[Apropos of the psychotherapy of a self-mutilating patient. Essay on the psychoanalytical significance of digital self-mutilation].
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Adult↗
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The functions of self-mutilation.
While pathological self-mutilating behavior has been clinically examined for over 65 years, and much of the literature hypothesizes some function for the behavior, there has been little attempt to integrate or differentiate between different functional ideas. This review uses six functional models extracted from the literature to organize a discussion of the multiple functions of self-mutilation, acknowledging the overdetermined nature of the behavior and attempting to understand how self-mutilation can serve multiple functions simultaneously. Contextual information about the definition, prevalence, phenomenology, patient characteristics, associated diagnoses, and associated symptoms of self-mutilation is first presented. Six functional models are then presented: the environmental model, the antisuicide model, the sexual model, the affect regulation model, the dissociation model, and the boundaries model. Support for these models in the empirical and theoretical literature is presented and treatment implications are explored.
Humans↗
Diagnostic issues in self-mutilation.
OBJECTIVE: Pathological self-mutilation--the deliberate alteration or destruction of body tissue without conscious suicidal intent--was examined both as a symptom of mental disorders and as a distinct syndrome. METHODS: Data from more than 250 articles and books were reviewed, as well as data obtained by the authors from their extensive clinical experience in treating self-mutilating patients. RESULTS AND CONCLUSIONS: The diverse behaviors that constitute pathological self-mutilation can be categorized into three basic types: major--infrequent acts that result in significant tissue damage, usually associated with psychoses and acute intoxications; stereotypic--fixed, rhythmic behavior seemingly devoid of symbolism, commonly associated with mental retardation; and superficial or moderate--behavior such as skin cutting, burning, and scratching associated with a variety of mental disorders. The authors propose that a syndrome of repetitive superficial or moderate self-mutilation should be regarded as an axis I impulse disorder. In most cases, the syndrome coexists with character pathology.
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On background factors of male genital self-mutilation.
Background factors of male genital self-mutilation have been suggested in a small series of cases. A review of 110 cases in the literature revealed that guilt feelings associated with sexual conflicts were the most important factors in the act of psychotic self-mutilation and also related to religious psychotic experiences that were often the direct motives for the act. Self-mutilators with sexual guilt feelings were likely to mutilate themselves more severely than those without. Even excluding transsexuals, disturbance of sexual identity was most participating in the act of nonpsychotic self-mutilators. In addition to these, previous history of self-injury took part in the act independently. Male genital self-mutilation is exceedingly rare in psychiatric practice even if it is not as uncommon as the paucity of published literature on the subject would suggest. According to Blacker et al., the earliest report in English of male genital self-mutilation is Stroch's brief communication in 1901. Greilsheimer and Groves found 53 cases in the English literature that had been reported till 1979. We present a case report with male genital self-mutilation and examine the background factors of this phenomenon from a review of the literature. We used the literature files 'Medline' from 1979 to 1993 and the references of famous reports. In statistical analyses, we performed two-tailed t tests for continuous variables and chi 2 tests with Yates correction for categorical variables.
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[A case of complete self-mutilation of penis].
Self-mutilation of the penis is extremely rare. A 69-year-old man was admitted after having amputated his own penis completely from its root. He had no history of psychiatric illness, but his physical condition on admission was abnormal. We performed urethrocutaneostomy, rather than replantation of the penis, because of the danger that he would reinjure himself. The patient was treated by a psychiatrist under a diagnosis of alcoholic dementia. To our knowledge, this is the 24th case of self-mutilation of the penis reported in the Japanese literature.
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Cutaneous self-mutilation and potential self-destruction in a schizoid psychopath.
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Humans↗
Orthognathic surgery for the treatment of chronic self-mutilation of the lips.
Self-mutilation by lip chewing is an uncommon problem, but may result in severe mutilation, infection and loss of tissue, with associated scarring. Many modalities of treatment have been proposed in the literature with variable success and morbidity to the patient. Alternative techniques involving orthognathic surgery to create an anterior open bite are described which may result in cessation of self-mutilation. A case is presented with a 13-year follow-up, the anterior open bite is still present, and no recurrence of self-mutilation.
Adult↗
Self-mutilation and suicide attempt: distinguishing features in prisoners.
