Self-mutilation in substance-dependent patients and relationship with childhood abuse and neglect, alexithymia and temperament and character dimensions of personality

OBJECTIVE

Aim of this study was to evaluate the prevalence of self-mutilation (SM) in Turkish male substance-dependent patients, and to investigate the relationship of SM with childhood abuse and neglect, alexithymia and temperament and character dimensions of personality.

METHODS

Participants were 136 consecutively admitted males with substance dependence (96 alcohol and 40 drug). Substance dependence was diagnosed by means of the Structured Clinical Interview for DSM-IV (SCID-I), Turkish version. Patients were investigated with the childhood abuse and neglect questionnaire, Toronto alexithymia scale (TAS-20) and temperament and character inventory (TCI).

RESULTS

Among substance-dependent patients 34.6% was considered as a group with SM. Rates of being single and unemployed, histories of physical and sexual abuse and suicide attempts were higher in the SM group. Current age, age at first substance use and age at regular substance use were lower in the group with SM. Mean of TAS-20 and 'difficulty in identifying feelings' (DIF) and 'difficulty in describing feelings' (DDF) subscales of TAS-20 were higher in SM group. There were no significant differences between groups in terms of TCI subscales. Age, childhood physical abuse and suicide attempt history predicted SM in logistic regression.

CONCLUSIONS

Young substance users with childhood physical abuse histories could be the target population to prevent self-mutilating behavior. This study also suggests that whenever self-mutilating behavior is present, the possibility of childhood abuse, alexithymia and suicide attempts must be evaluated.

Investigation of an alleged mechanism of finger injury in an automobile crash

This investigation centers on the case of an adult male whose finger was allegedly amputated by the steering wheel of his car during a crash. The subject claimed to have been driving with his left index finger inserted through a hole in the spoke of his steering wheel and was subsequently involved in an offset frontal collision with a tree. The finger was found to be cleanly severed at the mid-shaft of the proximal phalanx after the crash. This injury was alleged to have been caused by inertial loading from the rotation of the steering wheel during the crash. To determine whether this injury mechanism was plausible, three laboratory tests representing distinct loading scenarios were carried out with postmortem human surrogates loaded dynamically by the subject's steering wheel. It was found that the inertial loads generated in this loading scenario are insufficient to amputate the finger. Additionally, artificially constraining the finger to force an amputation to occur revealed that a separation at the proximal interphalangeal joint occurs rather than a bony fracture of the proximal phalanx. Based on these biomechanical tests, it can be concluded that the subject's injury did not occur during the automobile crash in question. Furthermore, it can be shown that the injury was self-inflicted to fraudulently claim on an insurance policy.

Botulinum toxin as a novel treatment for self-mutilation in Lesch-Nyhan syndrome

Lesch-Nyhan syndrome (LNS) is an X-linked recessive disorder resulting from a deficiency of the metabolic enzyme hypozanthine-guanine phosphoribosyltransferase (HPRT). This syndrome presents with abnormal metabolic and neurological manifestations including hyperuricemia, mental retardation*, spastic cerebral palsy (CP), dystonia, and self-mutilation. The mechanism behind the severe self-mutilating behavior exhibited by patients with LNS is unknown and remains one of the greatest obstacles in providing care to these patients. This report describes a 10-year-old male child with confirmed LNS who was treated for self-mutilation of his hands, tongue, and lips with repeated botulinum toxin A (BTX-A) injections into the bilateral masseters. Our findings suggest that treatment with BTX-A affects both the central and peripheral nervous systems, resulting in reduced self-abusive behavior in this patient.

Optic nerve massaging: an extremely rare cause of self-inflicted blindness

PURPOSE

To report a patient whose self-inflicted blindness was not clinically apparent by history or external signs of trauma.

DESIGN

Observational case report.

METHODS

A 12-year-old girl with a history of social and behavioral problems was noted to have visual loss in her right eye. Examination revealed no light perception, optic nerve atrophy, partial upper lid ptosis, exotropia, and hypoesthesia of the cheek, all on her right side.

RESULTS

After undergoing extensive examinations which were unrevealing for a diagnosis, the patient admitted to a recurrent maneuver, which she secretly used to relieve anxiety and stress. This maneuver consisted of inserting her index finger under the right supraorbital rim and forcibly subluxating her globe out of the orbital space.

CONCLUSIONS

Self-inflicted visual loss can occur in nonpsychotic and nonviolent patients. Accurate diagnosis is important, as there is a risk of similar involvement to the fellow eye, and referral for psychiatric counseling is mandatory.

