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Male genital self-mutilation is a phenomenon which transcends nosological boundaries. This article reviews 98 cases reported in the English language literature. We note that outcome is often better than is assumed. We emphasize the importance of close liaison between the psychiatric and surgical team in managing these patients.
OBJECTIVE: The goal of this study was to determine whether self-mutilators with personality disorders differ from nonmutilators with personality disorders in impulsivity, aggression, and other psychopathology and whether serotonergic dysfunction contributes to self-mutilation. METHOD: Twenty-six self-mutilators with personality disorders were matched to 26 control subjects with personality disorders for gender, age, education, axis I diagnosis of affective disorder, and axis II diagnosis of personality disorder. Numerous indexes of psychopathology as well as CSF 5-hydroxyindoleacetic acid (5-HIAA) levels and platelet imipramine binding sites (Bmax) and affinity (Kd) were determined. RESULTS: Self-mutilators had significantly more severe character pathology, had greater lifetime aggression, and were more antisocial than the control subjects. The self-mutilators scored higher on the Hamilton Rating Scale for Depression but not on the Beck Depression Inventory or the Beck Hopelessness Scale. The two groups did not differ on the Buss-Durkee Hostility and Guilt Inventory or on the Sensation Seeking Scale. The degree of self-mutilation was significantly correlated with impulsivity, chronic anger, and somatic anxiety. Both self-mutilation and impulsivity showed significant negative correlations with Bmax, although the two groups did not differ in CSF 5-HIAA levels or in platelet imipramine binding. CONCLUSIONS: The results demonstrate the contribution of severe character pathology, aggression, impulsivity, anxiety, and anger to self-mutilation and provide preliminary support for the hypothesis of underlying serotonergic dysfunction facilitating self-mutilation.
Most genital self-mutilations in nonpsychotic patients are found in transsexuals, and premeditation of sex-conversion surgery is the main objective. In this paper, we will describe the case of a male-to-female transsexual who took out his testes as a way to facilitate the surgery and to circumvent the Brazilian laws.
Intentional self-mutilation of the genitals in males is exceedingly rare and the most recent review included only about 50 cases. The ideal way to handle such cases is by microsurgical techniques, but they require special equipment, instruments and training. We therefore developed a simple, standard technique which can be performed by general surgeons. We report a 19-year-old male in whom the technique was used successfully.
Self-mutilating behavior (SMB) in prisons has long been recognized as a problem. MMPI data were obtained from 30 mutilating and 30 non-mutilating male inmates. Analyses of MMPI scores revealed significant differences on nine of the clinical and validity scales. Mutilators also had more frequent elevations over 70. Interpretation of scale and subscale configurations indicates that mutilators have more somatic complaints, subjective distress, alienation, inmature defenses, and acting out tendencies than controls. This is consistent with descriptions of SMB in the literature. SMB is conceptualized as a form of aggression in a population of impulsive and alienated individuals in a high-stress environment. The frustration-aggression model is proposed as a model for understanding and further investigating this phenomenon.
Edema caused by surreptitious self-mutilation leads to special diagnostic and therapeutic problems because the causal psychic illness is not immediately obvious or appears insignificant due to the diagnosis of edema and the frequent desire of the patients for invasive measures. The quickest clarification is achieved by contacting an experienced lymphologist, who can often classify the swelling as artificial edema at a glance. In order to avoid any secondary damage arising from the edema, it should be reduced as quickly as possible by referring the patient to a lymphological clinic for therapy. Thus, invasive diagnostics would certainly be avoided, and the patient's desire for invasive procedures circumvented by conservative therapy. A psychiatric/psychosomatic specialist must be consulted. Cooperation between patient, physicians in practice and hospital should be established as early as possible. In difficult cases, the patient should be referred to a psychiatric hospital. Even for the experienced lymphologist, cases in which Sudeck's disease in the congested extremity has to be taken into account and the compliance of the patient is restricted present particular problems.
