[The phenomenon of covert self-mutilation in the surgical routine]. / Das Phänomen der heimlichen Automutilation im chirurgischen Alltag.

Factitious disorders are conditions which are unknown to many physicians but have a prevalence of 1-5 % in outpatient departments and hospitals. In order to avoid prolonged and complicated (false) treatment in surgery this article gives a review of the definition, epidemiology and pathogenesis of factitious disorders as well as clinical symptoms and therapy options. A focus is placed on the identification of patients, treatment strategies and the prevention of malpractice. Additionally, clinical features of the disorder are illustrated with the description of some characteristic cases.

Hereditary sensory and autosomal peripheral neuropathy-type IV: case series and review of literature.

Hereditary sensory and autonomic neuropathy (HSAN) IV is a rare autosomal recessive disorder which is characterized by a decrease in the number of myelinated and non-myelinated nerve fibers of peripheral nerves which causes diminished or absent pain sensation leading to increase in self-mutilative habits. A retrospective study of eight cases ranging from age group of 4 to 17 years for oral and digital signs and symptoms is presented. All the patients showed congenital insensitivity to pain and anhidrosis. Oral self-mutilations, such as autoextraction of teeth and severe bite injuries (with resultant scarring) of the finger tips and oral soft tissues (tongue, lip, and buccal mucosa) were found in most patients. Our study suggests that early diagnosis and specific treatment plan are important for prevention of characteristic of the oral as well as digital trauma associated with this disorder.

Relation between the level of self-mutilation and the concentration of fecal metabolites of glucocorticoids incaptive chimpanzees (Pan troglodytes) / Relação do grau de automutilação com as concentrações de metabólitos fecais de glicocorticoides em chimpanzés (Pan troglodytes)

The influence of stress in an environment, according with the behavioral and endocrine variables of primates, are increasingly being studied by a diversity of authors, and have shown that abnormal behaviors associated with increased glucocorticoids may be directly related with the impairment of their well-being. In this work were used 22 adult chimpanzees (Pan troglodytes), 11 males and 11 females, kept in captivity in three different institutions. All animals had their behavior registered by focal session using a 30 seconds sample interval, during six months, totaling 4,800 registries per each animal. During this period, fecal samples were collected 3 times a week for the extraction and measurement of the concentration of fecal metabolites of glucocorticoid by radioimmunoassay. Of the total observed, stereotypical behaviors represented 13,45±2.76%, and among them, self-mutilation represented 38.28±3.98 %. The animals were classified into three different scores, according with the percentage of body surface with alopecia due to self-mutilation. It was found a positive correlation of high intensity between the scores of alopecia due to the observed mutilation and the average concentrations of fecal metabolites of glucocorticoids. This result strongly suggests that this measurement of self-mutilation in a chimpanzee can be used as an important auxiliary tool to evaluate de conditions of adaptation of an animal in captivity, functioning as a direct indicator of the presence of chronic stress...

A influência do estresse de um ambiente nas variáveis endócrino-comportamentais de primatas vem sendo cada vez mais estudada por diversos autores, e mostram que comportamentos anormais associados a aumentos de glicocorticóides podem estar diretamente relacionados ao comprometimento do bem-estar. Neste trabalho foram utilizados 22 chimpanzés (Pan troglodytes) adultos, sendo 11 machos e 11 fêmeas mantidos em cativeiro de três instituições diferentes. Todos os animais tiveram seus comportamentos registrados pelo método de amostragem focal por intervalo de tempo, durante seis meses, totalizando 4800 registros para cada animal. Amostras fecais foram coletadas três vezes por semana, durante este período, para extração e dosagem de metabólitos fecais de glicocorticoides por radioimunoensaio. Os comportamentos estereotipados representaram 13,45+2,76% do total observado, sendo que dentre estes comportamentos a automutilação representou 38,28+3,98%. Os animais foram classificados em três graus diferentes, de acordo com o percentual da superfície corpórea com alopecia decorrente da automutilação. Foi encontrada uma correlação positiva de intensidade forte entre os graus de alopecia decorrentes de mutilação observados e as médias de concentrações de metabólitos fecais de glicocorticoides. Este resultado sugere fortemente que esta graduação de automutilação de um chimpanzé possa ser utilizada como uma ferramenta auxiliar importante nas avaliações das condições de adaptação do animal ao cativeiro, atuando como um indicador indireto da presença de estresse crônico...

[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.