Use of the psychiatric consultation letter as a therapeutic tool

OBJECTIVE

Carefully crafted medical consultation letters can serve the dual purpose of transmitting the consulted psychiatrist's opinion to the referring doctor and enhancing the quality of the doctor-patient therapeutic relationship. Using the same document for both purposes simultaneously can enhance the consultation letter's overall effectiveness, as illustrated by three case examples.

CONCLUSIONS

Future teaching programmes for undergraduate and postgraduate psychiatry students should incorporate consultation letter writing workshops to improve students' skills in clearly expressing their opinions and management recommendations in written form.

A case of factitious disorder involving menstrual blood smeared on the face

This article presents a case of factitious disorder in which a female smeared menstrual blood on her face. The patient was admitted to our otolaryngology clinic complaining of bleeding from the mouth, nose, ears and eyes. This event reportedly occurred three to four times on a daily basis. She acknowledged nine prior admissions to different specialists over the last two years. Following psychiatric consultation, we diagnosed factitious disorder with predominantly physical signs and symptoms. She was started on Fluoxetine 20 mg/day and supportive interviews were organized. After diagnosis, we observed that her symptoms decreased over two months. The symptoms did not reoccur three to nine months after treatment. This case report outlines two important features. The first is that a case of this type has not been reported before, and the second feature is that this case demonstrates the effect of cultural factors greatly different from those seen in classical factitious disorder.

Habitual self-mutilation in Japan

The purpose of the present study was to clarify the relationship between bulimic behavior, dissociative phenomenon and sexual/physical abuse histories in Japanese subjects with habitual self-mutilation. Subjects consisted of 34 female outpatients who had cut their wrists or arms on more than 10 occasions. Two age-matched groups, which consisted of 31 general psychiatric outpatients and 26 non-clinical volunteers, served as controls. They were assessed with the Beck Depression Inventory-II, Bulimia Investigatory Test of Edinburgh, Adolescent Dissociative Experience Scale, and an original self-reporting questionnaire concerning various problematic behaviors and sexual/physical abuse histories. The habitual self-mutilation and the two control groups were compared. The habitual self-mutilation group had significantly higher scores on the Beck Depression Inventory-II, Bulimia Investigatory Test of Edinburgh, and Adolescent Dissociative Experience Scale than either of the two control groups (P < 0.001). Furthermore, the habitual self-mutilation group more frequently had a history of illicit psychoactive drug use (P = 0.001), shoplifting (P < 0.001), suicide attempts (P < 0.001), overdosing with medicine (P < 0.001), sexual abuse (P = 0.011), and childhood physical abuse (P = 0.001) than the general psychiatric controls. These results are consistent with those in Western studies. Habitual self-mutilation is likely to coexist with depression, bulimia, and dissociation. Such patients frequently have clinical features similar to those of 'multi-impulsive bulimia'. Evidence supports the association between habitual self-mutilation and sexual/childhood physical abuse in Japan.

Rituals and compulsivity in Prader-Willi syndrome: profile and stability

BACKGROUND

Prader-Willi syndrome (PWS) is characterized by an increased risk for obsessive-compulsive disorder. This study investigated the nature of compulsive-like behaviours in the PWS.

METHOD

Parents of 50 individuals with PWS (aged 5-18 years) and 50 typically developing 4-year-old children completed the Childhood Routines Inventory. This instrument measures compulsive-like behaviours in normative childhood.

RESULTS

Many childhood compulsive behaviours are prevalent among older children and adolescents with PWS. Group differences were observed in that the PWS group, independent of age, gender and cognitive dysfunctions, exhibited more intense compulsive behaviours related to insistence on sameness in many daily activities and social contexts. Findings also revealed an age-independent low-prevalent pattern of PWS compulsivity, probably related to other features in the PWS symptomatology.

CONCLUSIONS

Compulsions of childhood do not subside with age in adolescents with PWS. The findings indicate that the differentiation between delayed childhood rituals and pathological manifestations of compulsive features is complex in PWS populations.

Apotemnophilia masquerading as medical morbidity

We report a case of apotemnophilia, or "love of amputation," in a man in his mid-20s. Apotemnophilia is defined as self-desired amputation driven by the patient's erotic fantasy of possessing an amputated limb and overachieving despite being handicapped. The desire of a patient with apotemnophilia for amputation is obsessive, and a history of repeated, unexplained injuries to the same segment of the body is common among these patients. Patients with apotemnophilia secretly harm themselves to necessitate amputation of an injured limb, which creates a diagnostic challenge for the health care provider because of the atypical presentation of self-inflicted medical morbidity caused by apotemnophilia.

