Oral self-inflicted accidental trauma in patients with neurological disorders: a case report of dental management in infants with cerebellar hypoplasia.

Self-inflicted oral injuries, accidental or otherwise, can cause major consequences. Measures need to be taken to protect individuals from chronic self-injurious behaviour; however, there are no official guidelines on the subject. The purpose of this article is to show the case of a 1-year-old patient with neurological disorders who, following the eruption of deciduous teeth, had self-inflicted a traumatic ulcer on his tongue and lower lip. Following a multidisciplinary approach involving several operating units of our hospital to make a diagnosis, an oral device was designed to completely cover the dental elements to prevent recurrence of the trauma and to prevent further worsening of the injuries already caused. The purpose of this work is to demonstrate that although the surgical approach, such as extraction of the dental elements, may be the quickest solution in situations similar to the one presented, the high biological cost and irreversibility of the result lead to seeking alternatives and more conservative solutions such as the one described.

Facial self-mutilation: an analysis of published cases.

OBJECTIVES: Facial self-mutilation is rare. It is usually discussed from the psychiatric or psychoanalytic perspectives but has little prominence in general medical literature. Our objective was to describe facial self-mutilation in terms of its comorbidities, and to outline the different types of facial mutilation, as well as the basic approach to the patients with facial self-mutilation. METHODS: We undertook a review of all published cases of facial self-mutilation (1960-2011). RESULTS: We identified 200 published cases in 123 relevant papers. Four major groups of comorbidities emerged: psychiatric, neurological and hereditary disorders, and a group of patients without identified comorbidities. There were three general patterns of facial self-mutilation: (1) major and definitive mutilation, with the ocular globe as primary target--seen in patients with psychotic disorders; (2) stereotypical mutilation involving the oral cavity and of variable degree of severity, most often seen in patients with hereditary neuropathy or encephalopathy; (3) mild chronic self-mutilation, seen in patients with non-psychotic psychiatric disorders, acquired neurological disorders, and patients without comorbidities. About 20% of patients that mutilated their face also mutilated extra-facial structures. Patients with psychiatric conditions, especially those with psychotic disorders, had significantly higher (p<0.05) rates of permanent facial self-mutilation than others. Most treatment plans were very individually based, but some principles, such as prevention of irreversible loss of function and structure, or development of infection are applicable to all patients with facial self-mutilation. CONCLUSIONS: Facial self-mutilation is a potentially severe manifestation of diverse conditions. Several aspects of facial self-mutilation remain to be fully characterised from a clinical perspective.

[Management in the intensive care unit: between indications, constraints and contradictions]. / Prise en charge en chambre de soins intensifs: entre applications, contraintes et contradictions.

A patient with a pervasive developmental disorder was treated in the intensive care room for over a year; the freedom to come and go is an inalienable human right. How can the gap between legislative framework and the world of psychotic deficit be filled? The apparent contradiction between appropriate psychiatric care and the clinical condition of a patient with severe TED and intellectual deficit and the recommendations of the High Authority of Health is addressed. Narrative account in this context.

Helping self-mutilating adolescents: descriptions of Finnish nurses.

This study focused on the views of Finnish nurses in regards to providing help for adolescents who self-mutilate. Nine nurses participated, and when the interviews and written descriptions were qualitatively analysed, four main categories of information emerged. The first category comprises the nurses' views on self-mutilation. The second category describes the people who are able to be helpers. The third category describes the content of help, which is made up of a variety of acts provided by non-health professionals that promote the healthy development of adolescents. The fourth category describes care provided by nurses to adolescents who self-mutilate. Guidelines for caring for self-mutilating adolescents are needed, including information on the phenomenon of self-mutilation.

[Congenital insensitivity to pain: difficulty of management]. / L'insensibilité congénitale à la douleur : difficultés de prise en charge.

INTRODUCTION: Congenital insensitivity to pain with anhidrosis (CIPA) is a very rare disorder, most often of genetic origin. CASE REPORT: The authors present the case of two siblings, 10 and 13 years old, both followed-up since the age of 2 for CIPA diagnosed after discovering insensitivity to pain during iterative falls, burns, and of severe oro-digital self-mutilating behavior. Sural nerve biopsy and an electromyogram confirmed the diagnosis. DISCUSSION: CIPA with anhidrosis is a very rare disease. It is characterized by unexplained fever episodes, anhidrosis, pain insensitivity, self-mutilating behavior, and sometimes mental retardation. Complications of this insensitivity (non-treated fractures, burns, and oro-digital mutilation) may be lethal. Treatment remains preventive. The patient must observe a very strict hygiene. Prevention for maxillofacial involvement consists in breaking the cycle of oral self-mutilation.

