk for self-injurious behavior) or when there is a past, well-documented history of nonresponse or intolerance to pharmacological intervention. Limited data indicate that bipolar depressed patients may be at risk for a switch to mania when given a standard TCA. A mood stabilizer alone (i.e., lithium, valproate, carbamazepine, lamotrigine), or in combination with an antidepressant, may be the strategy of choice in these patients. Some elderly patients and those with acquired immunodeficiency syndrome may also benefit from low doses of a psychostimulant only (e.g., methylphenidate) (see also Chapter 14, The HIV-Infected Patient ). Fig. 7-1 summarizes the strategy for a patient whose depressive episode is insufficiently responsive to standard therapies. 

Although reduced sleep is often an early prodromal symptom, patients are usually brought for evaluation and treatment when their behaviors create the potential for more severe consequences (e.g., self-injurious behavior, atypical sexual behavior, significant financial indiscretions). 

Bernstein GA, Hughes JR, Mitchell JE, Thompson T. Effects of narcotic antagonists on self-injurious behavior a single case study. J Am Acad Child Adolesc Psychiatry 1987 26 886-889. McDougle CJ, Holmes JP, Bronson MR, et al. Risperidone treatment of children and onset bipolar adolescents with pervasive developmental disorders a prospective, open label study. J Am Acad Child Adolesc Psychiatry 1997 36 685-693. 

Aggressive and hostile symptoms can overlap with positive symptoms but specifically emphasize problems in impulse control. They include overt hostility, such as verbal or physical abusiveness or even assault. Such symptoms also include self-injurious behaviors, including suicide and arson or other property damage. Other types of impulsiveness, such as sexual acting out, are also in this category of aggressive and hostile symptoms. 

In actual practice, many patients are already suicidal when they are started on the drug, increasing the likelihood that the drug will push them over into self-injurious behavior. Similarly, in real-life clinical practice, compared to controlled clinical trials used for research, busy doctors provide much less supervision or monitoring, the patients are almost never tested or evaluated for suicidality, multiple drugs are often given at once, and the doctors know little about looking for adverse effects on the mind. 

Gualtieri (1991) described the case of a mentally handicapped gentleman whose rates of self-injurious behavior doubled on fluoxetine, and then fell to baseline after the drug was withdrawn (p. 393). Gualtieri pointed out that fluoxetine can cause apathy and indifference in some patients and, conversely, mania in others. 

Patients with bipolar disorders may benefit from risperidone. This has been observed in an open trial of ten patients with rapid cycling bipolar disorder who were refractory to lithium carbonate, carbamazepine, and valproate eight improved after 6 months of treatment. One patient dropped out through non-adherence to therapy and one because of adverse effects (agitation, anxiety, insomnia, and headache) (5). There was a similar beneficial effect in eight adults with moderate to profound mental retardation (6). Risperidone was associated with a significant reduction in aggression and self-injurious behavior, whereas adverse effects were primarily those of sedation and restlessness. 

Cohen SA, Ihrig K, Lott RS, Kerrick JM. Risperidone for aggression and self-injurious behavior in adults with mental retardation. J Autism Dev Disord 1998 28(3) 229-33. 

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