[Male genital self-mutilation: A case series]. / Automutilation des organes génitaux externes chez l'homme.

INTRODUCTION: Genital self-mutilation is a rare phenomenon that often occurs on a psychotic ground. Its diagnosis is clinical and its management involves a coordinated action of urologists and psychiatrists. MATERIALS AND METHOD: We report a retrospective monocentric series of 14 cases of genital self-mutilation (penis and testicles), collected from January 2000 to May 2019. In addition to psychiatric care and according to the type of lesions, we performed implantations of penis, cutaneous urethrostomies, hemostatic ligature of spermatic cord, ablation of rings. The implantations of the penis were done without microscope or magnifying glass and on the basis only of an end-to-end anastomosis of the erectile bodies and the urethra. Sexual abstinence was indicated for 6weeks. RESULTS: The average age of our patients was 31.5years. We have identified ten cases of penis section including two incomplete, two cases of strangulation of penis by a metal ring, an isolated wound of the glans and three cases of testicular ablation, two of which were associated with a section of penis. We performed as first line: 5 penis reimplantation, 5 cutaneous urethrostomy, 2 ablation of strangulation rings and 3 hemostatic ligature of the spermatic cord. Three reimplanted patients had fairly satisfactory immediate operating suites: 2 patients healed well with good penile sensitivities, while one patient presented with a loss of penile skin sensitivity. The other two patients, on the other hand, presented on D1 a necrosis of the reimplanted stump, requiring an amputation and cutaneous urethrostomy. Also, necrosis of the strangulated penis was observed in one case and also required a second operating time with an amputation of the necrotic penis and a cutaneous urethrostomy. One patient died on D7 by autolysis. From a distance, the sexual and urinary function of reimplanted patients could not be assessed because they were lost to follow-up. Only a few patients who received a skin urethrostomy were seen at follow-up consultations. And with an average follow-up of 3years, no functional urinary disorder was found in them. CONCLUSION: The management of genital self-harm requires coordination between urologist and psychiatrist. With our conditions the results are mixed and penile reimplantation should ideally be done under a microscope with an experienced surgeon. However, it can be attempted as long as possible, with the possibility of making an urethrostomy in the second time in case of failure. The pillar of care for these patients, however, lies in a good psychiatric balance because they are not immune to recurrence or autolysis. LEVEL OF EVIDENCE: 3.

Secretan's syndrome: case report.

Secretan's syndrome is a rare clinical condition with recurrent swelling of the forearm and dorsum of the hand, together with flexion contracture of the fingers and a thumb that is spared. The disease is associated with automutilation. We present a typical case of a 42-year old women with Secretan's syndrome.

Severe clinical events in 100 patients with schizophrenia: a retrospective clinical description using a system-specific psychopathological approach.

Catatonic states and numerous other severe clinical events can complicate the course of schizophrenia. Whether these severe courses are associated with particular system-specific symptom dimensions remain unclear. Aim is to assess the frequency of severe clinical events in a clinical population and to investigate the association of these events with sociodemographic data and system-specific psychopathology, combining qualitative and quantitative data. We performed a comprehensive retrospective description of a well-described and geographically stable sample of 100 patients with schizophrenia or schizoaffective disorder and linked severe clinical events with sociodemographic data at inclusion into the study (as indicators of social functioning) and symptoms at first admission, classified with the Bern Psychopathology Scale (BPS). We found 12 mentions of catatonic stupor or excitement, 45 of suicide attempts, 26 of suicidality, 18 of deliberate self-harm, 18 of self-threatening behaviour other than deliberate self-harm, 34 of violence against other persons, 18 of violence against objects and six of sexual harassment. Disinhibited language on first admission seemed to be a protective factor against suicidality and disinhibited motor behaviour seemed to predict self-threatening and violent behaviour. Catatonia and violence in particular seemed to be socially disabling. This exploratory study showed that the BPS is a promising instrument and might represent a system-specific approach in identifying patients at risk for severe sequelae of schizophrenia. This will have to be tested in future prospective studies.

The assessment of skin picking in adolescence: psychometric properties of the Skin Picking Scale-Revised (German version).

