Research Notes: Self-harming

Int J Neuropsychopharmacol. 2002 Jun.
Topiramate attenuates self-injurious behaviour in Prader-Willi Syndrome.
Shapira NA, Lessig MC, Murphy TK, Driscoll DJ, Goodman WK.
Department of Psychiatry, Evelyn F and William L McKnight Brain Institute of the University of Florida, Gainsville, USA.

Self-injurious behaviour (SIB), most notably skin picking, has been described by various terms in the literature ranging from neurotic/psychogenic excoriations to compulsive/pathological skin picking. Prader-Willi Syndrome (PWS) is a neurogenetic multisystem disorder characterized by infantile hypotonia, mental retardation, short stature, hypogonadism, dysmorphic features, and hyperphagia with a high risk of obesity. Psychiatric manifestations include SIBs in the form of skin picking, nail biting and rectal gouging. Topiramate is a novel anti-epileptic medication without significant liability of weight gain. There are no published reports of topiramate being utilized in PWS or SIB. We report attenuation of SIB with resultant lesion healing in three PWS adults treated with topiramate in an 8-wk open-label trial. Although our findings should be treated with caution, they suggest that double-blind or cross-over studies with topiramate are warranted to establish the possible role of topiramate in attenuating SIB in PWS and other disorders that involve SIB.

Arch Pediatr. 2001 Oct.
Rectal self-mutilation, rectal bleeding and Prader-Willi syndrome. [Article in French]
Campeotto F, Naudin C, Viot G, Dupont C.
Service de neonatologie, hopital Saint-Vincent-de-Paul, 82, avenue Denfert-Rochereau 75674 Paris, France.

Prader-Willi syndrome is a genetic disorder characterized by infantile hypotonia, obesity, hypogonadism and mental retardation. Individuals with Prader-Willi syndrome manifest a severe skin picking behavior, including rectal picking. CASE REPORT: We report the case of a girl (12 years old) with this syndrome in whom rectal picking resulted in rectal bleeding and solitary rectal ulcer. CONCLUSION: Caregivers of children with Prader-Willi syndrome should be aware of a potential rectal picking behavior, which results in significant bleeding. Early recognition of such a behavior helps to avoid misdiagnosis.

Eat Weight Disord. 1998 Dec.
Hyperphagia and self-mutilation in Prader-Willi syndrome: psychopharmacological issues.
Yaryura-Tobias JA, Grunes MS, Bayles ME, Neziroglu F.
Department of Biopsychosocial Research Institute for Biobehavioral Therapy and Research, Great Neck, NY, USA.

This study focused in the treatment of two major Prader-Willi symptoms: hyperphagia and self-injurious behavior (SIB). Four patients participated in a four-year study with monthly follow-ups. Patients lived in a behaviorally structured environment, and were treated with selective serotonin reuptake blockers and phenothiazines. Psychopharmacological intervention improved SIB symptoms, but was ineffective to control appetite satiation.

Neuropediatrics. 1998 Jun.
Impaired peripheral somatosensory function in children with Prader-Willi syndrome.
Brandt BR, Rosen I.
Center of Child and Youth Habilitation, Lund, Sweden.

The Prader-Willi syndrome (PWS) is associated with a tendency to self-injury and a reduced sensitivity to painful stimuli. Somatosensory functions were studied in 5 children aged 11-13 years with PWS. Tactual perception in the hands (stereognosis) was apparently normal in 4 of them. Sensory nerve conduction velocities in the median nerve and latencies for sensory evoked potentials were similar in the PWS subjects and in 10 healthy controls indicating a preserved myelinisation of sensory nerve fibers in PWS. Sensory nerve action potential amplitudes in the PWS group were on an average only 40-50% of normal size (p = 0.03), suggesting a reduced number of normal axons in the median nerve. The results may be relevant for the impaired pain sensitivity in PWS because similar neurographic findings and a low density of peripheral nerve fibers have been reported in patients with hereditary or congenital insensitivity to pain.

Ann Dermatol Venereol. 1997.
Self-induced cutaneous lesions in Prader-Willi syndrome. [Article in French]
Plantin P, Milochau P, Broussine L, Blondin G.
Service de Dermatologie, Hopital Laennec, Quimper.