Self-mutilation of tongue and lip in a patient with simple schizophrenia.

Self-inflicted lesions that cause mutilation are observed in schizophrenic patients. This case report describes the diagnosis and treatment of simple schizophrenia in a 31-year-old male patient who bit his own tongue and lower lip. The dental treatment proposed included the construction of a splint to prevent new lesions and to allow healing of existing ones. The treatment afforded to avoid tooth extraction before the patient responded to psychiatric drug treatment. The importance of a transdisciplinary approach to self-mutilation due to psychiatric disorders is stressed. The interaction between the two teams, stomatology and psychiatry, was crucial for the improvement of the patient's condition.

A concept analysis of suicidal behavior.

OBJECTIVE: Suicidal behavior is a significant global public health problem. Despite this, many health care professionals remain unaware of the distinction among suicidal behavior, self-mutilation, and deliberate self-harm. The aim of this study was to conduct a concept analysis of suicidal behavior. METHOD: Walker and Avant's 8-step method of concept analysis was used to examine the concept of suicidal behavior. Sources for analysis were identified using a systematic search of Medline, CINAHL, ProQuest Nursing & Allied Health Source, and the reference lists of related journal articles. RESULTS: Suicidal behavior was found to be associated with a constellation of external hazards and internal crises, lack of coping mechanisms and social support structures, and degree of suicidal intent, which, in the worst-case scenario, results in successful suicide. The antecedents of suicidal behavior are vulnerability characteristics that make painful events seem unbearable, and the consequences are death or failed suicide. In cases of failure, the medical consequences may be serious and long lasting. CONCLUSIONS: Defining the concept of suicidal behavior provides a basis for public health nurses to better understand suicidal behavior, thus improving their ability to care for suicidal patients during home visits.

[Differential indications for psychotherapies in borderline personality disorder]. / Indication différentielle des psychothérapies adaptées au trouble de la personnalité limite.

BACKGROUND: Borderline personality disorder (BPD) accounts for 10% of outpatient psychiatric practice. The risk of suicide attempts is high and the psychosocial impairment significant. Different theoretical streams have suggested psychotherapeutical approaches for BPD. OBJECTIVE: to examine the efficacy of psychotherapy for BPD patients on affective symptoms, behavioural outcomes, interpersonal and social functioning, as well as BPD criteria. METHODS: We reviewed the medical literature from 1990 to 2008 on Medline by combining the following keywords "borderline personality disorder" and "psychotherapy" (inclusion criteria). We restricted the analysis to "randomised control trial" or "meta analysis". RESULTS: Of the 39 abstracts that came out from the search, we selected 17 (44%) after applying the exclusion criteria. According to our review, different types of psychotherapies have shown some efficacy on reducing affective symptoms and BPD criteria, as well as improving behavioural outcomes and psychosocial functioning. Dialectical behavioural therapy presents the best-documented efficacy, notably on reducing self-mutilating and suicidal behaviours (five randomized controlled trials [RCT]). Mentalization based treatment seems to be efficient on the four types of outcomes, but has been the object of only one RCT. Finally, some evidence suggests that Manual Assisted Cognitive Treatment and Systems Training for Emotional Predictability and Problem Solving are the most cost-effective and easiest to be implemented. CONCLUSION: According to our review, some evidence supports an efficiency of psychotherapies in the management of several features of BPD. It is likely that, depending on the target symptoms, one type of therapy might be more efficient than another. The acceptability of these long-term treatments is however unknown.

Unsweetened ice popsicles impart a positive feeling and reduce self-mutilation after paediatric dental treatment with local anaesthesia.

AIM: The purpose of the current study was to assess whether an unsweetened ice-popsicle imparts a positive feeling to children after dental treatment in which local anaesthesia is administered, and whether it reduces the tendency of children to self-mutilate (bite the lip, cheek or tongue) after the administration of local anaesthesia. DESIGN: Crossover study of 31 children aged 4-11 years old who needed similar dental treatments on both sides of the mandible or maxilla under local anaesthesia. At the end of each appointment the child received a toy or an ice-popsicle especially made for this study. Patients and parents answered a questionnaire regarding the children's behaviour and feeling immediately after the treatment, and 10 and 30 min after receiving the ice-popsicle or toy. RESULTS: Children who received ice-popsicles after dental treatment under local anaesthesia felt less discomfort and suffered less soft tissue trauma than they did when they received a toy. Reduction in soft tissue trauma was evident 10 min after receiving the ice-popsicles. CONCLUSION: Licking of an ice-popsicle after dental treatment with local anaesthesia reduces the feeling of discomfort and the biting of soft tissue and self- mutilation.