BACKGROUND: Skin picking disorder has received growing attention since the release of DSM-5, yet there are no evidence-based assessment instruments for adolescent samples. AIM: The present study examines the psychometric properties of the Skin Picking Scale-Revised (SPS-R, German version) in adolescents. METHODS: A total of 76 adolescents (96% female) completed the SPS-R, the Clinical Psychological Diagnostic System (KPD-38), and a questionnaire assessing demographics and clinical characteristics online. RESULTS: The SPS-R had high internal consistency (α = 0.89) and significant small-to-medium correlations with reduced competence skills, psychological impairment, general life satisfaction, social support, and social problems on the KPD-38. Similar to prior findings for adults, an exploratory factor analysis suggested a two-factor model for the SPS-R in adolescents. Group comparisons failed to show significant differences on SPS-R scores between participants with and without dermatological conditions. CONCLUSIONS: The current results suggest that the SPS-R can be useful in adolescent samples as a reliable and valid instrument for the assessment of skin picking severity. Future research investigating scale validity and factor structure in a clinical sample of adolescent skin pickers is warranted.

[Self-injury in hospitalized patients: Concerning 19 cases]. / L'automutilation chez les patients hospitalisés : à propos de 19 cas.

INTRODUCTION: Self-mutilating behaviour is expanding, especially among adolescents and patients with a psychiatric disorder. CLINICAL MATERIAL: We have tried to describe the self-mutilating behaviour in Moroccan inpatients of the psychiatric department of Mohammed V Military Hospital of Rabat, through a prospective and descriptive longitudinal study over a period of four months, based on a questionnaire prepared according to the literature data to allow discussing its results. RESULTS: The rate of participation was 90.4%, or 19 patients. All patients were male. The age of onset of self-injury was between 14 and 62 years with an average of 26.3 years. Only two patients had an age of onset in adolescence, before age 20, the majority (57.8%) in a young adult age. Eight patients (42.1%) report having experienced physical abuse while only four patients were sexually abused, especially by relatives. The number of episodes varied from one episode in twelve cases (63.15%), to seven cases (37%) with repetitive self-mutilation. The most common type of self-injury was cuts (16 cases), twelve patients inflicted burns, and two patients inflicted fist blows. The forearm was the most common location. All patients were unable to resist the pressing need to self-harm after various reasons, often in a relational or professional frustration state. The use of concomitant substances to self-mutilation was reported in nine episodes, alcohol in seven episodes (24.1%) and cannabis in three episodes (10.3%). Only five patients reported receiving medical care for physical consequences of self-harm. Only two patients underwent a psychiatric care following their self-mutilation and admitted to our service. Personality disorders was the psychiatric disorder most diagnosed in our sample, followed by mood disorders. Borderline personality disorder was the pathological personality disorder most commonly diagnosed in our study with nearly two thirds of cases, followed by antisocial personality. DISCUSSION: The size of our population and the prevalence of self-harm are comparable to most studies on self-mutilation in clinical populations. The low prevalence of patients beginning this behaviour early was low in our population, explained by the pre-commitment visits, which limit their integration into the military body. The role of physical and sexual abuse in childhood in the development of self-harm behaviour in adolescence is still a subject of discussion, but shame and fear of the breakdown of the family union have significantly limited the mention of such a history by our patients. The use of self-harm to relieve an intolerable anger thus the absence of suicidal intent, confirms the difference between self-harm and suicide. The intolerant nature of the military environment to self-behaviour limits its repetition and allows their early management. The high frequency of personality disorders in our sample is consistent with studies indicating high levels in patients who self-harm, including borderline personality, and supports that the DSM-IV considers self-harm to be a diagnostic criterion of this personality disorder. CONCLUSION: Self-injury is a common pathological behaviour and serious in its relational impact. Our present data collected mainly similarities with that of the literature. For cultural reasons, the self-mutilation in our sample is more linked to an impulse control problem than to childhood abuse. So the establishment of a system of care adapted to preserve the privacy of patients, understanding of self-harm, informing the general public and the early treatment of victims of abusive families seems essential to reduce expansion of this behaviour.

Anxious temperament as a risk factor of suicide attempt.

OBJECTIVE: Suicide has been reported to be associated with cyclothymic, irritable, depressive and anxious temperaments. In contrast, hyperthymic temperament has been reported to be protective against suicide. In the present study, we hypothesized that Japanese patients with suicide attempt may have higher scores of cyclothymic, irritable, depressive, and anxious temperaments but lower scores of hyperthymic temperament than non-suicidal patients. In order to examine this hypothesis, we investigated Japanese patients of a university emergency center. METHODS: The association of temperament and suicide attempt was investigated in 116 patients referred to a university emergency center for intoxication or injury. Of them, 35 patients of suspected suicide attempt were categorized as 18 patients who intended to die with attempted suicide and suffered from self-inflicted but not fatal injury (Suicide Attempt II), 4 patients whose intention to die were undetermined although they suffered from self-inflicted injury (Undetermined Suicide-Related Behavior II), and 13 patients who had no intention to die although they suffered from self-inflicted injury (Self-Harm II). Logistic regression analyses and multiple regression analyses were used to identify factors associated with the present suicide attempt and the number of suicide attempts, respectively. RESULTS: Anxious temperament scores were significantly and directly associated with Suicide Attempt II group whereas irritable temperament scores were associated with Self-Harm II group. CONCLUSION: The present findings suggest that those with anxious temperament may have more suicide attempts than those with other temperaments, indicating anxious temperament as a risk factor of suicide attempt.

