Psychobiological response to pain in female adolescents with nonsuicidal self-injury.

BACKGROUND: Nonsuicidal self-injury (NSSI) is associated with reduced pain sensitivity and alterations in top-down processing of nociceptive information. The experience of acute pain is characterized by reactivity of the autonomic nervous system (ANS) and hypothalamic-pituitary-adrenal (HPA) axis, which to our knowledge has not been systematically investigated in the context of NSSI. METHODS: Adolescents fulfilling DSM-5 diagnostic criteria for NSSI and matched healthy controls received cold pain stimulation. We obtained self-reports on psychological distress and measured blood pressure, heart rate variability (HRV) and saliva cortisol. Regression analyses were used to investigate group differences on observed difference scores, adjusting for confounding variables. RESULTS: We included 30 adolescents engaging in NSSI and 30 controls in our study. Adolescents in the NSSI group showed a greater pain threshold. Groups significantly differed in their psychological response to pain. In patients with NSSI, mood and body awareness increased after painful stimulation; in controls it decreased. Tension increased in controls only. The HPA axis response to painful stimulation was increased in the NSSI compared with the control group. Analysis of ultra-short-term recordings of HRV revealed significant group differences during the anticipation of pain and recovery. LIMITATIONS: Future studies should incorporate multiple measures of saliva cortisol and replicate the present findings in a naturalistic setting. CONCLUSION: Compared with controls, individuals engaging in NSSI show psychological benefits in response to pain. Biological findings highlight decreased physiologic arousal before and prolonged arousal (ANS and HPA axis response) after painful stimulation in adolescents engaging in NSSI. Greater pain-inflicted autonomic arousal and cortisol secretion may counteract dissociative states, reduce negative affect and increase body awareness in adolescents engaging in NSSI, lending support for a neurobiological pathomechanism underlying the intraindividual and antisuicide functions of NSSI.

Autonomic nervous system and hypothalamic-pituitary-adrenal axis response to experimentally induced cold pain in adolescent non-suicidal self-injury--study protocol.

BACKGROUND: Adolescent non-suicidal self-injury (NSSI) is associated with altered sensitivity to experimentally induced pain. Adolescents engaging in NSSI report greater pain threshold and pain tolerance, as well as lower pain intensity and pain unpleasantness compared to healthy controls. The experience of pain is associated with reactivity of both the autonomic nervous system (ANS) and the hypothalamic-pituitary-adrenal (HPA) axis. However, previous research has not yet systematically addressed differences in the physiological response to experimentally induced pain comparing adolescents with NSSI and age- and sex-matched healthy controls. METHODS/DESIGN: Adolescents with NSSI and healthy controls undergo repeated painful stimulation with the cold pressor task. ANS activity is continuously recorded throughout the procedure to assess changes in heart rate and heart rate variability. Blood pressure is monitored and saliva is collected prior to and after nociceptive stimulation to assess levels of saliva cortisol. DISCUSSION: The study will provide evidence whether lower pain sensitivity in adolescents with NSSI is associated with blunted physiological and endocrinological responses to experimentally induced pain compared to healthy controls. Extending on the existing evidence on altered pain sensitivity in NSSI, measured by self-reports and behavioural assessments, this is the first study to take a systematic approach in evaluating the physiological response to experimentally induced pain in adolescent NSSI. TRIAL REGISTRATION: Deutsche Register Klinischer Studien, Study ID: DRKS00007807; Trial Registration Date: 13.02.2015.

Associations between psychological factors and the presence of deleterious oral habits in children and adolescents.

OBJECTIVES: This study aimed to evaluate the associations between psychological factors and the presence of deleterious oral habits in children and adolescents. STUDY DESIGN: 147 students aged 8 to 14-years-old were divided in two groups concerning the presence and absence of DOH Habit group (HG) and Habit free group (HFG). Participants were asked about the presence of DOH using the domain III (Oral Habits) of the Nordic Orofacial Test-Screening (NOT-S). Symptoms of anxiety and depression were evaluated using the Brazilian Portuguese versions of the Revised Children's Manifest Anxiety Scale (RCMAS) and the Children's Depression Inventory (CDI), respectively. Saliva was collected 30 min after waking and at night to determine the diurnal decline in salivary cortisol (DDSC). Data were analyzed using the Chi-squared, Mann-Whitney, Spearman's correlation and logistic regression. RESULTS: The prevalence of DOH was higher in females than males (65.1 vs 34.9; p < 0.05). The most frequent DOH was nail biting (58.7%). HG presented more depressive symptoms than HFG (p < 0.05). There was positive correlation between salivary cortisol levels and age (p < 0.01). Logistic regression analysis found association between symptoms of anxiety and the presence of DOH (OR = 2.35; p < 0.05). CONCLUSIONS: In conclusion, children and adolescents with DOH presented more symptoms of depression than their counterparts. Moreover, they were more likely to report symptoms of anxiety.

