Sunday, March 27, 2011

Self abusive and aggressive behavior in mentally retarded as manifestation of autoeroticism

Since I do not "screen" patients before seeing them, and have no problem accepting any patient in to my practice as long as they can pay my fees, over the years I have accumulated quite a few mentally retarded individuals in my service.
The most common complaint, not by such patients - for they are mostly non-verbal, or in possession of limited vocabulary - but by their caregivers, is their destructiveness. And the usual solution suggested by them is for me to prescribe more medications. And sometimes it does help to raise their medications though they are quite often already on the maximum dosages of anti-psychotics, sometimes two or three of them, in addition to couple of mood stabilizers like depakote or lamictal along with an anti-anxiety agent or two and an antidepressant.
So what do I do?
Besides lowering the dosages of their psychotropic in good many cases, over the years I have been struck by something about these patients which is worth mentioning in the blog. I find their destructiveness, more often directed against themselves than against others, is often due to undischarged sexual tensions. Their scratching of their skin, sometimes to the point of digging deep in to the flesh, tearing off their clothes, sometimes to the point of outright stripping buck naked in public, repetitively playing with their hair, sometimes to the point
of pulling them out, scratching and clawing themselves and their caregivers, defecating or urinating in bed or in common areas of the Group Homes, despite having mental capacity to go to the toilet, digging into rectum or other private parts, banging their head against the wall, eating rubbish, licking the floor, singing or humming to
themselves relentlessly, doing other repetitive activities like brushing their hair or asking others to do it for them, staring longingly at some caretaker, trying to touch or rub against others, gripping hands and not letting it go, they all appear to be means to discharge sexual tensions.
Now such bizarre and aggressive behavior could have origins in other pathologies as well, but quite often they are conduits to get rid of sexual cravings.
Mental retardation does not necessarily mean retardation of sex drives as well. Granted some retarded patients with genetic or chromosomal defects may have across the board stunted growth, including stunted
sexual drives. But most don't. Specially those who develop mental retardation due to cerebral palsy, viral infections in infancy, or closed head injuries in first years of life. In mental retardation sexual tensions often become pathologically reinforced because there are limited areas of satisfaction for these individuals from other activities of life. Social pleasures are hardly present and therefore deriving of satisfaction from sexual discharge become preeminent. In those whose retardation occurs due to environmental insults, they often have good genetic endowment but not enough brains to keep pace with their physical and sexual development.
These individuals are most troubled by their high sex drive. As a rule, high sex drive is sine qua non of
good genetic endowment. And generally the high sex drive also brings with it good brains to keep the drives and the rational part of the individual (ego) which controls it in good balance, channelizing most of sexual strivings into sublimated socially acceptable higher goals than direct sexual behaviors. In fact intelligence may be nothing more than complex displacement of sex seeking behavior. The high energy that comes with strong sex drive leads one to relentlessly search for suitable partners to mix one's sexual substances with. And this means constant scouring of the environment and finding the right pathways to such partners. Mentally retarded individuals do not have enough brains to make pathways to suitable partners to mix their sexual substances
with and discharge their sexual tensions.
But sexual drive is a constant thing. The human organisms are relentlessly pressured, albeit the pressure builds up so slowly, by secretion of chemicals that power the sexual drives. And when these drives become super saturated with the chemicals, they push the person to do something about it. And when another suitable person cannot be found because of the handicapp, the person starts treating his or her own body as a sexual object. And slowly the masturbatory activities or even more regressed forms of auto-eroticism take over the person's mind. When restrain is put upon it, they fight and get aggressive. Occasionally no external restraints are needed and the activation of internal restraints, for we seem to have genes to do that too, create a
fight within the individual, and after masturbation, or sometimes even before indulging in it, the person starts a fight. Sometimes these patients will slap themselves for indulging in the forbidden sexual behaviors, and in an occasional patient one can see masturbation and hitting oneself going on simultaneously.
In this context it may be worth mentioning that rocking and repetitively banging the head against the wall seem to be a most preferred method of releasing sexual tensions. Hitting against the wall seems to be like a symbolic action of finding a break (crack) in the world where one can release one's sexual tensions.
Anyway, do I have any practical tips for dealing with this sex driven destructiveness, besides high psychoanalysis, which of course one has fat chance of applying with these patients who hardly know themselves from the their rocking movement?
I have found that naltraxene (Revia) which blocks the opiate receptors sometimes reduces this sex driven destructiveness. Not always, but it does show some efficacy in quite a few such patients. The success is
partial and over time it does fade some, but blocking the naturally occurring opiate activity in the brains of people does lessen the urge to satisfy oneself auto-eroticially.
Why does it do that?
I think the infliction of pain on others and oneself releases opiate like neurochemicals in the brain. And these opiates facilitate sexual behavior. They lessen the anticipation of pain and thus lessen the fear of indulging in auto-eroticism. By giving naltraxene the effect of the natural opiates is blocked. The patient decreases hurting himself or others because with naltraxene blocking the opiate activity there is no point in being destructive and generating the opiate like neurochemicals.
One may mention in passing that giving of SSRI such as Paxil and Prozac also help in some of these patients. Increase in serotonin reuptake is a known damper of sex drive. Less pressured by sex drive the patients have less urges to be destructive.

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