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A patient with Gilles de la Tourette syndrome and severe self-injurious compulsions who had failed to respond to drug treatment and behavioural therapy obtained a complete and sustained resolution of his destructive behaviour and improvement in his tics following bilateral limbic leucotomy.
This study reports on the relationship between behavioural and psychiatric perceptions of mentally handicapped subjects. A Standardised Psychiatric Interview schedule was found to characterise psychiatric problems in the mentally handicapped along eight dimensions: depression, neurasthenia, psychoticism, phobias, histrionic elation, hypochondria, mental retardation and medication effects. A Behavioural Disturbance Scale characterised disturbances along six dimensions: aggressive conduct, mood disturbance, withdrawal, antisocial conduct, idiosyncratic mannerisms and self-injury. The relationships between the two modes of assessment were investigated using multiple regression. Clinical features were not expressed in behaviour disturbances, nor were they related to age, sex or hospitalisation. The communicativeness of an interviewee was, however, found to limit the detection of depression.
Behaviour disturbance was investigated in mentally handicapped adults who were living in hospital or at home. The first part of the study describes an empirically derived typology of disturbed behaviour patterns and gives the details of a scale by means of which behaviour disturbance can be quantified along six dimensions: aggression, mood disturbance, communicativeness, antisocial conduct, idiosyncratic mannerisms, and self-injury. The second part of the study used the scale in a longitudinal study of behavioural disturbance. Different forms of disturbed behaviour exhibited different kinds of longitudinal stability, and the long-term changes in one aspect of disturbance depended on subjects' other disturbance scores.
A contingent response that previously increased self-injurious air-swallowing (aerophagia) by a profoundly mentally retarded woman (Holburn & Dougher, 1985) was shown to decrease her air-swallowing when the response was presented in accord with the response deprivation/satiation hypothesis, which suggests that any free-operant response can serve as a reinforcer or a punisher depending upon specific contigency arrangements. The results offer an explanation for the earlier increase in air-swallowing.
A review of current research in the treatment of self-injurious and stereotyped behaviour is made using rule-out criteria for methodologically inadequate studies and meta-analytic procedures. It was found that profoundly mentally retarded persons between 16 years of age and over are the most likely to be effectively treated. Sex of the subject seemed to have no effect, while the level of mental retardation and the degree to which it was a factor in treatment effectiveness was unclear. The behaviour most frequently treated were head hitting and body rocking. It may also be the case that reinforcement is more effective than frequently believed when compared to punishment. The greatest effectiveness was apparent with DRO, lemon juice therapy, time-out, air splints, and DRO plus overcorrection. The implications of these data for clinicians and future research are discussed.
OBJECTIVE: To study the use of psychoactive drugs for the treatment of long-stay developmentally disabled individuals in an institution in New South Wales. SETTING: Three wards dedicated to the long-term care of developmentally disabled individuals situated on the premises of a large psychiatric hospital. SUBJECTS: All residents (n = 53) of these wards in August 1989. METHOD: All subjects were examined by the author. Charts and medication records were extensively reviewed. Mental retardation was classified by DSM-III-R criteria. Categorisation of problem behaviour was done with the assistance of nurses, who also supplied information on behavioural problems and functional level and completed checklists of self-injurious and stereotypic behaviour. A standardised neurological examination was performed and scales for abnormal involuntary movements completed. RESULTS: The most commonly used drugs were the neuroleptics, with 60.4% of subjects currently receiving one or more neuroleptic drug at relatively large doses. The use of these drugs was not associated with current or past psychiatric illness, but was more closely related with the severity of problem behaviour. Thirty-four per cent of the subjects receiving neuroleptics had dyskinetic movements suggestive of tardive dyskinesia, and 30% had mild tremor. Antidepressant, anxiolytic and sedative drugs were used less commonly. The management of epilepsy was considered to be suboptimal. CONCLUSION: Even though studies over the last two decades have consistently highlighted the problem of overmedication of intellectually handicapped individuals in institutions, the problem does not seem to have been redressed in at least some institutions.
The clinical features of 53 British-born patients with Gilles de la Tourette syndrome are described. The mean age at onset of body tics was seven years and for vocalisations 11 years. Coprolalia was present in 39%, copropraxia in 21%, echolalia in 46% and echopraxia in 21%. Complicated antics and mannerisms were also common, often involving the compulsive touching of objects or self-injurious behaviour. Forty-six per cent of cases had a family history of tics in a single close relative and in two individuals a further member of the family had Gilles de la Tourette syndrome. Focal dystonia was present in four patients who had never received neuroleptics drugs and chorea was seen in two other untreated patients. In three patients acoustic startle consistently induced brief eye blink followed by a whole body jerk or jump. Rapid repetitive movements of the hands increased the frequency and severity of tics in 13 patients, but the performance of mental arithmetic under time pressure had a much more unpredictable effect. Electroencephalographic abnormalities occurred in eight (13%) but no definite CT brain scan abnormalities were detected. The incidence of left handedness did not differ from that in the general population and no evidence to suggest organic impairment was found on neuropsychological testing. This study provides no support for the notion that Gilles de la Tourette syndrome is a degenerative disorder of the central nervous system but provides some evidence for heterogeneity.
