Release of Endorphins During Self-Injurious Behavior in Psychiatric Patients

Hurts So Good

 

Release of Endorphins During Self-Injurious Behavior in Psychiatric Patients

By Karina Fatova

 

“No, I don’t want to kill myself! I just want people to know my pain, the way I feel it…the emptiness. When I pick up that razor and run it across my wrist, I have the control again, and the stinging and burning make me forget that I either don’t feel anything, or feel too much.”

 

My one-month rotation at the Jacobi Psychiatric Emergency Department exposed me to the presence of various self-harm behaviors in patients with a variety of psychiatric diagnoses. Self-harm is defined as the intentional, direct injuring of the body most often done without suicidal intentions. Patients, who engage in self-harm, such as creating superficial cuts on their arms, or swallowing screws, often carry the diagnosis of Borderline Personality Disorder (BPD). BPD is a disorder marked by instability in moods, behaviors, and interpersonal relationships. Borderline patients often report a compulsive quality to their self-injurious behavior, typically associated with a need to relieve tension, or alleviate emotional pain. BPD is primarily a behavioral and mood disorder stemming from childhood trauma and inconsistent primary relationships with family. However, after seeing many BPD patients with a history of “cutting,” I began to wonder if there was any underlying neurobiochemical basis for the presence of self-harm in someone who grew up with pervasive trauma.

Stanley et al. in “Nonsuicidal Self-Injurious Behavior, Endogenous Opioids, and Monoamine Neurotransmitters” (2010) postulated that while dopamine and serotonin were often implicated in suicide, the endogenous opioid system may play a more prominent role in self-injury when there is no suicidal behavior. The article focuses on patients with diagnosed Borderline Personality Disorder (BPD). There is a well-established relationship between pain perception and endogenous opioids. Beta-endorphin and met-enkephalin, which are mu and delta receptor agonists respectively, play a role in increased tolerance for pain (antinociception), and are involved in stress-induced analgesia. Dynorphin, which binds primarily to the kappa opioid receptor has a more complex role in the pain system, but primarily is involved in stress-induced hyperalgesia (“numbing”). Stanley et al. have shown that there is increased pain tolerance in BPD patients who cut, burn, or hit themselves. Taken together, the evidence suggests that dysregulation of the endogenous opioid system could underlie nonsuicidal self-injury.

 

In the study, twenty-nine psychiatric patients gave their written informed consent to become participants. The participants all had an Axis II Cluster B Diagnosis (Borderline, Narcissistic, Anti-Social, or Histrionic), and they were divided into two groups depending on the presence or absence of non-suicidal self-harm in the patients. The participants were free of medication for seven to fourteen days prior to the collection of their cerebrospinal fluid by lumbar puncture to ascertain their endogenous opioid levels. The mean age of the subjects was thirty-five, and the majority were unemployed, single, Caucasian females, with sixty-two percent of them having attended college. The cerebrospinal fluid samples were assessed for concentrations of beta-endorphin, met-enkephalin, and dynorphin, and the results showed that the self-injury group had significantly lower levels of beta-endorphin and met-enkephalin, with no difference in CSF dynorphin.

 

The results showed that opioid deficiency could result from chronic childhood stress and trauma, such as abuse and neglect. Childhood trauma and self-harm have a high co-occurrence. Because endogenous opioids play a role in pain threshold and perception, self-injury may bolster levels of endorphins in order to ameliorate emotional pain and tension. Patients who self-injure have even reported enhanced mood right after self-injury. Non-suicidal self-injurious behavior may be an effort on the part of the patient to bolster endogenous opioids to restore homeostasis. Interestingly, the article proposes treating patients who engage in self-injury with a long-acting opioid antagonist, which would block the reward of enhanced endogenous opioids caused by self-harm behaviors and subsequently lead to their extinction (Stanley et al.). Indeed, the article cites previous research where naloxone and naltrexone, types of opioid antagonists, aided in diminishing self-injury.

The idea that individuals with low endogenous opioids engage in more self-harming behavior is liberating because it opens up the conversation to why certain people have deregulation in their neurobiochemistry, and the answer may often lead to a history of severe stress. Perhaps as the medical community gains more knowledge in the matter of how abuse changes the brain, greater empathy and ability to treat those who self-harm will become available. Patients will thank us with their own personal progress.