INTRODUCTION: The Prader-Labhart-Willi syndrome was first described in 1956. Prader-Labhart-Willi syndrome is the most common genetic form of human obesity and the incidence of Prader-Labhart-Willi syndrome has been estimated to 1 in 10,000 or 25,000 live births. Skin-picking was frequently reported in Prader-Labhart-Willi syndrome and two patients who displayed repetitive skin picking are described. OBSERVATIONS: Two childrens (6 year-old girl and 7 year-old boy) were examined and noted superficial ulcers of their arms and legs. This cutaneous lesions were induced by children themselves. Skin-picking, in our cases, were associated with behavior problems (temper tantrums, violence). CONCLUSIONS: Skin-picking appears to occur in the great majority of patients with Prader-Labhart-Willi syndrome and constitutes a minor criteria of diagnosis. Hypopigmentation in Prader-Labhart-Willi syndrome appears to be as common as previously features. Significant differences in hair color, sun sensitivity and complexion were found between those patients with chromosome 15 deletion and those with normal chromosome. Association between obesity (onset before 6 years) and skin picking constitute a sign for diagnosis of Prader-Labhart-Willi syndrome.

Pediatrics. 1996 Feb.
Rectal bleeding in Prader-Willi syndrome.
Bhargava SA, Putnam PE, Kocoshis SA, Rowe M, Hanchett JM.

Individuals with Prader-Willi syndrome manifest severe skin picking behavior. We report three patients with this syndrome in whom an extension of this behavior to rectal picking resulted in significant lower gastrointestinal bleeding and anorectal disease. The recognition of this behavior is important to avoid misdiagnosing inflammatory bowel disease in this group of patients.

Psychopharmacol Bull. 1994.
Self-injurious behavior and serotonin in Prader-Willi syndrome.
Hellings JA, Warnock JK.
Department of Psychiatry University of Kansas Medical Center, Kansas City.

Low central nervous system (CNS) serotonin levels have been associated with impulsive, aggressive and self-injurious behavior (SIB). Persons with Prader-Willi Syndrome (PWS) often engage in self-injury by severe compulsive skin picking and gouging and often manifest compulsive eating, hoarding, and explosive outbursts. Some of the compulsive behaviors seen in patients with obsessive-compulsive disorder (OCD) bear similarity to behaviors associated with PWS: Skin picking, trichotillomania, and onychophagia (nail biting). There is abundant evidence that selective serotonin reuptake inhibitors (SSRIs) are effective in treating OCD. Three cases are described in which persons with PWS responded favorably to SSRI treatment. Two persons showed a significant decrease in skin picking. The third case showed a significant decrease in hoarding and explosive outbursts. Strategies are discussed for investigating the possibility of a shared neurochemical basis for the self-injurious, aggressive, and compulsive behaviors in persons with PWS. PWS may provide a relatively homogenous model for the study of skin picking and explosive outbursts among other populations.

J Am Acad Child Adolesc Psychiatry. 1993 Jul.
Naltrexone and fluoxetine in Prader-Willi syndrome.
Benjamin E, Buot-Smith T.
Phoenix Children's Hospital.

The case discussed is of a 9-year-old boy with a diagnosis of Prader-Willi, compulsive eating, severe skin picking, mild mental retardation, and behavioral problems. Prehospital, hospital, and posthospital course is reviewed. An approach using fluoxetine and naltrexone shows a marked improvement in weight control, skin picking, and behavior. Obesity and self-mutilation are discussed with regard to the use of fluoxetine and naltrexone.

Arch Dermatol. 1992 Dec.
Pharmacologic treatment of severe skin-picking behaviors in Prader-Willi syndrome. Two case reports.
Warnock JK, Kestenbaum T.
Department of Psychiatry, University of Kansas Medical Center, Kansas City.

BACKGROUND. Prader-Willi syndrome (PWS) is characterized by hypotonia at birth, hypogonadism, early childhood obesity, and mental deficiency. Other behavioral symptoms that become prominent during adolescence and adulthood include temper outbursts, stealing and hoarding food, and skin picking. The self-excoriating skin picking behavior observed in individuals with PWS is quite common and can lead to persistent sores and infections, even requiring hospitalization. OBSERVATION. Two patients with PWS who displayed repetitive, self-mutilatory behavior of skin picking are described. They were both treated successfully with different doses of fluoxetine, a selective serotonin reuptake inhibitor. CONCLUSIONS. The skin-picking behavior in patients with PWS may be a variant of the spectrum of obsessive-compulsive disorders. Obsessive-compulsive disorders have been successfully treated with serotonin reuptake inhibitors such as fluoxetine. Thus, fluoxetine may be considered an option in the management of skin-picking behavior in patients with PWS.