Nonlethal forms of self-injury are often discussed together with suicide attempts as though they belonged on a continuum of self-harm. Both types of self-injury are common in prisons, which have a predominantly male population; however, most studies of nonlethal self-injury have been done with female subjects. This exploratory study tested the hypothesis that prisoners who injured themselves without intending to die would differ clinically from prisoners who had attempted suicide. Inmates admitted to the prison unit of a public hospital for treatment of self-inflicted wounds or who had a history of previous self-injury were administered a standardized intake protocol by the first author, which included asking about their intent at the time they injured themselves. Patients were classified as self-mutilators or suicide attempters on the basis of intent. Fifteen patients reported that they had attempted to take their own lives, while 16 reported other reasons for harming themselves. Suicide attempt was associated with adult affective disorder 13/15 versus 2/16 mutilators); self-mutilation with a history of childhood hyperactivity (12/16 versus 1/15 suicide attempters) and a mixed dysthymia/anxiety syndrome that began in childhood or early adolescence (9/16). Prison self-mutilators and suicide attempters had very different clinical presentations and histories. The history of childhood hyperactivity in self-mutilators deserves further study in both correctional and noncorrectional populations.
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The identification and management of self-mutilating patients in primary care.
Self-mutilation has been described as a complex group of behaviors resulting in the deliberate destruction of body tissue without conscious suicidal intent. Clinical reports suggest that many adults who engage in self-destructive behavior have childhood histories of trauma and disrupted parental care. Painless cutting after a period of depersonalization, followed by relaxation and repersonalization after bleeding, is the typical pattern reported. Complications include social rejection and condemnation as a response both to the behavior or the resulting disfigurement. The most serious complication of self-mutilation is death as a direct result of damage inflicted on the body or from a drug overdose. Primary care providers are in an excellent position to identify and intervene in self-injurious behavior. Establishing a trusting relationship appears to be the most critical component of assessing and treating the client who self-mutilates. Psychotherapy and psychotropic medications, though not specific to self-mutilation, remain the most compelling treatment options.
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Self-mutilation in adolescence as addictive behaviour.
Self-mutilation as addictive behaviour has been mentioned in a few studies in recent years. We present the case of a girl with narcissistic borderline personality disorder (DSM III-R: 301.83, 301.81), who undertook multiple, repetitive self-mutilating acts. Self-mutilation is discussed as addictive behaviour in this case. We emphasize the evaluation of repetitive self-mutilating acts by applying criteria for addictive and dependence disorders, in order to achieve additional adequate strategies for treating patients showing this behaviour.
Adolescent↗
Nonpharmacologic management of stereotypic self-mutilative behavior in a stallion.
Self-mutilative behavior, a form of stereotypic behavior, can be a serious problem in stallion management. An 11-year-old Quarter Horse stallion was referred for evaluation of repeated episodes of self-mutilation and aggressive behavior. Historically, this behavior worsened when the horse was isolated from other animals and confined to a stall for long periods. Observations of the stallion revealed episodes of self-mutilation and other forms of stereotypic behavior precipitated by stressful situations. Modification of this behavior was achieved by environmental and nutritional management and provision of adequate exercise. Nonpharmacologic intervention can be a simple and inexpensive way to correct self-mutilative behavior.
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Carbamazepine trial for Lesch-Nyhan self-mutilation.
Anticonvulsants may reduce the self-mutilation of acquired sensory neuropathy, and one report described sensory neuropathy in an older patient with Lesch-Nyhan syndrome. We performed nerve and muscle biopsies on four patients with Lesch-Nyhan syndrome and initiated an uncontrolled pilot trial to see if carbamazepine would reduce the self-mutilation in these patients. All of the boys had clinical features typical of Lesch-Nyhan syndrome, and the diagnosis was confirmed in each by enzyme analysis. No specific abnormalities were identified in either nerve or muscle. Nevertheless, self-mutilation and the need for constant restraint diminished in all four patients, though in one the effect was only transient. Two patients had increased self-mutilation when carbamazepine was stopped, then improved a second time when treatment was restarted. Sensory neuropathy was not confirmed, so any effect of carbamazepine is likely to be on the central nervous system.
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Self-mutilation resulting in bacterial meningitis.
Self-mutilation and particularly self-destructive dermatoses are not usually life-threatening. This case involves a man who met the DSM-III R diagnostic criteria for delusional (paranoid) disorder, somatic type. His destructive behavior involving the face and scalp resulted in osteomyelitis and pneumococcal meningitis. He responded to treatment initially, but was later lost to follow-up. No similar case of self-mutilation has been reported.