Body Focused Repetitive Behavior Disorders: Behavioral Models and Neurobiological Mechanisms. / Beden Odakli Tekrarlayici Davranis Bozukluklari: Davranis Modelleri ve Nörobiyolojik Mekanizmalar.

OBJECTIVE: Body Focused Repetitive Behaviors (BFRB) is an umbrella term for undesirable, repetitive motor activities such as Trichotillomania (TTM), Skin Picking Disorder (SPD), nail biting, cheek chewing, lip biting, finger sucking, finger cracking and teeth grinding. Such behaviors are engaged in to eliminate a part of the body and may result in impaired functionality. The frequency of presentation to clinicians is low since BFRB are defined as harmless, although the number of studies on this condition has increased rapidly recently, including those making a clear determination of epidemiological data, those investigating the etiopathogenesis and those providing treatment guidelines, although they remain inadequate. The present study provides a review of studies investigating the etiology of BFRB to date. METHOD: Articles published between 1992 and 2021 stored in the Pubmed, Medline, Scopus and Web of Science databases were reviewed, and the prominent research studies of the condition identified were included in the evaluation. RESULTS: Studies investigating the etiopathogenesis of BFRB were found in most cases to investigate adult populations, and were hampered by such confounding factors as clinical heterogeneity, high rates of comorbid psychiatric diseases and small sample sizes. The identified studies reveal that attempts have been made to explain BFRB based on behavioral models, and that the condition is inherited at a high rate. Treatment planning is mostly associated with monoamine systems (especially glutamate and dopamine) and interventions were directed to addiction elements. Furthermore, cognitive flexibility and motor inhibition defects in neurocognitive area and cortico-striato-thalamocortical cycle abnormalities in neuroimaging studies have been reported. CONCLUSION: Studies investigating the clinical features, incidence, etiopathogenesis and treatment of BFRB, which holds a controversial place in psychiatric classification systems, would contribute to a better understanding of the disease and a more appropriate definition of the condition.

Botulinum Neurotoxin Injections in Children with Self-Injurious Behaviors.

Self-injurious behaviors are repetitive, persistent actions directed toward one's body that threaten or cause physical harm. These behaviors are seen within a broad spectrum of neurodevelopmental and neuropsychiatric conditions, often associated with intellectual disability. Injuries can be severe and distressing to patients and caregivers. Furthermore, injuries can be life-threatening. Often, these behaviors are challenging to treat and require a tiered, multimodal approach which may include mechanical/physical restraints, behavioral therapy, pharmacotherapy, or in some cases, surgical management, such as tooth extraction or deep brain stimulation. Here, we describe a series of 17 children who presented to our institution with self-injurious behaviors in whom botulinum neurotoxin injections were found helpful in preventing or lessening self-injury.

Coincidence and awareness of oral parafunctions in college students.

OBJECTIVE: The aim of the study was to determine the prevalence and awareness of particular types of oral parafunctions in young healthy students and any association with temporomandibular disorders (TMD). MATERIAL AND METHODS: The study was performed in a randomly selected group of 303 healthy students (mean age 18.8 years) from the vocational technical school in Wroclaw, Poland, who underwent a routine clinical examination and functional analysis of the mouth. On taking the history all subjects were asked about their awareness of various forms of parafunctional activity in their mouth. RESULTS: Almost all subjects revealed various oral parafunctions such as: bruxism, nail and pen biting, chewing gum, and biting the mucosa of lip or cheek. These habits were present singly or as double, triple or even fourfold coincidences in a single person. The most frequent oral parafunctions were habitual gum chewing and bruxism. Subjects were very seldom aware of the last parafunction. TMDs were more prevalent in the presence of bruxism than in other oral parafunctions. CONCLUSIONS: The studied students revealed various types of oral parafunctions, however most of them were not aware of clenching and grinding their teeth.