The challenge of self-mutilation among humans arises from the imprecision of much of the existing literature, as well as the countertransference such disturbing behavior mobilizes. Self-mutilation is defined as an individual's intentionally damaging a part of his or her own body apparently without a conscious intent to die. The importance of understanding this behavior is reflected in the frequency with which it is encountered among psychiatric patients, particularly those diagnosed with borderline personality disorder or schizophrenia. The distinguishing characteristics of dermal, ocular, and genital self-mutilation illustrate the diverse clinical settings in which mutilation arises. Numerous explanations with differing degrees of complexity and merit have been offered; yet, no clear consensus has emerged. Psychotherapy, behavior therapy, and chemotherapy, while controversial, remain the most compelling treatment options. Salient areas for further study include epidemiology both for specific groups and the general population, possible biologic bases for the behavior, and additional management options.
The traditional management of factitious patients with self-inflicted injuries consists of medical/surgical treatment of the physical lesions, followed by psychiatric referral. The former is assigned to the dermatologist, the surgeon, or the primary care physician. More often than not, the subsequent psychiatric referral for treatment of the psychiatric disorder underlying and actually causing the self-mutilation fails because of self-mutilators' notorious resistance to psychiatric help. The integration of a psychiatric strategy into the medical management is more effective than a sequential division of medical/surgical and psychiatric treatment. This integrated treatment strategy is based on three key issues: education of the medical team in understanding the self-mutilation as a morbid form of help-seeking behavior, the judicious use of confrontation as a therapeutic tool, and the combination of psychotropic drug treatment with psychotherapeutic techniques.
In summary, both self-mutilators and eating-disordered individuals come from dysfunctional homes with a very controlling mother and usually absent father. They often have a history of trauma. They are depressed and obsessive, attached to their mothers, who discourage attempts at emancipation. The symptoms serve the purpose of keeping them as little girls with negative feelings toward menstruation, sexual maturity, development, and femininity in general. These symptoms comprise self-destructive behavior in the service of removing sexual thoughts, temptation, and activities. Favazza (1987) included both eating disorders and self mutilation in his "deliberate self-harm syndrome." The symptoms, whether they be anorexic, bulimic, or a form of self-mutilation are seen as "autoerotic in nature and a substitute for normal masturbation" (Hull & Lane, 1988). Eating disorders and delicate self-mutilation are said to have "a cathartic, self-purifying, function in that they modulate states of anxiety, sexual tension, anger or dissociated emptiness, and they bring about a tremendous quasi-physical sense of relief" (Cross, 1993, p. 50). These patients' use of substitutes prevents maturation and growth as women, causing regression to pregenital phases with the use of pregenital defenses, and the demise of the demands of puberty and mature sexuality.
Self-mutilation in humans occasionally accompanies physiological disorders such as the deLange syndrome. If pemoline-induced self-biting is behaviorally similar to self-mutilation in the deLange syndrome, similar neurochemical mechanisms may be involved in both. Oral administration of 140 and 220 mg/kg pemoline reliably induced persistent self-biting in rats. This behavior was indistinguishable from stereotyped grooming and its most common target was the medial digits of the foreleg. Pemoline-induced self-biting was accompanied by hyperactivity, stereotyped behavior, abnormal social behavior, abnormal sensorimotor behavior, and unresponsiveness or avoidance of moderate levels of sensory stimuli. Several of these behaviors have also been reported in deLange patients.
