Self-mutilation has the power to confuse, frustrate, and frighten patients and their families. Psychiatrists, too, are not immune to the intense emotional responses that pathologic self-mutilation can provoke.
One definition of self-mutilation is any self-directed, repetitive behavior that causes physical injury.1 Examples vary widely and include skin cutting, burning, or picking as well as head banging and extreme injuries such as auto enucleation. Most acts of self-mutilation are not suicide attempts but behaviors meant to express or release emotional turmoil.
As difficult as self-mutilation may be to understand, managing this condition may be even more complex. A multidisciplinary approach may be required, but evidence for the effectiveness of psycho- and pharmacotherapies is limited. This article reviews some theories of pathologic self-mutilation and describes emerging clinical strategies to treat it.
Four types of self-mutilation
DSM-IV does not recognize self-mutilation as a separate disorder but sees it as a symptom of other psychiatric conditions.2,3 It is briefly mentioned as one criterion for diagnosing borderline personality disorder (“recurrent suicidal behaviors, gestures or threats or self-mutilating behaviors”), and it also appears in the catch-all diagnosis of impulse control disorders, not otherwise specified (NOS). Other self-injurious behaviors such as substance use disorders, trichotillomania, and, in some respects, pathologic gambling have found their way into DSM-IV as addiction or impulse control disorders. Self-mutilation appears to fall between these diagnostic categories, as it contains elements of many psychiatric disorders, such as:
- loss of behavioral control
- repetitive actions despite negative consequences
- and clear dysregulation of thought and emotions.4
Self-mutilation presents in a variety of forms and encompasses many behaviors, from the socially acceptable to the bizarre and grotesque (Table 1). Favazza and Rosenthal described three main forms of pathologic self-mutilation.2,5 A fourth form (such as ear piercing) is socially accepted and not considered pathologic.
Table 1
FOUR TYPES OF SELF-MUTILATION
| Type | Example | Common causes |
|---|---|---|
| Severe | Eye enucleation, castration, amputation | Psychotic states, intoxicated states (especially with use of amphetamines) |
| Stereotyped | Head banging, biting | Mental retardation, Lesch-Nyhan syndrome, Tourette’s syndrome |
| Superficial or moderate | Skin cutting, burning, picking | Personality disorders secondary to axis I disorders, impulse control disorder |
| Socially accepted | Ear piercing, tattoos | Accepted cultural practices |
| Source: Adapted and reprinted with permission from Favazza AR, Rosenthal RJ. Diagnostic issues in self-mutilation. Hosp Community Psychiatry 1993;44(2):134-40. | ||
- Severe self-mutilation manifests as extensive (and often irreversible) body damage. Examples include eye enucleation, castration, or amputation. Intense psychotic states and intoxication from illicit substances—usually amphetamines—are the main causes of this relatively rare type, which fortunately is not frequently repeated.
- Stereotyped self-mutilation is self-directed physical injury (head banging, biting oneself) seen in mental retardation and developmental disorders. This type has a stereotyped and repetitive rhythm and presents in the clear context of a neurobiological insult.
- Superficial or moderate self-mutilation—seen most commonly in general psychiatric practice—includes skin cutting, burning, or picking by nonpsychotic, nonmentally retarded patients. The behavior tends to be repetitive. Patients with this type usually present with comorbid conditions, particularly personality disorders.
- Socially accepted self-mutilation includes ear piercing, tattoos, or culturally based behaviors, such as lip piercing or ear stretching seen in some African cultures.
An impulse control disorder?
Over the last 15 years, increasing evidence has suggested that pathologic self-mutilation may be an impulse control disorder.6 Many clinical case reports demonstrate that self-mutilation shares two characteristics of impulse control disorders that involve such behaviors as gambling, sex, or stealing:
- failure to resist impulses/urges to participate in a particular behavior
- increasing tension or physical arousal before the act and release of pleasure or gratification after the act.
In the case report, “Pain from cutting makes me feel alive” (box), the patient describes being unable to resist thoughts of cutting herself or to stop the behavior, despite knowing that she should. Self-mutilators also have been shown to have biological measures of impulsivity—namely decreased serotonin levels—similar to those seen with other impulse control disorders.7,8 Finally, evidence is emerging that acts of self-mutilation are socially triggered expressions of impulsive psychological traits.5-7
Risk factors
Accurate estimates of self-mutilation’s incidence and prevalence are lacking, mainly because the behavior is difficult to define. In the U.S. population, Favazza estimated the prevalence as 0.75% and the incidence between 14 and 600 per 100,000 persons annually.5 Known risk factors are:
- female gender
- adolescence and college age
- substance abuse and/or personality disorders
- history of self-mutilation3,9,10 (Table 2).
Comorbidities such as depression, bipolar disorder, substance abuse, and schizophrenia are common. Axis II phenomena are common, especially the cluster B traits of histrionic, narcissistic, and borderline personalities.
Finally, little is known about the course of self-mutilation, but it tends to begin in adolescence and follows an episodic, recurrent pattern.11 Reports are scant of self-mutilation in the elderly, although clinical experience tells us that it does occur in this age group.