Relationship between saliva opiorphin levels, pain threshold, and cutting number in adolescents with non suicidal self injury.

Various opinions have been suggested regarding non suicidal self-injury (NSSI) and pain relationship. Opiorphin is a recently found peptide that inhibits enkephaline-catabolizing enzymes. Analgesia caused by opiorphine has been demonstrated in animal experiments. No studies have examined the relationship between opiorphin and pain sensation until today. We aimed to investigate opiorphine and pain threshold among self-injuring adolescents. Adolescents aged 14-18 years were included in the study. The NSSI group consisted of 37 adolescents diagnosed with NSSI according to DSM-V Section 3, and the non-NSSI group consisted of 36 adolescents without any psychiatric disorder. We measured pain threshold with a pressure sensitive algometer device and analyzed saliva opiorphin levels by ELISA method. Mediation analysis was performed using Process Macro developed by Hayes. NSSI group had statistically significantly higher pain threshold and opiorphin levels than the non-NSSI group. There was a positive correlation between pain threshold values and opiorphin levels in the NSSI group. Also, a positive correlation between opiorphin levels and total cutting episode number was found. We searched for a probable relationship of pain threshold with episode number of each type of NSSI act. Accordingly, a positive correlation with two major act and a negative correlation with two minor act was shown. The opiorphine was found to be a mediator variable in the relationship between the pain threshold and the cutting number. The relationship between opiorphin, pain threshold and cutting number and their mediating effects with each other may highlight the pain-based biological origins of NSSI.

Oral factitious injury in a child diagnosed with Kabuki syndrome.

Factitious injury or self-injurious behavior is a common manifestation in children affected by neurologic, developmental, or psychiatric disease. The nature and presentation of this behavior in the oral cavity varies among diagnoses, and such behavior can be easily missed. This report describes the presence of self-injurious behavior in a child diagnosed with Kabuki syndrome who presented to a pediatric dentistry referral practice for evaluation of gingival bleeding, and provides a brief overview of the known etiology and management of this challenging condition. Clinicians should be aware of the possibility of self-injurious behavior when treating children diagnosed with Kabuki syndrome.

Gingival abscess due to an unusual nail-biting habit: a case report.

AIM: Nail-biting is one of the most frequent deleterious oral habits in children. It can result in systemic diseases or oral traumatic lesion. This report describes a case of gingival abscess in a child due to a fingernail-biting habit. CASE DESCRIPTION: A 5-year, 6-month-old female presented gingival swelling and fistula in the primary maxillary left central and right lateral incisors as an unusual sequelae to the periodontal tissues from fingernail-biting. A periodontal curette was used to remove the fragments and to curette the area. After the curettage, an exudate of blood and pus was drained. Then the area was irrigated with 0.12% chlorhexidine solution; applying finger pressure controlled the secretion. After one week, the patient returned with gingival swelling present in the same teeth. The same curettage procedure was performed. It was suggested that the deleterious habit was related to emotional tension and anxiety behaviors and the patient was referred for psychological treatment. When the patient returned one month later, she was still biting her fingernails, but she had stopped placing fragments into the gingival crevice. No more gingival inflammation or swelling was observed. SUMMARY: his paper presents an unusual case report of a gingival abscess due to a fingernail-biting habit in a child, probably related to an emotional condition. CLINICAL SIGNIFICANCE: The fingernail-biting habit can induce a periodontal traumatic injury yielding a more serious complication such as a gingival abscess.

Preventing Self-Harm From Repeat Foreign-Body Ingestion.

Mental health disorders in adolescents present some of the most challenging of all ethical dilemmas. This is particularly true when they lead to self-injurious behavior that can only be prevented by either limiting the freedom of the adolescent or forcing treatments on them that they do not want. Intentional and repeated foreign-body ingestion (FBI) in youth is a poorly understood self-injurious behavior that can be life-threatening. It poses unique clinical and ethical challenges. Ingestion of sharp or magnetic objects increases the need for endoscopic retrieval or surgical intervention with associated risks, including perforation and anesthesia-related adverse events. When behavior modification efforts fail to prevent recurrent FBI, the cumulative risk of medical intervention mounts. Sometimes, as a last resort, doctors consider surgical procedures that limit jaw movement and may physically prevent recurrent FBI. In this Ethics Rounds article, we present a case in which doctors consider whether it is in the best interest of a teenager with this behavior to undergo orthodontic jaw wiring as a next step in treatment of repeated FBI. Doctor commentary on the ethical decision-making process is provided.