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Treatment of self-mutilation with olanzapine.
BACKGROUND: Self-mutilation or dermatitis artefacta is a facet of a much broader spectrum of factitial disease. Three nonpsychotic patients with self-mutilation are presented in this article who were successfully treated with low dose olanzapine when all other modalities of therapy had failed, including trials with numerous antidepressants and antipsychotics. OBJECTIVE: The patients were simultaneously evaluated and treated by a dermatologist and a psychiatrist who run the psychodermatology or consultation-liaison clinic based at McMaster University. After dermatologic conditions had been excluded as a cause of the clinical findings, olanzapine was prescribed on a trial basis due to its low risk of parkinsonian side-effects and its antihistaminic properties. CONCLUSIONS: The excellent clinical response of the patients can be attributed to the low side-effect profile of the drug but also to the anti-impulsive effect which stems not only from antihistaminic properties but also from its antidopamine and serotonin-blocking action.
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Psychological models of self-mutilation.
The descriptive models of self-mutilation fall into three broad categories. The psychodynamic formulation; the second category includes the anxiety reduction model, the hostility model, the behavioral learning model and the appeal model; the third social learning category includes the group-epidemic model and aspects of the violence and punishment model. The three models support the view that there is no single cause or motive responsible for self-mutilating behavior. Having a number of factors in mind allows for flexibility and enables clinicians to test particular hypotheses during management and gives them the opportunity to alter intervention accordingly. The problems faced by self-mutilating patients are so varied that no single form of treatment is likely to be universally appropriate.
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Psychiatric and surgical management of male genital self-mutilation.
Cases of genital self-mutilation are usually seen in the general hospital setting and can be difficult to manage especially in those patients who have psychiatric illness. A joint effort between the psychiatric and the surgical services will be required right from the beginning of hospital admission to diagnosis and later, to follow-up. Psychiatric consultation strategies at the different phases of intervention will be needed to cater for the special needs of the surgical team, patient and family. We describe three cases of genital self- mutilators and the general management of these patients.
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Exploring the inner world of self-mutilating borderline patients: a Rorschach investigation.
Psychiatric patients who engage in self-destructive behavior by cutting, burning, or abrading their skin are currently one of the most difficult-to-treat groups in both inpatient and outpatient settings. The complexities of treating these patients, the risk factors associated with this symptom, and the rise in the prevalence of self-mutilation in America's adolescents and young adults provided the impetus for the current study. This article explores aspects of aggression, dependency, object relations, defensive structure, and psychic boundary integrity that may contribute to the genesis and maintenance of self-mutilation. Rorschach protocols from 90 borderline personality-disordered inpatients (48 self-mutilators and 42 non-self-mutilators) were scored using five psychoanalytic content scales. Results indicate that self-mutilating patients exhibit greater incidence of primary process aggression, severe boundary disturbance, pathological object representations, defensive idealization, devaluation, and splitting than did a matched group of non-self-mutilating borderline patients. Clinical theory and technical recommendations are considered in light of the current empirical findings.
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Clinical predictors of self-mutilation in hospitalized forensic patients.
This study evaluated the clinical correlates and inpatient course of self-mutilation in a diagnostically diverse sample of hospitalized forensic patients. Fifty-three male forensic inpatients, treated in a maximum-security hospital, who engaged in at least one instance of self-mutilation during a 2-year period, were studied and compared with 50 male forensic patients at the same hospital who had not engaged in self-mutilation. Self-mutilating patients were younger, more likely to carry a diagnosis of personality disorder or mental retardation, engaged in more outwardly directed aggressive behavior as assessed by the Overt Aggression Scale, were treated with substantially higher doses of neuroleptics, and were more likely to be civil or correctional patients than insanity acquittees. The two groups did not differ on variables such as history of suicide, history of violence, neurological characteristics, and other demographic variables. After an incident of self-mutilation, the probability of recurrence was high. The substantially higher level of outwardly directed aggression of self-mutilating patients, along with their higher apparent need for neuroleptization and the high risk of recurrence of the self-mutilation, suggest that they are a subset of violent individuals who are relatively unresponsive to treatment and who are dangerous to self and others.
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