OBJECTIVES: The aim of the study was to describe the development of self-mutilation after extensive dorsal rhizotomy of the brachial plexus performed during early ontogeny in rats. SETTINGS AND DESIGN: The rhizotomy was performed in three groups of rats according to the central nervous system maturation: infant, young, and adult. After the surgery the occurrence of self-mutilation behavior was compared. Rats from the infant group and non-mutilating deafferentated rats from the adult group underwent extracellular recordings from intralaminar thalamic neurons. Interspikes intervals of the records were compared by means of chaodynamic methods. RESULTS: In the infant group self-mutilation did not develop at all. Among the young group self-mutilation developed in 40% of rats and consisted of superficial wounds in all cases. In adult self-mutilation appeared in 80% rats and consisted of both superficial wounds (75%) and amputation (25%). In the newborn group and the deafferentated adult group without any signs of self-mutilation means of the parameters were not significantly different and were significantly lower than those of intact adult rats. MAIN FINDINGS: 1. Self-mutilation does not develop after the rhizotomy in the infant rats. 2. Neurons behave in chaotic way in adult as well as in young animals. 3. Chaodynamic parameters do not differ between infant and adult rats without any signs of self-mutilation. CONCLUSIONS: The results suggest that development of self-mutilation behavior in rats strongly depends on the ontogenetical period of nervous system injury, and that mature nervous system is required for the development of described pathological behavior.
In the present study two broad hypotheses about the origins of self-mutilation in psychiatric patients were evaluated. The first hypothesis states that self-mutilation originates from child abuse and experiences of neglect and is connected to dissociation in later life. The second hypothesis views self-mutilation as the consequence of impulse control problems. To test these two hypotheses, data concerning traumatic childhood experiences and dissociative symptoms (hypothesis 1), as well as data concerning aggressiveness, obsessive-compulsiveness and sensation seeking (hypothesis 2) were collected in a sample of 54 psychiatric inpatients. Twenty-four out of 54 patients (44%) reported having engaged in self-mutilation. Mean age of onset of this behaviour was 23 years. Self-report measures of self-mutilators were more in line with the first than with the second hypothesis. That is, patients who engaged in self-mutilation reported more traumatic childhood experiences and dissociative symptoms than did control patients. The two groups did not differ in terms of aggressiveness, obsessive-compulsiveness, and sensation seeking. In line with earlier studies, the current results indicate that self-mutilating behaviour is linked to a history of abuse and neglect.
Self-inflicted injuries can be classified in groups. One group deals with the simulation of illness, another with the occurrence itself and the application of chemical, thermic or mechanical methods. One sector concerns self-mutilation, which, from a psychiatrist's point of view, is interesting. At this time we are more concerned with the problems of proving it. In wartime and even during military service in peace-time soldiers inflict mutilating injuries on themselves. They are motivated by the notion that they will gain benefit from their action. Economic gain plays a role in the case of people who have taken out private accident insurance: self mutilation to simulate the result of an accident. Our investigation into self-mutilation started with an analysis under the following aspects of 123 cases: age, sex, occupation, place of residence, place and time of deed, method employed (weapon used), localisation, single or multiple wound, direction of injury, position of fingers, nature of edges of wound. Whether or not an injury was suffered voluntarily or involuntarily can only be determined with the help of auxiliary facts. It must be clarified whether or not the information given by the injured person ties in with facts concerning the place where the injury was sustained, its position and its direction. The medico-legal expert should not interpret medical findings without relating them to the facts of the case. Indeed, he should start by examining the claimant's account of the accident. To some extent it almost requires the work of a general staff to compare the findings of a careful medical investigation with the injuries themselves. If the injury was inflicted by a certain tool information must be available regarding, for example, the "accident with the saw" together with an assessment of the wounds sustained (utilization of clinical material). Sometimes tests on corpses need to be carried out because these can provide information on mechanical and physical problems. When the direction of the wound is being clarified together with an appraisal of any traces found electron scanning and microscopic tests should also be incorporated into the examination in addition to medical and X-ray tests. At the slightest suspicion that a wound might have been self-inflicted appropriate tests should be carried out immediately. Conclusions should only be drawn by someone who has made an intensive study of this special field which is of such great forensic interest.
Self-mutilation, a very unusual situation in routine urology, is a rare phenomenon. It is generally observed in a psychotic context, but can be secondary to drug or alcohol abuse. Treatment and management vary according to the severity of the lesions, the time to presentation and the patient's mental state. The authors report 3 cases of self-mutilation, including 1 case of penis amputation, 1 case of strangulation by a metal ring and 1 case of bilateral castration. In the light of these cases and a review of the recent literature, the authors analyse the various psychiatric medicolegal and urological aspects of this deliberate self-injury.