[Unusual case of oesophageal foreign body as part of a self-harm syndrome]. / Ungewöhnlicher Osophagusfremdkörper im Rahmen eines Autoaggressionssyndroms.

INTRODUCTION: Foreign bodies in the oesophagus represent a frequent emergency situation in ENT medicine. Usually the cases involve lumps of meat, bones, shards of glass, bottle tops, batteries or dentures. We would like to report about an unusual foreign body found in the oesophagus. PATIENT: A 45-year-old patient presented himself in our interdisciplinary casualty department where he claimed to have swallowed a butter-knife that morning as a bet. The ENT examination showed no abnormal findings. The thorax X-Ray revealed a 14 cm-long foreign body in projection to the oesophagus, which matched the knife. Following consultation with the thorax surgeon, a rigid oesophagoscopy was conducted under endotracheal intubation and the knife was easily removed using tongs. Archive searches conducted in the meantime showed that foreign bodies had been removed from the patient on numerous occasions by fellow surgeons either laparoscopically or via open surgery. As a result, the patient was transferred to the psychiatric ward with unimpeded swallowing reflex with a suspected self-harming syndrome. DISCUSSION: As an ENT emergency, a foreign body in the oesophagus generally requires intervention because of the risk of complications such as perforation or pressure-induced necrosis of the oesophagus wall with resulting mediastinitis. Suitable instruments are the flexible oesophagoscope, the rigid oesophagoscope under anaesthesia or transcervical/transthoracic removal. The choice of procedure crucially depends on the type and localisation of the foreign body in the oesophagus. Particularly in cases of unusual foreign objects or repeated foreign object ingestion, it should be considered whether a psychological illness could be the cause and whether the introduction of appropriate therapy could be expedient.

Hypothalamic-pituitary-adrenal axis dysregulation in depressed adolescents with non-suicidal self-injury.

Non-suicidal self-injury (NSSI) is characterized by causing harm to one's own body without the intent of suicide. While major depressive disorder (MDD) has been associated with elevated cortisol (at least in some subgroups), prior studies in NSSI have suggested that NSSI is associated with blunted reactivity to stress of the hypothalamic-pituitary-adrenal (HPA) axis, possibly consistent with an allostatic load model. The present study used a multi-level approach to examine salivary cortisol in the context of a social stressor in 162 adolescents (ages 12 to 19 years old) with MDD with a history of repeated engagement in NSSI (MDD/NSSI) versus MDD without repeated NSSI (MDD), and healthy controls (HC). Observed (expressed) and self-reported (experienced) ratings of stress were also obtained during the social stress paradigm. The results showed that MDD/NSSI exhibited lower salivary cortisol levels and differed in cortisol trajectories in the context of a social stressor compared to HC and MDD. Observed stress, but not self-reported stress, during the social stress paradigm was greater for the MDD/NSSI than HC. Follow-up analyses suggested the possibility that this pattern of lower cortisol for those who engage in NSSI was present in females and males, and was more pronounced in those with repeated NSSI (but not subthreshold NSSI) and those with a history of NSSI and suicide attempts. Overall, these findings add to the prior literature and begin to show a consistent pattern for how stress is processed in atypical ways for those who engage in repeated NSSI. Importantly, these results suggest that some of the heterogeneity across adolescent depression may be better represented by these underlying biological processes, perhaps even representing subgroups that will benefit from different types of intervention. Hypothalamic-Pituitary-Adrenal Axis Dysregulation in Depressed Adolescents with Non-Suicidal Self-Injury.

