Michael Crowe

Repeated self-injury and its management

The forms of self-harm described here are somewhat different from those detailed in the other papers in this volume. The degree of risk is usually less than that which is present in most cases of parasuicide, and the aim is usually that of reducing tension rather than of ending life; although in many cases parasuicidal behaviour such as overdosage may also occur. However, the frequency of the typical self-harm is often much greater than even that of repeated parasuicide, and the work engendered in accident and emergency (A&E) departments by each individual may be great. It is a problem which traditionally has been seen as difficult to treat in both general psychiatric settings and in the medical and surgical wards where many of the patients are treated. There are a number of syndromes under the heading of self-injury, as reviewed by Favazza (1996). They are all characterized by repeated self-harm, but the reasons given for the self-harm are very different in the various groups. Favazza interviewed a large number of self-harmers and found that those who were psychotic or depressed tended to give religious or sexual explanations for the behaviour, whereas personality disordered or neurotic individuals blamed either anger against self or others, the need to relieve tension or the wish to impress on others the degree of their own pain. In other groups there may be more manipulative motives, such as the wish by long-term prisoners to be transferred to the hospital wing. In the case of some patients with learning disabilities the self-harm may be an integral part of the disease, as in Lesch-Nyhan syndrome. In yet others the selfmultilation has a recreational or cult value (Musafar, 1996), and there are also culturally sanctioned forms of self-harm such as ritual self-castration in certain groups in India. Repeated self-harm is included in a number of diagnostic descriptions in ICD-10 and DSM-IV. In both of these in ̄ uential manuals it is a de® ning cr iter ion for `emotiona l personality disorder (borderline type)’ and there are also speci® c entries under the categories of `external causes of morbidity’ for various forms of self-harm including cutting or burning.The diagnosis of the syndrome of self-injury as a personality disorder is not very satisfactory, since many of the patients are not obviously personality disordered, but cannot otherwise be characterized except by the speci® c consequences of their selfharm. It would probably be preferable to use a diagnostic label which sim ply describes the selfharming behaviour, as suggested by Kahan and Pattison (1984). The syndrome of `self-wounding’ has been reviewed by Tantam and Whittaker (1992) in a wide ranging article.They estimate from a variety of British articles that self-injury sufficient to take the patient to hospital occurs in 1 in 600 of the population, but this may be a slight overestimate because it includes many who took overdoses of tablets on one occasion only. Selfharming behaviour is likely to begin in adolescence, and to continue into middle life, but there are some cases in which the behaviour begins in adults for the ® rst time fo llowing a bereavement or a difficult childbirth, or in the context of a depressive illness. Neither self-poisoning nor self-injury are necessarily carried out with suicidal intent, and in many repeated self-harmers the explanation given may be that of relief of tension, which may last for up to 24 hours. The aetiology of self-harming behaviour may be divided into pred isposing , precipitating and maintaining factors. In most cases there is guilt and self-blam e, and the individuals will usually also experience low self-esteem. In some of the patients there are also command hallucinations, and in others there are delusions as part of the syndrome.There is a high prevalence of reported childhood abuse, both sexual and physicalÐ up to 80% in some reports (Tantam & Whittaker, 1992) and certainly 60% in our own series (Crowe, 1997). However, this does not mean that the abuse is necessarily the main cause of the self-harm, because many other adverse childhood factors (such as time spent in care) may be present in those with an abuse history. Psychodynamic explanations (Feldman, 1988) include aggression turned inwards, the need for control and a wish for self-punishment for sexual impulses. The precipitating and maintaining factors include the relief of tension, the shedding of blood, the pain experienced, the need for punishment and in some cases the response of others. In forensic settings there is more of a likelihood that there will be some gain from the self-harm such as the privileges involved in

The golombok rust inventory of marital state (GRIMS)

Abstract The Golombok Rust Inventory of Marital State (GRIMS) is a new short (28 item) questionnaire for the assessment of the quality of a relationship. The GRIMS is a companion test to the Golombok Rust Inventory of Sexual Satisfaction (GRISS) which is in use in sex therapy and sexual dysfunction clinics and research. Its development and construction are described, together with details of item analysis and other psychometric procedures. The scale, which can be used for either men or women, has good reliability (.90 for women and .92 for men). Content and face validity are good. Some evidence of discriminative validity is also given. The GRIMS will have clinical and research application for marriage guidance and marital therapy clinics. Some further consideration is given to various differences between men and women in their perceptions of a good relationship.

Form and content in the conjoint treatment of sexual dysfunction: a controlled study.

Abstract Forty eight couples with impotence, anorgasmia or loss of libido were randomly allocated to one of three treatment conditions: (i) modified Masters and Johnson (male and female therapist), (ii) modified Masters and Johnson (one therapist) and (iii) marital therapy and relaxation comparison procedure (one therapist). The major variables investigated were type of therapy, number of therapists (one or two) and sex of therapist. Post-treatment and one year follow-up assessments showed no significant difference in outcome between treatment approaches. No significant effects were found for sex of therapist and the interaction between sex of therapist and sex of presenter.