Six male patients in a maximum-security hospital committed acts of urethral self-mutilation by insertion of a foreign body. The characteristics of the self-mutilators and of this unusual form of self-mutilation are described. The social contagion aspects of the self-mutilation are strongly suggested by the perpetration of urethral insertion for the first time by five patients after direct personal contact with a previous urethral self-mutilator. Techniques used in the management of these patients are described. Self-mutilation evokes strong emotional responses in staff members, and proper patient management also must include attention to the needs and concerns of treatment staff.
OBJECTIVE: Individuals who mutilate themselves are at greater risk for suicidal behavior. Clinically, however, there is a perception that the suicide attempts of self-mutilators are motivated by the desire for attention rather than by a genuine wish to die. The purpose of this study was to determine differences between suicide attempters with and without a history of self-mutilation. METHOD: The authors examined demographic characteristics, psychopathology, objective and perceived lethality of suicide attempts, and perceptions of their suicidal behavior in 30 suicide attempters with cluster B personality disorders who had a history of self-mutilation and a matched group of 23 suicide attempters with cluster B personality disorders who had no history of self-mutilation. RESULTS: The two groups did not differ in the objective lethality of their attempts, but their perceptions of the attempts differed. Self-mutilators perceived their suicide attempts as less lethal, with a greater likelihood of rescue and with less certainty of death. In addition, suicide attempters with a history of self-mutilation had significantly higher levels of depression, hopelessness, aggression, anxiety, impulsivity, and suicide ideation. They exhibited more behaviors consistent with borderline personality disorder and were more likely to have a history of childhood abuse. Self-mutilators had more persistent suicide ideation, and their pattern for suicide was similar to their pattern for self-mutilation, which was characterized by chronic urges to injure themselves. CONCLUSIONS: Suicide attempters with cluster B personality disorders who have a history of self-mutilation tend to be more depressed, anxious, and impulsive, and they also tend to underestimate the lethality of their suicide attempts. Therefore, clinicians may be unintentionally misled in assessing the suicide risk of self-mutilators as less serious than it is.
OBJECTIVE: To determine the lifetime history of suicide attempts in incarcerated youths and psychological factors related to suicidal and self-mutilative behaviors during incarceration. METHOD: A 25% systematic random sample chart review of adolescents admitted to a juvenile correctional facility yielded a sample of 289 adolescents. Seventy-eight of these adolescents were clinically referred for psychiatric assessment. Suicidal behavior was assessed with the Spectrum of Suicidal Behavior Scale and self-mutilation with the Functional Assessment of Self-Mutilation. RESULTS: Of the 289 adolescents, 12.4% reported a prior suicide attempt. Almost 60% of these attempts were made using violent methods (e.g., cutting). Of the 78 clinically referred subjects, 30% reported suicidal ideation/behavior and 30% reported self-mutilative behavior while incarcerated. Suicidal clinically referred adolescents reported more depression, anxiety, and anger than nonsuicidal youths. Adolescents who reported self-mutilative behavior had higher anxiety, anger, and substance use than non-self-mutilative adolescents. CONCLUSIONS: Results suggest that incarcerated adolescents have higher rates of suicide attempts and use more violent methods of attempt than adolescents in the general population. Furthermore, incarcerated clinically referred suicidal and self-mutilative youths report more severe affective symptoms than their nonsuicidal and non-self-mutilative counterparts, suggesting a need for mental health treatment.
Self-tattooing is a form of self-mutilation and may sometimes come close to an 'artefact'. Self-tattooing as an action of autoaggressive self-mutilation or self-destruction is not always necessarily psychotic in nature; it may also be found in patients in whom a depressive personality structure is accompanied by strong masochistic tendencies at a neurotic level. The masochistic excess expresses subconscious guilt and aggression as well as a primitive sense of autonomy. Close collaboration between dermatologist, psychiatrist and psychotherapist is necessary to provide an effective treatment for these patients.