Serotonin Syndrome and Atypical Antipsychotics
American Journal of Psychiatry
TO THE EDITOR: We studied the relationship between acts of self-mutilation and fluctuations in levels of nocturnal urinary cortisol excretion in a female inpatient who developed borderline personality disorder after traumatization during childhood. Ms. A, a 36-year-old woman, had pronounced repetitive self-mutilating behavior in addition to borderline personality disorder diagnosed according to an interview with the German version of the Dissociative Disorders Interview Schedule (1) (DSM-IV
... ule (1) (DSM-IV diagnoses 296.32, 300.6, 300.12, 300.15, 300.81, 301.83, and 307.1). She collected her entire nocturnal (8:00 p.m. to 8:00 a.m.) urine output on 86 consecutive nights (2) Her nocturnal urinary volumes were almost identical (mean=983 ml, SD=128), but the fluctuations in her nocturnal cortisol excretion were extreme, varying from 2 to 30 µg a night. Compared to normative data (cortisol excretion during 24 hours: 20-90 µg/day), her nocturnal cortisol secretion appears low on average; this is in accordance with data from other studies (3). However, our longitudinal study revealed that periods of low cortisol excretion were followed by periods of continuous increases in excretion over several nights. Above 20 µg a night, she performed one or several acts of selfmutilation. Subsequently, an instantaneous decrease to low initial baseline values of cortisol was observed. Thereafter, her nocturnal cortisol excretion remained at this low level for several days. The next period of increasing cortisol secretion was again terminated by an episode of selfmutilation. Adler L, Wedekind D, Pilz J, Weniger G, Huether G: Endocrine correlates of personality traits: a comparison between emotionally stable and emotionally labile healthy young men. Neuropsychobiology 1997; 35:205-210 3. Yehuda R, Giller EL, Southwick SM, Lowy MT, Mason JW: Hypothalamic-pituitary-adrenal dysfunction in posttraumatic stress disorder. Biol Psychiatry 1991; 30:1031-1048 4. Winchel RM, Stanley M: Self-injurious behavior: a review of the behavior and biology of self-mutilation. Am J Psychiatry 1991; 148:306-317 5. van der Kolk BA, Perry JC, Herman JL: Childhood origins of selfdestructive behavior. Am J Psychiatry 1991; 148:1665-1671 6. Jones IH: Self-injury: toward a biological basis. Perspect Biol Med 1982; 26:137-150 7. Kraemer GW, Clarke AS: The behavioral neurobiology of self-injurious behavior in rhesus monkeys. Prog Neuropsychophar macol Biol Psychiatry 1990; 14(suppl):S141-S168 8. Huether G: The central adaptation syndrome: psychosocial stress as a trigger for adaptive modifications of brain structure and brain function.