The coming of age of self-mutilation.

Self-mutilation (SM), the deliberate, nonsuicidal destruction of one's own body tissue, occurs in such culturally sanctioned practices as tattooing; body piercing; and healing, spiritual, and order-preserving rituals. As a symptom, it has typically been regarded as a manifestation of borderline behavior and misidentified as a suicide attempt. It has begun to attract mainstream media attention, and many more who suffer from it are expected to seek treatment. This review suggests that SM can best be understood as a morbid self-help effort providing rapid but temporary relief from feelings of depersonalization, guilt, rejection, and boredom as well as hallucinations, sexual preoccupations, and chaotic thoughts. Major SM includes infrequent acts such as eye enucleation and castration, commonly associated with psychosis and intoxication. Stereotypic SM includes such acts as head banging and self-biting most often accompanying Tourette's syndrome and severe mental retardation. Superficial/moderate SM includes compulsive acts such as trichotillomania and skin picking and such episodic acts as skin-cutting and burning, which evolve into an axis I syndrome of repetitive impulse dyscontrol with protean symptoms.

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.

Varieties of Pathological Self-mutilation.

Pathological self-mutilation appears as a non-specific symptom as well as a specific syndrome. Since psychotic persons may commit horrifying acts, such as enucleation of an eye or amputation of a body part, identification of high risk patients is crucial. Stereotypical self-mutilation, such as head banging and biting off of fingertips, is associated with mental retardation and with the syndromes of Lesch-Nyhan, deLange, and Tourette. This type of self-mutilation is the focus of biological research or endorphins and on dopamine receptors. Skin cutting and burning, the most common type of self-mutilation, is often associated with personality disorders, post-traumatic stress disorder, and multiple personality disorder. When cutting and burning become established as responses to disturbing psychological symptoms on environmental events, a specific Axis I impulse disorder known as Repetitive Self Mutilation may be diagnosed. Patients with this newly identified syndrome may alternate their direct acts of self-mutilation with eating disorders and episodic alcoholism.

Female habitual self-mutilators.

Data are presented on 240 female habitual self-mutilators. The typical subject is a 28-year-old Caucasian who first deliberately harmed herself at age 14. Skin cutting is her usual practice, but she has used other methods such as skin burning and self-hitting, and she has injured herself on at least 50 occasions. Her decision to self-mutilate is impulsive and results in temporary relief from symptoms such as racing thoughts, depersonalization, and marked anxiety. She now has or has had an eating disorder, and may be concerned about her drinking. She has been a heavy utilizer of medical and mental health services, although treatment generally has been unsatisfactory. In desperation over her inability to control her self-mutilative behavior this typical subject has attempted suicide by a drug overdose.

Why patients mutilate themselves.

Self-mutilation, the deliberate destruction or alteration of body tissue without conscious suicidal intent, occurs in a variety of psychiatric disorders. Major self-mutilation includes eye enucleation and amputation of limbs or genitals. Minor self-mutilation includes self-cutting and self-hitting. The author examines patients' explanations for self-mutilation which frequently focus on religions or sexual themes, and discusses scientific explanations that draw on biological, psychological, social, and cultural theories. Although no one approach adequately solves the riddle of such behaviors, habitual self-mutilation may best be thought of as a purposeful, if morbid, act of self-help.

Self-mutilation and eating disorders.

Patients with eating disorders are at high risk for self-mutilation (e.g., skin cutting and burning), and vice versa. Evidence for this linkage comes from a literature review, from patient interviews, from responses to an instrument we have developed (the Self-Harm Behavior Survey), and from three instructive case reports. Even if the self-mutilation in these patients is regarded as a Borderline Personality Disorder symptom, DSM-IV should list it as an associated feature or a complication of Anorexia Nervosa/Bulimia Nervosa. In lieu of a dual diagnosis, we postulate that the combination of self-mutilation, anorexia, bulimia, and other symptoms (such as episodic alcohol abuse and swallowing foreign objects) may be manifestations of an impulse control disorder known as the "deliberate self-harm syndrome."

The plight of chronic self-mutilators.

Self-mutilation is a more common behavior than generally realized; its prevalence may be 750 per 100,000. From the responses of 250 subjects to a Self-Harm Behavior Survey we have learned that self-mutilation typically begins in early adolescence and may assume a chronic course characterized by severe psychosocial morbidity. Some chronic self-mutilators already are heavy and generally dissatisfied users of mental health services. The number of them seeking help may increase as a result of heightened public awareness. Community mental health facilities may be hard-pressed to meet the needs and demands of these clinically vexing patients.

Brief reactive psychosis in a deaf man.

A prelingually deaf man developed a brief reactive psychosis that was influenced by sociocultural, community, and interpersonal conflicts. Resolution of symptoms followed interventions that addressed all areas of conflict.

Modern Christian healing of mental illness.

Healing of mental illness through religious practices was a key element of early Christianity. In the early twentieth century such healing was associated with blue-collar and rural Fundamentalists, but religious healing practices have gained widespread acceptance by many middle-class, conservative Christian groups. "Evil demons" are now equated with envy, pride, avarice, hatred, and obsessions with alcohol and gambling. Many psychotherapeutic techniques of modern Christian healers appear to be rediscoveries of psychoanalytic insights expressed in religious metaphors. Most responsible healers encourage clients to seek medical and psychiatric help, especially for serious mental disorders. Psychiatrists need not share patients' religious beliefs, but for treatment to be effective these beliefs must be understood and respected.