Repetitive self-mutilation among Japanese eating disorder patients with drug use disorder: comparison with patients with methamphetamine use disorder

Repetitive self-mutilation and drug use disorder are less prevalent in Japan, although the prevalence of eating disorder is comparable with rates in Western countries. However, repetitive self-mutilation has not previously been described in relation to eating disorder and drug use disorder in Japan. Subjects consisted of 19 patients with eating disorders and drug use disorders (ED+DUD) and 12 patients with methamphetamine use disorders (MAP). Subjects were drawn from 180 patients who were referred because of eating disorders and 22 patients who were referred because of methamphetamine-related problems. All subjects underwent a semistructured interview. Repetitive self-mutilation tended to be more prevalent among ED+DUD patients than MAP patients. Conversely, history of oppositional defiant disorder and antisocial personality disorder tended to be more prevalent in MAP patients than in ED+DUD patients. The low prevalence of repetitive self-mutilation appears to be due to low risk factors in Japan, even though the pathogenesis of these behaviors seems to be universal.

Self-inflicted (factitious) conjunctivitis

PURPOSE

To describe the diagnosis and management of self-inflicted factitious conjunctivitis in conscripted soldiers.

DESIGN

Prospective, noncomparative, consecutive case series.

PARTICIPANTS

Seventeen conscripted soldiers.

METHODS

Soldiers with chronic conjunctivitis (>3 weeks) were referred by ophthalmologists, and cases of shorter duration were referred by primary-care physicians. All cases underwent thorough ophthalmic and systemic history and examination, as well as questioning regarding their military units, military duties, and social background. Exclusion criteria were any condition that may cause conjunctivitis. Inferior fornix specimen microscopy and culture and eye photography were performed in most cases. In cases suspected of self-inflicted conjunctivitis all medication, besides lubricant drops, was stopped. Underlying psychosocial problems were investigated and managed. Cases were followed for at least 3 months after resolution of the conjunctivitis, at which point the diagnosis was confirmed, and the case entered the analysis.

MAIN OUTCOME MEASURES

Resolution of the conjunctivitis.

RESULTS

Seventeen consecutive cases of self-inflicted conjunctivitis, 8 of long duration and 9 of short duration, were studied. All cases demonstrated inconsistent clinical findings. The ocular signs most suggestive of self-inflicted conjunctivitis were purulent discharge purposely left on the lashes and periorbital skin, discharge more severe than in conjunctival hyperemia, less conjunctival chemosis than in hyperemia, mainly inferior conjunctival involvement, and an uninvolved cornea. Five of the 8 chronic cases had significant underlying psychologic or social problems. Their conjunctivitis resolved only after their underlying problems were addressed. Two cases admitted introducing freshly scraped dental plaque into the lower conjunctival sac. In the remaining 15 the similarity of the clinical findings suggested that a similar method was used.

CONCLUSIONS

In the context of a subject standing to gain by assuming the sick role and after exclusion of ocular pathology, self-inflicted conjunctivitis can be reliably diagnosed by noting the characteristic clinical profile. Effective management includes addressing the underlying psychologic and social problems.

[Male genital self mutilation--a cause of hematuria]

Pathological self-mutilation is defined as a deliberate destruction of body tissue without conscious intent. It is sometimes associated with several pathologies such as mental disorders and mental retardation. We report a non-psychotic male, with borderline mental retardation who practiced sporadic moderate genital self-mutilations as a masturbation technique and presented as a case of recurrent gross hematuria.

Are suicide attempters who self-mutilate a unique population?

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.

Self-inflicted anterior scleritis

PURPOSE

To describe and clinically characterize a syndrome of self-inflicted scleritis.

STUDY DESIGN

Case reports and literature review.

METHODS

Two patients had persistent scleritis at presentation. Both did not respond to prescribed therapy, including systemic corticosteroids and immunosuppression. The first had unexplained, diffuse anterior scleritis and persistent linear keratoconjunctival abrasions after a work-related injury. Several objective indicators pointed to concealed noncompliance with medications. The second patient was a medical assistant with diffuse, unilateral anterior scleritis and unexplained visual loss. Systemic work-up was negative. She had pharmacologic mydriasis and keratoconjunctival abrasions at presentation.

RESULTS

Systemic therapy was stopped in both patients. The first patient, who was in the process of requesting permanent disability status, showed persistent inflammation on each follow-up visit. The second patient improved with no further therapy after she was confronted with objective indicators of a self-inflicted condition.

CONCLUSIONS

Although the presentation of self-inflicted scleritis can be similar to that of idiopathic or autoimmune anterior scleritis, the former may show additional findings of traumatic conjunctival and corneal abrasions. Indicators of self-inflicted etiology, of which malingering is one such entity, include evidence of concealed noncompliance with prescribed treatments and lack of response to potent antiinflammatory and immunosuppressive agents. Correct diagnosis including early psychiatric evaluation in all such cases, may help prevent unnecessary treatment and unjustified work-related compensation.

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.