Biological Therapies in Psychiatry
Self-injurious behavior is a heterogeneous phenomenon, occurring in patients with borderline personality disorder, psychosis, and mental retardation, among various other neuropsychiatric conditions. Because some scientists have postulated that abnormalities in the regulation of endogenous opiates might enable this behavior, clinicians have tried opiate antagonists to treat it. (1)
Casner and coauthors observed that between 10% to 66% of institutionalized people with mental retardation injure themselves. (2) Noting widespread use of the opiate antagonist naltrexone (Revia) in Texas state schools for people with mental retardation, the authors conducted a retrospective analysis of such cases.
Over a 5-year period, 56 residents of these facilities received naltrexone to treat self- injurious behavior. These people had received up to 10 previous psychotropics, and 84% had taken a neuroleptic at some time. The chart review revealed that they had received naltrexone, 25 to 300 mg/day, for periods of 3 to 87 months.
Clinicians believed 32 (57%) of the 56 were responders, and these patients were being maintained on naltrexone treatment. A blind reviewer looking for at least a 50% decrease of the behavior after naltrexone was started rated only 13 (25%) as improved ("objective responders").
Two adverse reactions were discovered. One patient had transient elevation of liver enzymes that reversed when naltrexone was discontinued. Another had a rise in blood pressure that was counteracted by coadministration of propranolol (Inderal and others).
Significantly (P = .025) more of the 13 "objective responders" functioned in the severe to profound range of mental retardation compared to the nonresponders. Responders also exhibited significantly (P = .0004) less concurrent aggression than nonresponders. One other finding intrigued the authors: the 13 objective responders accrued their benefits gradually and continuously over time -- even after 3 years of treatment.
In our field, theories generate preliminary clinical experimentation. Initial observations must then be followed by more rigorous pursuit of proof. If and when a phenomenon is validated, hypotheses can be reworked to fit the new data. We are only in the preliminary phase of gathering data about opiate antagonists as potential treatments for people with self-injurious behaviors. But these behaviors cause suffering and disability, and they are notoriously difficult to treat. Careful experimentation with naltrexone in individual cases seems warranted at this time. What we need now, of course, are more rigorously designed studies of this condition in a variety of patient populations.
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Dr. Bob is Robert Hsiung, MD, firstname.lastname@example.org
Alan J. Gelenberg, M.D.
Original article copyright 1997 Biological Therapies in Psychiatry.
Web page copyright 1998 Robert Hsiung.