Individuals who have sustained traumatic brain injury may provide friends, family, and rehabilitation professionals with challenges through an increased likelihood of their engaging in socially inappropriate behaviours. At extremes the inappropriate behaviours include vocal and physical assault, non-compliance, self-injurious behaviours, elopement, and property destruction. While these maladaptive behaviours are by themselves troublesome, for some individuals they provide severe barriers to rehabilitation. One option for the challenging rehabilitation client is a neurobehavioural programme, typically offering an access-limited or otherwise secure physical environment and which focuses on behaviour reduction. While outcomes from neurobehavioural programmes are typically positive, their expense and the negative connotations of this type of programme will at times dissuade family members from enrolling the client. We describe an alternative, less restrictive behavioural programme operated in the physical and social context of a larger, more typical community-based rehabilitation programme for traumatically brain-injured individuals. This programme has been in operation for nearly three years, successfully serving more than 200 clients, of which approximately 20% posed behaviour management problems. Identified variables accounting for these successes include: formal guidelines for programme development, staff training and monitoring, data collection, integration of an interdisciplinary team, discharge planning and post-discharge follow-up. We provide a general programme description followed by discussions of four brief case studies to illustrate basic principles of the programme. Programme strengths are discussed, as are constraints placed on the programme by the physical and social environments in which it operates.
Autistic children with an IQ below 70 and with an IQ above 70 were systematically compared. The two groups differed somewhat in the pattern of symptoms, but were closely similar in terms of the main phenomena specifically associated with autism. However, the low IQ and high IQ autistic children differed more substantially in terms of other symptoms such as self-injury and stereotypies and there were major differences in outcome. The possibility that the nature of the autistic disorder may differ according to the presence or absence of associated mental retardation needs to be taken into account in planning studies of etiology.
The treatment of a 16-year-old severely mentally retarded and blind female client exhibiting severe biting of self and others consisted of the contingent application of an aversive gustatory stimulus (Tabasco Sauce), brief timeout, DRO, and contingent restraint against biting while in time-out. This is the first use of Tabasco as the aversive stimulus against biting. Deceleration of biting was rapid and maintained for 20 months after initiation of treatment.
Thirty (33%) of 90 patients with the Gilles de la Tourette syndrome exhibited self-injurious behaviour. Fourteen were head bangers, of whom two had cavum septum pellucidum. Clinical correlates of self-injury were the severity of Gilles de la Tourette syndrome symptoms and psychopathology, with special reference to obsessionality and hostility. We discuss an additional patient who died from a subdural haematoma as a result of head banging, and three who had permanent vision impairment from self inflicted eye injuries.
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A 14-year-old autistic girl presented with severe, chronic head-banging, some relief being obtained by restraint harnesses. Withdrawal of her straitjacket resulted in extreme SIB. Exhibition of fluphenazine relieved the condition.
Self-injurious behaviour (SIB) is a relatively common phenomenon among severely retarded persons and involves various repetitious behaviours resulting in tissue damage. Perhaps because of the damage it does, the behaviour has generated a considerable amount of applied research and discussion, and much of this research has involved attempts to reduce SIB through the manipulation of antecedents or consequences. The purpose of this paper was to determine the extent to which those conducting this research used a functional analysis of SIB to determine why the behaviour was occurring and subsequently matched treatment to one of these reasons. Results showed that only a small proportion of the studies reported analyses that would allow the experimenter to determine reasons for the self-injurious behaviour. The discussion centres on why functional analyses are not conducted in ways that would lend treatment to be based on hypotheses of why SIB occurs.
The results are described of a behavioural programme designed to modify self-injurious behaviour of a child with Lesch-Nyhan syndrome. The treatment combined extinction of the injurious behaviour and reinforcement of alternative behaviour, and was successful in the controlled hospital environment. However, an attempt to teach the parents to continue the treatment at home failed. The results are discussed in terms of the possible relationship between organic and environmental factors in maintaining the injurious behaviour, and the importance of analysing both the behaviour itself and the factors (including familial) maintaining it. It is suggested that parents should be advised about management of behavioural problems at an early age.
Self-destructive behavior is a major clinical problem in psychiatry. A review of the literature reveals the existence of enough clinical data to identify a diagnostic entity, "The Deliberate Self-Harm Syndrome" (DSH). The authors present a diagnostic formulation of the DSH syndrome (in the DSM-III format) which consists of four essential clinical features, a group of associated features, clinical features, a group of associated features, a clinical course of typical onset in late adolescence, with multiple recurrent episodes, with multiple methods of low lethality physical self-injury, extending over many years. On the basis of relatively exclusive association of clinical signs and symptoms a heuristic clinical entity is proposed.
Despite the widespread nature of stereotyped and self-injurious behaviours within many patient groups, the precise relationship between these two behaviours has never been clearly delineated. A classification based on the frequency of emission is proposed which suggests separate forms of treatment for each behaviour class.