Mortalidade por violência autoprovocada em mulheres em idade fértil no Rio Grande do Norte / Mortalidad por violencia autoprovocada en mujeres en edad fértil en Rio Grande do Norte / Mortality by self-inflicted injury in fertile women of Rio Grande to Norte state

Introdução:A violência autoprovocada é um importante problema de saúde pública. Esse agravo produz impactos no campo da saúde do indivíduo, da família eda coletividade com desdobramentos sociais e econômicos. Objetivo:Analisar a mortalidade por violência autoprovocada em mulheres em idade fértil no estado do Rio Grande do Norte, Brasil, entre os anos de 2012 e 2021. Metodologia:Trata-se de um estudo ecológico com abordagem quantitativa e utiliza-se como base o estado do Rio Grande do Norte. Os dados foram coletados do Departamento de Informática do Sistema Único de Saúde, por meio das Informações em Saúde,nas seções de estatísticas vitais e população residente com a seleção sexo feminino e faixa etária de 10 a 49 anos.Resultados:Entre os anos de 2012 a 2021, no estado do Rio Grande do Norte,foram registrados 213 óbitos de mulheres em idade fértil por lesões autoprovocadas. Considerando o início e o final desse período, é possível destacar que a faixa etária de maior ocorrência de suicídio foi de 30 a 39 anos em 2012 e de 40 a 49 anos em 2021. Observou-se, nos anos avaliados, que as mulheres eram em sua maioria solteiras, de raça parda/preta e que a própria residência da vítima foi o local predominante para o desfecho da lesão autoprovocada. No que se refere à escolaridade e à relação do óbito com período de gravidez ou puerpério é preciso ressaltar o alto índice de "Não informada" e "Ignorada" nos registros.A taxa média de mortalidade por lesões autoprovocadas em mulheres em idade fértil entre 2012 e 2021 foi de 2,0 óbitos por cada 100.000 habitantes. Conclusões:Assim, conclui-se que o cenário da mortalidade por violência autoprovocada em mulheres em idade fértil no Rio Grande do Norte necessita de estratégias para prevenção do suicídio nessa faixa etária (AU).

Introduction: Self-inflicted injury is a major public health problem that impacts the health, social, and economic areas of individuals, their families, and society. Aim: To analyze mortality by self-inflicted injury in fertile women from the Rio Grande do Norte state between 2012 and 2021.Methodology: This ecologic and quantitative study collected vital statistics of women aged between 10 and 49 years. Data were obtained from the Health Information Systems of the Brazilian Health Informatics Department.Results: A total of 213 deaths of fertile women by self-inflicted injury were registered between 2012 and 2021. Considering the age groups, most deaths occurred between 30 and 39 years in 2012 and between 40 and 49 years in 2021. In addition, women were mostly single andwith brown or black skin color, and most of the self-inflicted injuries happened at their houses. Regarding education level and the relationship of death with pregnancy or postpartum, most registries presented a high incidence of "Not informed" or "Ignored" answers. Last, the mean mortality by self-inflicted injury in this population was 2.0 per 100,000 inhabitants between 2012 and 2021.Conclusions: Strategies must be implemented to reduce the mortality by self-inflicted injury of fertile women from the Rio Grande do Norte state (AU).

Introducción: La violencia autoinfligida es un importante problema de salud pública. Este problema tiene impactos en la salud del individuo, la familia y la comunidad con consecuencias sociales y económicas.Objetivo: Analizar la mortalidad por violencia autoinfligida en mujeres en edad fértil en el estado de Rio Grande do Norte, Brasil, entre los años 2012 y 2021.Metodología: Se trata de un estudio ecológico con enfoque cuantitativo y utiliza como base el estado de Rio Grande do Norte. Los datos fueron recolectados del Departamento de Tecnologías de la Información del Sistema Único de Salud, a través de Información en Salud, en las secciones de estadísticas vitales y población residente con la selección del género femenino y rango de edad de 10 a 49 años. Resultados: Entre los años 2012 y 2021, en el estado de Rio Grande do Norte, se registraron 213 muertes de mujeres en edad fértil por lesiones autoinfligidas. Considerando el inicio y final de este periodo, es posible resaltar que el grupo etario con mayor incidencia de suicidio fue el de 30 a 39 años en 2012 y el de 40 a 49 años en 2021. Se observó, en los años evaluados, que las mujeres eran en su mayoría solteras, de raza mestiza/negra y la propia residencia de la víctima era el lugar predominante para la autolesión. En lo que respecta a la educación y la relación entre muerte y embarazo o puerperio, es necesario resaltar el alto índice de "No informados" e "Ignorados" en los registros. La tasa media de mortalidad por autolesiones en mujeres en edad fértil entre 2012 y 2021 fue de 2,0 muertes por 100.000 habitantes. Conclusiones: Así, se concluye que el escenario de mortalidad por violencia autoinfligida en mujeres en edad fértil en Rio Grande do Norte requiere estrategias para prevenir el suicidio en este rango de edad (AU).

