Memory reconsolidation for treatment-resistant aggression and self-injurious behaviors.

CASE A 47-year-old man diagnosed with intermittent explosive disorder, polysubstance dependence (in a controlled setting), significant childhood neglect and abuse, and mild mental retardation (IQ of 56 per Wechsler Adult Intelligence ScaleFourth Edition) was hospitalized in a state inpatient hospital with a long history of aggression and SIB. Aggressive behaviors included spitting, punching, and kicking staff and peers along with SIB of scratching arms, swallowing items, and banging, punching, or breaking glass windows. There were no consistent predisposing factors to these behaviors, but he would sometimes state he did these behaviors when he felt lonely, wanted soda or money and had none, or when he was bored and wanted to be placed on constant observation. The patient developed and acquired these reinforcing properties over a long period, and clinical observation and interpretation suggested that this became a part of his pattern of interacting with others, serving to both modulate internal distress (as he had limited verbal capacity to express his feelings directly) as well as establish socioenvironmental control over others toget his desires met on the unit. These behaviors had kept him from being placed with community providers, and as a consequence, he had been hospitalized for over 7 years. All previous attempts to mitigate these behaviors through medication (adequate trials of risperidone, haloperidol, olanzapine, quetiapine, topiramate, bupropion, paroxetine, trazodone, clonazepam, and naltrexone had been tried in combination and/or as necessary) and behavioral interventions (including weekly individual therapy, peerbased groups, transition care counseling, substance abuse counseling [including alcoholic anonymous meetings], multiple individualized coping skills treatments, and a differential reinforcement of other behavior schedule) did not have lasting results of decreasing the targeted behaviors. Given the failure of these specialized pharmacologic and behavior treatments and after a through review of the patient’s history, we began a trial of modafinil. This was chosen because of his addiction history, the habitual nature of these behaviors (which seemed to be rewarding and therefore could be perceived as a behavioral addiction), the novel mechanism of the drug, and clinical research suggesting a modulating effect on addiction and processes requiring cognitive control. He had a good initial response at 100 mg with a decrease in self-harm and had the dose increased to 200 mg after some of the problem behaviors returned after 6 weeks. He was maintained on this dose with good effect, and after the second month of treatment, he had no SIB and was recommended for a possible discharge to an appropriate outpatient facility. At that time,hehadaburstofaggression/ SIB (which accumulated in 32 restraints in 2 months), and modafinil was tapered and discontinued by a treating psychiatrist because it was thought that this was possibly activating the patient given the potential stimulating properties of the drug.Noother treatments (including multiple doses of different antipsychotics and behavioral techniques) could effectivelymanage these behaviors at this time. Given the lack of efficacy of previous and current treatments and the seriousness of these behaviors, we discussed trying a new (and somewhat controversial) technique based on memory reconsolidation. Briefly, memory reconsolidation focuses on when memories are retrieved and are briefly open to a more physiologically malleable state where they can be either strengthened or weakened based on technique (please see Schwabe et al, Lee, and Nader and Hardt for reviews). Importantly for this case, these methods have been found to effectively reduce addiction and emotionally ladenmemories inhumanpopulations. Propranolol, an adrenergic receptor antagonist, was chosen as the preferred method because it has been previously studied, cited widely in the literature, and safe in this clinical context. The patient consented, and then the procedure was started on the unit (Fig. 1). A 1-time dose of 40 mg propranolol was given approximately 5 hours after an SIB episode in which he was restrained. After waiting 90 minutes (when peak levels of propranolol can be expected in humans after oral administration), we had him remember in as much detail as possible the things that led up to the episode, the actual incident, and his emotional response to the situation. After that session (30 minutes), we led him to the window and asked him if he wanted to hit it. He declined and stated he was tired. The rest of the week showed a dramatic reduction in SIB with only 1 short episode of hitting the window in which he was redirected without a restraint. We tried the propanolol session again the next week (with the same perimeters) after he was triggered in a trauma group by a peer and escalated with another restraint. He maintained a marked reduction in SIB incidents afterwards (a total of Letters to the Editors Journal of Clinical Psychopharmacology & Volume 35, Number 1, February 2015