TWO CASES WITH DIFFERENT EPILEPSY TYPE AND DYSMORPHIC FEATURES ASSOCIATED WITH 17q21.31 MICRODELETION SYNDROME.

The 17q21.31 microdeletion syndrome is characterized by intellectual disability, epilepsy, facial dysmorphism and friendly behavior. Recently, KANSLJ gene has been considered as a major causal gene for this phenotype. Here we report on two Turkish patients with different seizure types and additional dysmorphic features associated with 17q21.31 microdeletion syndrome. A 4 year-old female patient with generalized tonic-clonic seizures, mild mental retardation, dysmorphic features and friendly behavior and a 14 years-old female with intractable epilepsy, different dysmorphic features, severe mental and motor retardation and self-mutilation were evaluated by array-based comparative genomic hybridization (microarray CGH). Array CGH identified 17q21.31 microdeletion that contains MAP7 CRHR1, KANSLI, PLEKHMI genes in case I and CRHR1, PLEKHM but not KANSLJgenes in case 2. To the best of our knowledge this is the first report of a patient with the 17q21.31 microdeletion which does not encompass KANSLI gene. These data imply another gene or genes causing similar phenotype in this patient.

[Recurrent voluntary ingestion of metallic objects in prison by a female patient]. / Ingestion volontaire d'objets métalliques à répétition chez une patiente en milieu carcéral.

INTRODUCTION: Recurrent and intentional ingestion of metallic objects is a rare but important phenomenon. It has attracted great interest among mental health professionals over the last decades. However, this issue is rarely reported in the literature. A deep exploration of its clinical and specific psychopathological aspects remains limited. CASE REPORT: We report the case of a 32-year-old female patient, who was sentenced to 20 years in prison for homicide against her cousin, the daughter of an uncle who had raped her when she was 14. This affair was hushed by the patient's family and the patient was submitted to several acts of abuse by her family. Following her incarceration, she repeatedly ingested metallic objects requiring repeated admissions in a department of surgery for endoscopic extractions or surgical interventions. She impulsively ingested more than 30 times various metallic objects such as wire, razor blades, spoons, etc., under the pressure of impulsiveness and massive anxiety. Voluntary metal ingestions, associated with iterative self-mutilation behaviors, took place within the framework of a borderline personality disorder, the incarceration and the conditions of imprisonment playing a role in initiating and retaining the behavior. CONCLUSION: Through this case report, we examine the specific psychiatric aspects of intentional ingestion of metallic objects in order to better understand this behavior.

Factitious hand disorders: review of 29 years of multidisciplinary care.

PURPOSE: To improve our understanding of factitious hand disorders with a review of our experience over 29 years in a multidisciplinary hand center. METHODS: A retrospective chart review was performed to identify workers' compensation patients treated for factitious hand disorders in the multidisciplinary hand center between January 1981 and September 2010. Multidisciplinary evaluation at this center involved evaluation by hand surgeons, occupational therapists, and psychologists. Data collected include age, sex, race, educational level, clinical presentation, number of diagnostic tests, number of surgeries, time to referral to the multidisciplinary center, direct cost of care, psychological diagnosis, Minnesota Multiphasic Personality Inventory, treatment modalities, and work status. RESULTS: We identified 174 workers' compensation patients with factitious hand disorders. Presentation was used to classify patients into 1 of 4 categories: psychopathological dystonia, factitious edema, psychopathological complex regional pain syndrome, and factitious wound creation and manipulation. There were statistically significant differences between the 4 categories in demographics, utilization of medical resources, psychopathology, treatment modalities, and return-to-work status. Patients with factitious wounds were more educated, used more medical resources, demonstrated an angry or hostile profile, and experienced a lower return-to-work rate. Patients with dystonia were less educated, used less medical resources, demonstrated a hypochondriasis or depressed profile, and experienced a higher return-to-work rate. CONCLUSIONS: Treatment of factitious hand disorders remains frustrating and costly due to failure or recurrence after traditional approaches. This review is a large-scale examination of the factitious hand disorder population that demonstrates the unique pathology involved in each of the 4 categories. There is a specific association between the category of hand disorder and the underlying pathology and prognosis. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Gender differences in methods of suicide attempts and prevalence of previous suicide attempts.