Self-Directed Violence After Medical Emergency Department Visits Among Youth.

INTRODUCTION: Identifying medical encounters that precede self-directed violence may allow for important prevention opportunities. This study examined the risk of self-directed violence after visiting the emergency department for a range of physical health conditions among youth. METHODS: This retrospective cohort study used 2012-2013 statewide emergency department data from six states. Among patients aged 15-29 years, the exposure group included 2,192,322 emergency department visits for 16 selected conditions, coded by whether visits for those conditions were the first, second, or third or later visit for that condition. Emergency department visits for a minor infection served as the reference group (n=149,163). A Cox proportional hazard model was used to assess the risk of a self-directed violence event within 6 months for each condition. Analyses were conducted in 2017. RESULTS: Overall, 8,489 (0.4%) of all patients visited the emergency department for self-directed violence over a 6-month period. Initial visits for epilepsy or seizures conveyed a markedly elevated hazard ratio for subsequent self-directed violence at 6.0 and 5.7, respectively (p<0.001). Initial visits for other conditions showed moderately elevated risk with hazard ratios primarily <2. Second visits for various pain symptoms, syncope, vomiting, or non-self-directed violence injury also had a 3- to 5-fold increase in hazard ratios for subsequent self-directed violence. Hazard ratios for third or later visit increased to 8.8 for back pain, 6.9 for headache, about 5 for abdominal pain, dental complaints, and non-self-directed violence injury (p<0.001). CONCLUSIONS: Young people presenting to the emergency department for certain medical conditions are at an increased risk of subsequent self-directed violence. An awareness of these patterns may help guide screening efforts for suicide prevention in clinical settings.

Factitial pemphigus-like lesions.

The maxillofacial region is rarely subjected to self-inflicted conditions such as factitious disease. Nasal ulceration, facial emphysema, periorbital ecchymosis, mandibular subluxation, gingival and mucosal ulceration, dental and salivary gland pain and glossopharyngeal neuralgia have been reported as possible manifestations of factitious disease. We report a case of a young woman who presented with unilateral bullous and ulcerative oral and erythematous facial lesions that were initially diagnosed as pemphigus vulgaris but was later determined to be secondary to self-inflicted injuries. To the best of the authors knowledge, this clinical scenario has not been previously reported in the context of a factitious disease and, therefore, may be considered in the differential diagnosis of oral vesiculobullous disorders.

What worries parents of a child with Autism? Evidence from a biomarker for chronic stress.

BACKGROUND: Previous studies have reported correlations between various aspects of the behaviour and symptomatology of children with Autism Spectrum Disorder (ASD) and their parents' self-reports of stress via standardised scales. AIMS: To extend that literature, a physiological index of parental chronic stress was used instead of their self-reports-dysregulation of the Diurnal Rhythm (DR) of the Hypothalamic-Pituitary-Adrenal (HPA) axis. METHODS: A sample of 149 parents of a child with ASD provided salivary cortisol at the predicted time of daily maximum cortisol concentration and at a time of daily lower concentration. Adherence to the predicted DR was assessed via a dichotomous (present/not-present) as well as a continuous measure, and MANOVA and linear regression were used to detect significant associations between ASD-related variables in their children and parents' DR. RESULTS: Identified only a single significant correlate of DR dysregulation in both statistical procedures-Self-Injurious Behaviour (SIB) exhibited by their child and observed by the parents. CONCLUSIONS AND IMPLICATIONS: These findings extend previous data using self-report indices of parental stress and should be included in parent-support settings to alert parents to the long-term health effects of the stress they experience in regard to their child's SIB.

Self-inflicted nail-gun injury with 12 cranial penetrations and associated cerebral trauma. Case report and review of the literature.