The Vampire Myth Through The Lens of Medicine

 

 

by Karina Fatova

Vampire fascination waxes and wanes in mainstream media over time. Over the past several years Sparkly Edward, Brooding Bill, and most recently Dracula himself, played by Jonathan Rhys Myers on NBC, have been subtly, or sometimes not so subtly (think Eric lounging naked on a beach chair in the mountains), shaping our view of “the vampire.” Before these, there were the beautiful and conflicted Lestat and Louis of Anne Rice’s preternatural imagination, the fiercely powerful Blade, and many other enactments in movies and books of the nocturnal, elusive, and immortal. So, do vampires really exist? Yes….and no.

Clinical vampirism, or Renfield’s Syndrome, named after Dracula’s trusty servant, is described as “the compulsion to drink blood.” The diagnosis is not formally in the DSM-5, the psychiatric “manual” of diagnosis and symptomology, and is usually attributed to schizophrenia or a deviant sexual practice, known as a paraphilia. However, before the 1980’s rise of the coded categories of the manual, the psychiatric literature burst with case history reports of “extraordinary disorders of human behavior,” which not only included clinical vampirism, but also lycanthropy (werewolves) and possession with stigmata. According to the case reports, the condition starts with a key event in childhood that causes the experience of bloody injury, or the ingestion of blood, to be exciting. After puberty, the excitement becomes sexual in nature, and in adulthood consumption of blood can create a sense of power and control.

Individuals with Renfield’s are overwhelmingly male, and often start with autovampirism, ingestion of their own blood, before moving on to animal blood, and later human blood. Human blood can be obtained inconspicuously from blood banks and hospitals, from a willing “donor,” or by force, as evidenced by so-called “vampire” serial killers. Richard Trenton Chase, the man who killed six people within the span of a month in the late 1970s, started mixing dog blood with coca-cola and injecting himself with rabbit blood in early adulthood because he thought “someone had stolen his pulmonary artery,” and his heart was shrinking. His MO became shooting people, removing vital organs, and then drinking their blood.

It was later recognized that Chase suffered from a serious mental illness outside of his compulsion to drink blood. Of course, when we think of vampires, drinking blood is but one nail in the coffin (pardon the bad pun). Vampires are supposed to be afraid of garlic, have no reflection in mirrors, and stay away from sunlight for fear of burning to a crisp. But what if the vampire legend, with all its aspects, originated from medical reality? Porphyria, also known as “Vampire Syndrome” is believed to be responsible for the legend of the vampire. Porphyria is a condition marked by a deficiency of enzymes in the pathway to produce heme found in red blood cells. Patients with Porphyria suffer from anemia, aggressive behavior, red tears, photosensitivity, and other symptoms of the heme precursors, porphyrins, building up in the body.

Sufferers of skin, or cutaneous, Porphyria can develop severe burning and blistering on any body part exposed to the sun, and because of facial tissue erosion around the lips, the teeth may look more prominent, as if the individual has “fangs.” It might be difficult for a porphyria sufferer to face his own reflection in the later stages of the disease, when his face has been eaten away and his teeth are exposed in an ugly grin, which gives a nod to the belief that “vampires” have no reflection. Interestingly, some Porphyria patients cannot tolerate garlic because the compounds it contains aggravate symptoms and may cause excruciating pain, especially abdominal pain. Centuries before a name and cause were given to this disease, individuals with porphyria were known to alleviate their anemia by drinking blood. Nowadays, medical treatments include medications for symptoms, blood transfusions, and drawing blood to reduce iron in the body.

We crave vampires in our movies, books, and even Halloween costumes, yet it is important to remember that every myth is based in reality. Greater knowledge and understanding in psychiatry and medicine can help us separate patients who are truly suffering and in need of help, from those who choose to express themselves in an unconventional way. Speaking of the contemporary underground vampire scene, that’s a whole topic for a whole other blog entry…stay tuned.

Want to keep up with clinical vampirism? Open your free Scizzle account.