OBJECTIVE: Suicide attempts are important predictors of completed suicide. Adolescents admitted to the emergency room of a large university hospital in Bern after a suicide attempt during the years 2004-2010 were prospectively assessed for methods of suicide attempt. METHOD: Adolescents (N = 257; 66.5% female; age 14-21 years), presenting after a suicide attempt, were assessed with the WHO/EURO Multicentre Study on Parasuicide assessment tool. RESULTS: Males more often used jumping from a high place (14% vs. 4.6% in females, p < .05) and less often intoxication (36% vs. 71.3%, p < .01). At least one previous suicide attempt was reported in 100 patients (44.4%; more females than males: Cramer-V = 0.21; p = .002). Of these, 35 adolescents did not present to this hospital or not at all for a previous suicide attempt. CONCLUSIONS: The present study is the first to examine methods of suicide attempts according to the ICD-10 X codes in this age group. Gender differences were observed. Because a relevant number of patients did not present to the same hospital or not at all for a previous suicide attempt, studies on pathways to care of adolescents after their first suicide attempt are important for early detection and intervention strategies.

[Delusional disorder, autoaggression und suicide]. / Wahnerkrankung, Autoaggression und Suizid.

The authors report on the suicide of a 27-year-old woman with extreme self-inflicted injuries. The victim suffered from schizophrenic psychosis with several stays in mental institutions and one previous suicide attempt. Autopsy revealed multiple cut and stab injuries in various body regions (51 stabs to the chest, cutting off parts of ears and nose, stab to the eye and transection of the scalp). Death was caused by exsanguination.

A case of autophagia: a man who was mutilating his fingers by biting them.

Self-mutilating behaviors could be minor and benign, but more severe cases are usually associated with psychiatric disorders or with acquired nervous system lesions and could be life-threatening. The patient was a 66-year-old man who had been mutilating his fingers for 6 years. This behavior started as serious nail biting and continued as severe finger mutilation (by biting), resulting in loss of the terminal phalanges of all fingers in both hands. On admission, he complained only about insomnia. The electromyography showed severe peripheral nerve damage in both hands and feet caused by severe diabetic neuropathy. Cognitive decline was not established (Mini Mental State Examination score, 28), although the computed tomographic scan revealed serious brain atrophy. He was given a diagnosis of impulse control disorder not otherwise specified. His impulsive biting improved markedly when low doses of haloperidol (1.5 mg/day) were added to fluoxetine (80 mg/day). In our patient's case, self-mutilating behavior was associated with severe diabetic neuropathy, impulsivity, and social isolation. The administration of a combination of an antipsychotic and an antidepressant proved to be beneficial.

Bilateral corneal perforations and autoproptosis as self-induced manifestations of ocular Munchausen's syndrome.

PURPOSE: To report a patient with bilateral corneal perforations and autoproptosis in a case of ocular Munchausen's syndrome. DESIGN: Case report. PARTICIPANT: A 26-year-old white male referred to the oculoplastics service with one month history of decreased vision bilaterally and painful right eye. Multiple eyelid scars and right corneal opacity were noted. The patient was previously seen at another institution for rapid loss of vision in both eyes. INTERVENTIONS: An orbit decompression among many procedures failed to controlled extreme pain and proptosis. MAIN OUTCOME MEASURES: Resolution of proptosis, stabilization of vision, pain resolution. RESULTS: Three weeks after enucleation of the right eye was offered, patient presented with spontaneous left ruptured globe. After multiple episodes of self-mutilation and infections, both eyes were exenterated. CONCLUSIONS: Munchausen syndrome can be seen with ophthalmic manifestations and should be considered in the differential diagnosis when ocular abnormalities cannot be explained after a thorough evaluation. Recognition of this psychiatric disease is not only important for correct medical diagnosis and treatment, but also essential in protecting the patients from unnecessary invasive and aggressive medical procedures.

[Congenital corneal anesthesia. A case report]. / Anesthesie corneenne congenitale: a propos d'un cas.

Congenital corneal anesthesia (CCA) is an uncommon condition difficult to diagnose. We report the case of a 4-year-old girl who presented with bilateral congenital corneal anesthesia revealed by a corneal ulcer which had been unresponsive to adapted local treatment. Self-inflicted corneal injuries were present. It is important to search for corneal anesthesia in children with chronic ulceration of the cornea and selfinflicted injuries.

[Self-mutilation--artifacts--case report]. / Samoozljedivanje--artefakti--prikaz bolesnika.