The Psychosexual Dysfunction Clinic at the Maudsley Hospital, London: A survey of referrals between January and December 1996

Abstract This paper describes the demographic characteristics, referral sources and types of referral problems of 135 patients referred to a psychosexual clinic located in an inner-city area of south London from January until December 1996. Results were comparable to those from another psychosexual clinic located in a similar inner-city area. Results from both these clinics differ from earlier reports of non-inner-city clinics in male to female distributions and most common referral source. The factors predictive of non-attendance were (a) non-return of a questionnaire asking for background information; (b) gender, with males being less likely to attend initial and treatment sessions; (c) place of birth, with non-UK born referrals being less likely to attend initial and treatment sessions; and (d) employment status, with the unemployed being less likely to attend treatment sessions. Identifying the characteristics of non-attenders can have important implications for the provision of cost-effective treatme...

Couple therapy and sexual dysfunction

In treating a sexual problem which exists in a relationship, the non-sexual interaction between the two people involved cannot be ignored. From Masters & Johnson onwards, sex therapists have treated the couple as the unit of therapy, unless there is no relationship to be treated. This review looks at the various dysfunctions and sexual motivational problems, their causation, the contribution of relationship factors, principles of couple therapy using the behavioural systems model and finally the specific management of some problems using couple therapy as well as sex therapy.

The Negotiated Timetable: A new approach to marital conflicts involving male demands and female reluctance for sex

Abstract The negotiated timetable is a treatment approach for couples in which the female partner is reluctant to have sexual intercourse, though in many cases she may experience physical pleasure and orgasms, whereas the male partner has a high sexual drive which leads him to press for frequent intercourse. When it becomes appropriate within treatment, the couple are asked to plan their sexual activity for specific days of the week with a ban on sex on other days. The approach is clinically successful in a majority of such cases, and helps towards the reduction of both sexual and non-sexual conflicts. Case reports are presented, together with a discussion of possible mechanisms involved.

Couples and mental illness

This is an underresearched area in the mental health field, despite the fact that a large number of patients suffer from psychiatric problems and many of them are in relationships with a partner. There is typically a change in the relationship involving extra responsibilities being taken by the partner. The partner may indeed become depressed as a result of the stresses experienced. The partner may in some cases be worsening the problems that the patient experiences, but may also be able to relieve them by using specific techniques. The particular problems presented by depression, schizophrenia, substance abuse, jealousy and folie È deux are discussed. Professionals need to increase their awareness of this issue, to treat the partner with understanding and to consider the stability of the relationship as part of their management.

Pharmacologically induced penile erection (PIPE) as a maintenance treatment for erectile impotence: A report of 41 cases

Abstract Forty-one patients with impotence, either organic in origin or unresponsive to psychosexual therapy, were treated by intracavernosal injections, in most cases using papaverine. Small test doses were given, progressing to higher doses if necessary, with instructions for self-injection. Older patients needed significantly higher doses than younger ones. Thirty-six of the 41 patients were able to achieve erections as a result of injections. Seventeen of these have continued self-injection at home; 14 achieved erections but had little or no further use of the injections at home; five achieved erections and used the treatment at home, but then discontinued it after the recovery of spontaneous erections. Five patients failed to achieve erections even with the maximum dose. Five patients early in the series experienced priapism, which was successfully treated. There were few other side effects.

Intimacy in relation to couple therapy

Abstract Intimacy is a central and important concept in couple relationships and couple therapy. It may be divided into four categories, namely sexual, physical, emotional and operational. Intimacy can vary with gender, culture and other influences, and there is no ideal level of intimacy to be striven for. Theories about the nature of intimacy derive from psychodynamic, interpersonal and systems concepts. A number of questionnaires have been devised to evaluate the level of intimacy in a couple. Certain syndromes and relationship problems, especially jealousy and depression, can be linked with intimacy conflict, and in most types of relationship problem there are intimacy elements. The management of intimacy problems in couple therapy is discussed and examples of therapeutic interventions given. In the final analysis, however, the aim should be to help the couple adjust to each others preferred levels of intimacy, rather than to impose an arbitrary ideal of intimacy on them.

Physical Treatments of Erectile Disorders

SummaryAlthough physical treatment of erectile disorders is not a recent phenomenon, its use is becoming increasingly sophisticated Various physical treatments are available ranging from vacuum pumps and intrapenile injections to surgical implants. Each has its advantages and disadvantages. In this paper we review the current status of physical therapies and draw together the research evidence. A thorough psychological and physical assessment of the erectile dysfunction as well as that of the relationship are important in planning treatment.