Self-injury

Giannini, A.J. Eighan, M.S. Loiselle, R.H. and Giannini, M.C. Comparison of haloperidol and chiorpromazine in the treatment of phencyclidine psychosis. J. Clin Pharmacol 244 202-204, 1984. Grove, V.E. Painless self-injury after ingestion of "angel dust." TAMA 242 655, 1979. 

The FDA has received 103 reports, occurring between August 29, 2005, and July 6,2006, of delirium, hallucinations, and self-injury in pediatric patients (mostly from Japan) following treatment with oseltamivir. 

Uses Prevention Rx influenza A (including 2009 Novel HlNl ) B, Action -1- Viral neuraminida.se Dose AduUs. Tx 75 mg PO bid X 5 d Prophylaxis 75 mg PO daily X 10 d Peds >1 yr. (Authorized 2009 by FDA for emergency use in <1 y) PO bid dosing <15 kg 30 mg 15-23 kg 45 mg 24-40 kg 60 mg >40 kg Adult dose -1- w/ renal impair Caution [C, /—] Contra Component allergy Disp Caps SE NA, insomnia, rqjorts of neuropsychiatric events in children (self-injury, confusion, delirium) caution urged in children as SEs are often more severe that the HlNl influenza Interaction T Effects W/ probenecid EMS Beware acute neuropsychiatric effects esp in children OD May cause NA symptomatic and supportive... 

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. 

The selective serotonin reuptake inhibitors (SSRI) have been used in adults for a wide variety of disorders, including major depression, social anxiety (social phobia), generalized anxiety disorder (GAD), eating disorders, premenstrual dysphoric disorder (PMDD), post-traumatic stress disorder (PTSD), panic, obsessive-compulsive disorder (OCD), trichotillomania, and migraine headaches. Some of the specific SSRI agents have an approved indication in adults for some of these disorders, as reviewed later in this chapter. The SSRIs have also been tried in children and in adults for symptomatic treatment of pain syndromes, aggressive or irritable ( short fuse ) behavior, and for self-injurious and repetitive behaviors. This chapter will review general aspects of the SSRIs and discuss their approved indications in children and adolescents. 

The part played by endogenous opioid systems in the regulation of these various physiological and behavioral functions has led to the experimental application of opiate antagonists in psychiatric disorders. This chapter focuses on autism and self-injury, which are two potential indications for opiate antagonists in pediatric populations. In adults, treatment with opiate antagonists has shown to be useful in the relapse prevention of alcoholism as part of a comprehensive treatment approach (Anton et ah, 1999, 2001). 

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. 

The best conclusion that can be drawn from these data is perhaps that treatment with naltrexone may offer promise for some, but certainly not all, patients with self-injury. Treatment effects may depend on background opioid levels, dosage, and treatment regimen. Noninvasive measures that predict individual treatment response have not been established. Self-injury is a heterogeneous phenomenon from a clinical and biological perspective (Buitelaar, 1993 Willemsen-Swinkels et ah, 1998). Further studies are required in this area, and and should include carefully clinically documented cases, large samples, and controlled designs. At this time, the use of naltrexone for the treatment of self-injury is to be considered experimental. 

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.R, and Taylor, D.V. (1993) Naltrexone reduces self-injury and improves learning. Exp Clin Psychopharmacol 1 1-17. 

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. 

Thompson, T, Hackenherg, T, Cerutti, D., Baker, D., and Axtell, S. (1994) Opioid antagonist effects on self-injury in adults with mental retardation response form and location as determinants of medication effects. Am J Ment Retard 99 85—102. 

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. 

Willemsen-Swinkels, S.H.N., Buitelaar, J.K., Nijhof, G., and Van Engeland, H. (1995a) Failure of naltrexone hydrochloride to reduce self-injurious and autistic behavior in mentally retarded adults. Double-blind placebo-controlled studies. Arch Gen Psychiatry 52 766-773. 

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