Post-surgical evisceration with or without autocannibalism in 333 dogs-a survey of veterinarians.

Background: Few reports of post-surgical evisceration, with or without autocannibalism, in dogs exist. Aims: To collect a large case series of dogs experiencing post-surgical evisceration, with or without autocannibalism. Methods: We surveyed practicing veterinarians who were members of the Veterinary Information Network about their experiences with post-surgical evisceration in dogs, variably accompanied by autocannibalism (ingestion of eviscerated organs or tissues). Responses were analyzed using descriptive statistics. Results: We identified 333 cases with sufficient information for analysis: 221 with evisceration and autocannibalism, and 112 with just evisceration. Most cases occurred following surgery for reproductive reasons (desexing, cesarean section, and pyometra). Most occurred in young adult or adult dogs. Most dogs received analgesia perioperatively had routine closure (simple interrupted or simple continuous muscle layer closure) and most did not wear an E-collar post-surgically. Most dogs eviscerated within 3 days of the initial surgery. Approximately 64% underwent surgical repair and survived long-term without complications, more frequently if the evisceration was not accompanied by autocannibalism. Conclusion: Our study suggests that post-surgical evisceration and autocannibalism can generally be successfully managed by practitioners and do not confer a uniformly poor outcome for the dog.

How repeated 15-minute assertiveness training sessions reduce wrist cutting in patients with borderline personality disorder.

OBJECTIVE: The aim of this work was to examine a possible treatment for patients with borderline personality disorder who have wrist-cutting syndrome, a condition characterized by repeated, superficial wrist cutting in a non-suicidal fashion. Within the current healthcare system in Japan, the average amount of time a doctor can spend with a psychiatric outpatient is about 8 to 15 minutes. We, therefore, examined whether repeated 15-minute psychotherapy sessions to improve patient assertiveness would be effective for reducing wrist cutting and possibly other forms of self-mutilation. METHODS: We treated 13 patients diagnosed with borderline personality disorder and wrist-cutting syndrome with assertiveness training during 15-minute, biweekly therapy sessions over a course of one to four years. RESULTS AND CONCLUSIONS: At the conclusion of psychotherapeutic treatment, 69% of outpatients showed a statistically significant reduction in wrist-cutting behavior.

Self-mutilation and coping strategies in a college sample.

The goal of this study was to examine the use of specific coping strategies among self-mutilating college students. The self-mutilating group (n = 44) reported utilizing avoidance strategies more often than did a control group (n = 44) matched for general psychological distress but with no history of self-mutilation. In addition, female, but not male, self-mutilators endorsed using problem-solving and social support seeking strategies less often than nonmutilators. These findings suggest that coping strategies in general and avoidance-based strategies in particular may be important targets for the treatment of self-mutilative behaviors.

The use of stock fluoride trays in the management of soft tissue trauma in children who are comatose.

Pediatric patients who are comatose may develop a neuropathological chewing or clenching reflex that results in self-inflicted injury to the soft tissues of the oral cavity. An early and quick response to these problems may minimize the extent of soft tissue trauma. The use of a stock fluoride tray in the hospital management of a pediatric patient who was neurologically impaired and unconsciously traumatizing his oral soft tissues is described. This treatment modality may serve as an initial or interim device in managing pediatric patients with uncoordinated mandibular movements or clenching. In some instances, given the sometimes self-limiting nature of this problem, fluoride trays may serve as the sole mode of treatment

[Planned hospitalization after deliberate self-harm]. / Korte, planlagte innleggelser ved villet egenskade.