[Traumatic enucleation. Accident or self-mutilation?]. / Traumatische Enukleation. Unfall oder Selbstverletzung?

A 52-year-old woman was admitted for emergency treatment after traumatic enucleation. Because of the position of the avulsed eye and the acute mental condition of the patient a trauma caused by self-mutilation could not be excluded. There was even the suspicion of self-enucleation in a second case and in both cases a psychiatrist was consulted but ultimately a disastrous accident was clearly verified for both patients. Nevertheless, an interdisciplinary evaluation should be initiated in cases of patients with a suspicious traumatic injury as in cases of self-mutilation the danger of relapse is high in the first hours and weeks after the primary event.

Body dysmorphia, self-mutilation and the reconstructive surgeon.

Body dysmorphic disorder (BDD) is a disabling preoccupation with a slight or an imagined defect in appearance. It is recognised in some patients who present to the plastic surgeon requesting multiple cosmetic procedures. Very rarely, BDD patients may wish for amputation of a healthy limb and may even mutilate themselves deliberately in order to necessitate amputation. These patients pose a diagnostic challenge as BDD is uncommon and they are often uncooperative whilst appearing mentally sound. Furthermore, they raise difficult ethical and legal issues for the surgeon. Although there is some guidance for the management of BDD patients seeking elective amputation, there is currently none for the management of those who present in the emergency setting. Illustrated by the case of a man who, having failed to find a complicit surgeon, attempted self-amputation of the hand, we review the relevant ethical, legal and management issues with advice by the British Medical Association and General Medical Council.

Queimadura autoinfligida em mulheres: a violência de gênero inscrita no corpo / Self-inflicted burn on women: gender violence in scribed on the body

O objeto deste estudo consiste na violência autoinfligida em mulheres por queimadura. As lesões por queimadura são consideradas causas externas (acidentes e violências) e tem contribuído para o aumento geral dos índices de morbimortalidade acarretando perda de anos de vida produtiva. São resultantes de múltiplos fatores como condições socioeconômicas, violências e desigualdade de gênero. Esta pesquisa teve como objetivos: analisar o perfil sociodemográfico das mulheres que vivenciaram queimadura autoinfligida; descrever as circunstâncias e o contexto social relacionados à queimadura autoinfligida em mulheres; analisar os fatores motivadores da queimadura autoinfligida em mulheres; e, discutir a queimadura autoinfligida em mulheres na perspectiva de gênero. Trata-se de uma pesquisa de abordagem qualitativa e exploratória. Os cenários da pesquisa foram dois Centros de Tratamento de Queimados (Municipal e Federal) localizados no Estado do Rio de Janeiro. Os sujeitos do estudo foram 10 mulheres com história de queimadura autoinfligida e que não tivessem história de tentativa de suicídio anterior e diagnóstico de sofrimento psíquico, uma vez que estas situações poderiam comprometer a análise das vivências de violência. A coleta de dados foi realizada através de entrevista semi-estruturada, com roteiro previamente elaborado, no período de novembro de 2009 a março de 2010. Os dados foram analisados através da técnica de Análise de Conteúdo de Bardin, tendo emergido duas categorias: a) A vida da depoente antes da queimadura: percepção da sua condição pessoal; relações familiares envolvendo mãe, pai, avós, irmãos e filhos; relações sociais e relação com o companheiro; b) Queimadura autoinfligida em mulheres: uma questão de violência de gênero: fatores motivadores da queimadura autoinfligida na perspectiva da mulher e queimadura autoinfligida como desfecho da vivência de violência conjugal...

The object of this study is self-inflicted violence in women by burning. Burn injuries are considered external causes (accidents and violence) and have contributed to the overall increase in mortality rates resulting in loss of productive life. They are the result of multiple factors such as socioeconomic status, violence and gender inequality. This study sought to analyze the demographic profile of women who experienced self-inflicted burns; describe the circumstances and social context related to self-inflicted burning in women, analyze the factors which motivated self-inflicted burn in women, and discuss self-inflicted burns in women from a gender perspective. This is both a qualitative and an exploratory study. The research scenarios were two Burns Treatment Centers (Municipal and Federal) located in the State of Rio de Janeiro. The study subjects were 10 women with a history of self-inflicted burns who didn´t have a history of previous suicide attempts and diagnosis of psychological distress, since these situations could compromise the analysis of the experiences of violence. Data collection was conducted by means of a semi-structured interview with a predefined script, from November 2009 to March 2010. Data was analyzed with Bardin´s Content Analysis technique, and two categories have emerged: a) The life of the deponent before the burn: perceptions of her personal condition, family relations involving mother, father, grandparents, siblings and children; social relations and relationship with her partner, b) Self-inflicted burn in women: a matter of gender violence: motivating factors to self-inflicted burns from a woman's perspective and self-inflicted burns as an outcome of the experience domestic violence...