Despite the knowledge and the development of sophisticated procedures in the treatment of wounds, many clinicians are faced with the wounds that heal very slowly or they do not heal at all. In spite of repeated reconsideration of the treatment strategies and focusing on the biological factors, we still pay little attention to the psychosocial factors that are listed as one of the causes of atypical wounds. One factor is self-mutilation caused by psychological disorder called hospital addiction syndrome or Munchausen syndrome, which belongs to a group of the states called imaginary disorder where someone with great need for attention turns to disease or injury. In people with "hospital addiction syndrome", we are confronted with evidence for the symptoms to be imaginary or consequential to self-inflicted injuries; they usually deny these clams and often leave the hospital despite advice but in search for other physicians and hospitals.

[Dermatitis artifacta--psychiatric causes]. / Artefaktni dermatitis--psihijatrijski uzroci.

Dermatitis artifacta is a psychodermatological condition in which skin lesions are produced or inflicted by the patient's own actions. Patients present with lesions of various forms and bizarre shapes, which are difficult to recognize. Lesions can mimic many different dermatological diseases, but they mostly resemble superficial erosion, hyperpigmented maculae, excoriation or ulcerations. Patients often deny responsibility, so the direct confrontation will mostly lead to withdrawal and seeking help somewhere else. An effective therapeutic relationship requires a nonjudgemental, empathic and supportive environment in order to encourage return to follow up, and eventually talk about the possible psychological basis of the disease. Dermatitis artifacta is difficult to diagnose and is rarely recognized, but it is estimated that 0.2%-0.5% of dermatological patients suffer from this disease. There is generally considered to be a female preponderance, but estimates vary from 1:3 to 1:20 male to female ratio. Most affected patients are in their teens or early adulthood. Many patients suffer from a psychiatric illness, mostly borderline personality disorder. Patients may suffer from anxiety, depression or somatoform disorders. There is strong association with eating disorders; it is estimated that dermatitis artifacta occurs in approximately one-third of patients with anorexia or bulimia. Patients may have subconscious compulsion based on psychological or emotional need to elicit care; the illness often serves as an extreme form of nonverbal communication. Dermatitis artifacta occurs in patients with poor coping skills and often represents a maladaptive response to psychological stressor. Treatment is very difficult and with variable outcomes. Dermatitis artifacta is a challenging condition that requires both dermatological and psychiatric expertise, but unfortunately psychiatric treatment is rarely conducted since patients deny their responsibility and refuse psychiatric help.

[Automutilation of the palate in a psychiatric patient]. / Automutilatie van het palatum bij een psychiatrische patiënt.

A 46-year-old man with a history of alcohol abuse was referred to an oral and maxillofacial surgeon with a large necrotic wound with raised edges on the palate. After history taking, radiography and clinical assessment, together with a psychiatrist, the lesion was diagnosed as an automutilation resulting from a period of alcohol abstinence. After a period of care in a medical centre, the lesion improved quickly. Following this treatment, the patient was admitted to a psychiatric treatment centre for supplemental treatment of his addiction problems.

Male genital self-mutilation due to tomophobia - case report and review of literature.

Self-mutilation is defined as a "deliberate destruction or alteration of body tissue without conscious suicidal intent". The prevalence of self-mutilation is about 1%, however the voluntary cutting of the genital organs remains extremely rare with fewer than 100 cases of genital self-mutilation reported in both sexes in the English literature to date. Genital self-mutilation is most often associated with psychiatric disorders, but it has also been reported in nonpsychotic individuals owing to various reasons. Here, we present the case of a 45-year-old man who was found deceased in his home in a pool of blood with a knife and a pair of scissors lying next to him. In addition to this, parts of the intestine were found next to the body. The patient was diagnosed with hydrocoele and had a known history of tomophobia which caused him to take matters into his own hands by incising his scrotum which led to his demise. Self-orchidectomy is an extremely rare phenomenon and is most often associated with psychiatric illness.

[Skin self-injuries in psychodermatological aspect]. / Samouszkodzenia skóry w aspekcie psychodermatologicznym.

Mental disorders are the most frequent cause of self induced injuries (self-injury). Self-mutilation is a form of auto-aggression, which is a manifestation of psychic discomfort. Skin changes, defined as self-induced skin diseases, constitute the secondary problem, and require patients to consult dermatologists. Self-induced skin diseases include Münchhausen syndrome, acne excoriée, trichotillomania, nail biting (onychophagia), dermatitis artefacta, neurotic self-mutilation, self-mutilation when associated with hallucinations and delusions. A knowledge of psycho-dermatological issues among dermatologists, general practitioners, psychiatrists and psychologists facilitates proper diagnosis and the appropriate choice and form of treatment and enables patients to be provided with more complex medical care.