BACKGROUND: Deliberate self-harm appears to be a common problem, especially among young people. In mental health care deliberate self-harm is often associated with emotionally unstable patients or with personality disorders of a more serious nature. Our department offers planned hospitalisation during 1-2 years for patients who deliberately and frequently harm themselves and often use psychiatric services. MATERIAL AND METHODS: Chart journals for 9 patients were examined retrospectively for determination of long-term outcome. Rates of deliberate self-harm were selected into two categories, suicide attempts and self-mutilation. The number and type of inpatient hospitalisations and inpatient days were used to estimate the use of psychiatric services. RESULTS AND INTERPRETATION: The rates of deliberate self-harm, use of psychiatric health services and especially use of acute psychiatric services were reduced after introduction of planned hospitalization. Planned hospitalisation may be useful for this group of patients, but the results of this study should be interpreted with care as they are based on a small retrospective study.

A preventive approach to oral self-mutilation in Lesch-Nyhan syndrome: a case report.

Lesch-Nyhan syndrome is a rare X-linked recessive disorder of purine metabolism, caused by complete absence of the enzyme hypoxanthine-guanine phosphoribosyl transferase. Persons affected with this incurable disease are developmentally and physically delayed, and suffer from self-injurious behavior. The most typical feature results in partial or total destruction of perioral tissues. The purpose of this paper was to discuss a case of Lesch-Nyhan syndrome with self-mutilative behavior and lip injuries, including some suggestions of a preventive approach avoiding the extraction of teeth. A soft mouthguard fabricated to prevent the destruction of perioral soft tissues and combined psychiatric pharmacologic therapy proved to have satisfactory results.

Overcoming the oral aspects of -self-mutilation: description of a method.

BACKGROUND/AIM: Self-injurious behavior (SIB) is a serious and chronic condition frequently seen in special needs populations, affecting 10% to 17% of individuals diagnosed with intellectual and/or developmental disabilities. A 2.5-year-old infant with SIB, whose presenting symptoms were severe tongue and lip lacerations accompanied by much hemorrhage, is presented here to illustrate the problem and to show how this may be prevented. MATERIALS AND METHODS: An appliance is described which effectively limits the damage caused by SIB and permits rapid healing of existing injuries. RESULTS: The method provides for a stable, retentive, and comfortable device on the infant's undererupted and largely nonretentive crowns of the deciduous teeth as well as for all permanent teeth in children, adolescents, and adults. CONCLUSIONS: The appliance has been successfully employed for the past 10 years in patients with SIB who have attended for treatment in the Special Needs Clinic in our Department.

Cornelia de Lange and Ehlers-Danlos: comorbidity of two rare syndromes.

We present a case of a young adult with both Cornelia de Lange syndrome and Ehlers-Danlos syndrome. The patient showed non-verbal autism, intellectual disability and severe/intractable self-harming behaviours that led to a life-threatening complication (ie, septicaemia). A significant reduction in the self-harming behaviours was attained in a multidisciplinary neurobehavioural inpatient unit after addressing all causes of somatic pains, managing pain using level II and III analgesics, stabilising the patient's mood, limiting the iatrogenic effects of multiple prescriptions and offering a specific psychoeducational approach.

Urethral insertion of foreign bodies. A report of contagious self-mutilation in a maximum-security hospital.

Six male patients in a maximum-security hospital committed acts of urethral self-mutilation by insertion of a foreign body. The characteristics of the self-mutilators and of this unusual form of self-mutilation are described. The social contagion aspects of the self-mutilation are strongly suggested by the perpetration of urethral insertion for the first time by five patients after direct personal contact with a previous urethral self-mutilator. Techniques used in the management of these patients are described. Self-mutilation evokes strong emotional responses in staff members, and proper patient management also must include attention to the needs and concerns of treatment staff.

Treatment of self-inflicted oral trauma in a comatose patient: a case report.

Trauma to oral soft tissues in comatose patients may be more widespread than reported, as no extensive study of this problem has been conducted. Various appliances for the prevention of self-inflicted injuries to oral tissues particularly in children and the physically and mentally challenged have been documented, but there is little information on their use in adult comatose patients. Because comatose patients lack cerebral control of the masticatory cycle, they can easily injure themselves. Although it is not uncommon for patients with a decreased level of consciousness and in need of intensive care to be restrained to prevent injury due to involuntary movement of the limbs, head and neck restraint is often difficult and may be dangerous to the patient. This case report presents a simple solution to the problem of self-inflicted trauma to oral tissues.

Adaptations of mouthguards for patients with special needs.

The adaptations and applications of mouthguard appliances are many and varied, with uses ranging from protective to therapeutic. These modifications serve the individual needs of patients. This requires problem-solving based on combining form and function with the skills of the dentist.