In this case report, the authors describe a 33-year-old man who presented with headache due to the presence of 12 nail-gun nails impacted in his cranium and cerebral parenchyma. The authors also review the relevant literature regarding penetrating brain injury. The patient's physical examination revealed a Glasgow Coma Scale score of 15 and impairment of abduction of the right eye and abduction of the jaw producing dysarthria; the remaining results of the neurological examination were normal. Both x-ray films and computerized tomography (CT) scans of the head revealed the presence of 12 nails, the majority of which were located intracranially. A scattering artifact limited the ability of CT scanning to demonstrate any intracranial hemorrhage. Angiography did not demonstrate any evidence of traumatic vascular injury. After general anesthesia had been induced in the patient, the nails were removed in the operating room. Following removal of the final nail, a small left temporal craniotomy was performed to control hemorrhage from a tear in the left middle meningeal artery. Despite the development of a postoperative insular hematoma, the patient was discharged home with minimal deficits. This patient is the only known survivor of the largest number of foreign objects (12) to penetrate the skull intentionally. Overall, self-inflicted nail-gun injuries are less common than accidental discharges. A review of the literature, however, suggests that for penetrating brain injury, self-infliction is the more common mechanism. For those patients who survive such an injury, clinical decision making must focus on preventing further cortical or vascular damage. A rational management strategy should permit these patients to be discharged with no additional injury.

Use of low-dose chlorpromazine in conjunction with environmental enrichment to eliminate self-injurious behavior in a rhesus macaque (Macaca mulatta).

A 7-year-old, captive-bred, female rhesus macaque was placed in a quarantine facility upon arrival at our institution. At release from quarantine, she was observed pawing at and chewing on her left cheek. Physical examination revealed ulcerative lesions on the buccal surface of the left cheek. Initial differential diagnoses included Cercopithecine herpesvirus 1 (B virus)-induced lesions and bacterial infection. Dental abnormalities and cheek pouch foreign body were ruled out during the physical exam. Treatment with 30 mg/kg cefazolin intramuscularly every 12 h was initiated. Twelve days later, the animal presented with a 2 x 2-cm, full-thickness erosion involving the opposite (right) cheek. Treatment with buprenorphine (0.1 mg/kg intramuscularly every 24 h) was initiated. Cultures for B virus were negative, and only nonpathogenic bacteria were isolated from swabs of the lesions. Hematology and serum chemistry profiles were normal. A wedge biopsy of the lesion revealed no definitive etiology. Further observation revealed that the lesions likely resulted from self-injurious behavior (SIB). Treatment with low-dose chlorpromazine (1 mg/kg intramuscularly once daily for 25 days, and then 0.5 mg/kg intramuscularly once daily for 25 days) was initiated. Bodyweight and condition were maintained during therapy, and serial hematology and serum chemistry profiles were normal. The animal was moved into a different room, and a toy "necklace" was created. The SIB was eliminated, and lesions healed within 35 days. Presently, 20 months after presentation, this animal remains in good health.

Facial emotion recognition in adolescents with nonsuicidal self-injury.

Adolescents with nonsuicidal self-injury (NSSI) have been described as having considerable impairment in social interactions, and social difficulties are often a trigger for NSSI. However, little is known about how adolescents with NSSI disorder process facial expressions of emotion. We investigated the recognition of facial expressions of emotion in 47 adolescents with NSSI disorder, 28 clinical controls without NSSI, and 51 nonclinical controls. Following a neutral or a sad mood induction, participants were presented with a dynamic facial expression that slowly changed from neutral to full-intensity happiness, sadness, anger, disgust, fear or neutral (closed/open mouth). Recognition of facial expressions was measured by the intensity of the expression at which participants could accurately identify the facial expression. No group differences in the recognition of facial expressions were found. All groups required comparable stages of emotional expressivity to correctly recognize emotions, and there were no significant differences in accuracy. Results indicate no mood effect on recognition or accuracy. Valence and arousal ratings of stimuli indicated that compared to the nonclinical control group but not to clinical controls, the adolescents with NSSI disorder rated the stimuli as significantly more unpleasant and arousing.

Coping strategies moderate the relation of hypothalamus-pituitary-adrenal axis reactivity to self-injurious behavior.

An alarming proportion of adolescents engage in purposefully self-injurious behavior (SIB). SIB is a maladaptive strategy for coping with extreme tension generated in response to stress, particularly interpersonal stress. This study investigated the relation of older adolescents' SIB to the reactivity of the body's major physiological system for responding to stress, the hypothalamus-pituitary-adrenal (HPA) axis, after interpersonal stress. Adolescents' behavioral, cognitive, and emotional coping strategies were shown to alter the relation between SIB and HPA reactivity after conflict with a romantic partner.