The risk-taking and self-harm inventory for adolescents: development and psychometric evaluation.

In this study, we report on the development and psychometric evaluation of the Risk-Taking (RT) and Self-Harm (SH) Inventory for Adolescents (RTSHIA), a self-report measure designed to assess adolescent RT and SH in community and clinical settings. 651 young people from secondary schools in England ranging in age from 11.6 years to 18.7 years and 71 young people referred to mental health services for SH behavior in London between the ages of 11.9 years and 17.5 years completed the RTSHIA along with standardized measures of adolescent psychopathology. Two factors emerged from the principal axis factoring, and RT and SH were further validated by a confirmatory factor analysis as related, but different, constructs, rather than elements of a single continuum. Inter-item and test-retest reliabilities were high for both components (Cronbach's α = .85, ru = .90; Cronbach's α .93, ru = .87), and considerable evidence emerged in support of the measure's convergent, concurrent, and divergent validity. The findings are discussed with regard to potential usefulness of the RTSHIA for research and clinical purposes with adolescents.

[Factitious disorder and self-mutilation in hand and plastic surgery]. / Artifizielle Störungen und selbstverletzendes Verhalten in der Hand- und Plastischen Chirurgie.

Self-mutilation in the context of factitious disorder can lead to prolonged and complicated treatment in every medical field. Because of a prevalence of 1-5% in hospitalised patients, it is important to be aware of this disorder to protect patients from self- and foreign-induced harm. Often the patient history gives important hints. The different manifestations of this disorder, the specific doctor-patient relationship, several techniques of confrontation and current treatment are presented. Clinical cases from the fields of hand and plastic surgery are presented.

[Self-mutilating behaviour: a study on 30 inpatients]. / Les conduites automutilatrices: étude portant sur 30 patients.

INTRODUCTION: Deliberate self-injury is defined as the intentional, direct injuring of body tissue without suicidal intent. There are different types of deliberate self-mutilating behaviour: self cutting, phlebotomy, bites, burns, or ulcerations. Sometimes, especially among psychotic inpatients, eye, tongue, ear or genital self-mutilations have been reported. In fact, self-mutilation behaviour raises nosological and psychopathological questions. A consensus on a precise definition is still pending. Many authors consider self-mutilating behaviour as a distinct clinical syndrome, whereas others hold it to be a specific symptom of borderline personality disorder. Self-mutilating behaviour has been observed in 10 to 15% of healthy children, especially between the age of 9 and 18 months. These self mutilations are considered as pathological after the age of 3. Such behaviour is common among adolescents, with a higher proportion of females, and among psychiatric inpatients. Patients use different locations and methods for self-mutilation. Deliberate self harm syndrome is often associated with addictive behaviour, suicide attempt, and personality disorder. CLINICAL MATERIAL: We report on an observational study including 30 inpatients and we compared the data with the existing literature. As a matter of fact, until now, most of the papers deal with case reports or with very specific patterns of self-mutilation (eye, tongue or genital self-mutilations). Otherwise, papers report the relationships between self-mutilation and somatic or personality disorders (Lesh Nyhan syndrome, borderline personality disorder, dermatitis artefacta, self-mutilation in children following brachial plexus related to birth injury, mental retardation...). Our study included all self harmed patients who had been admitted to our psychiatric hospital (whatever the location and type of self-mutilation). Patients suffering from brain injury or mental retardation were excluded. RESULTS: In our sample, there was a higher percentage of women (29 women and 1 man) and the mean age was 18 (12 to 37). More than half of the patients were aged under 18. Single parent families were reported in 30% of cases. Thirty percent of patients had been physically or sexually abused during childhood. Sixty percent had a comorbid psychiatric disorder, 63% had been hospitalised previously (half of them twice or more). Seventy-three percent of patients had previously attempted suicide (notably deliberate self-poisoning and cutting) that was not considered as self-mutilating behaviour by the patients themselves. Each patient had self harmed themselves at least twice and most often different methods and locations were used (deliberate self harm of forearms 90%, thighs 26.7%, legs 16.7%, chest 10%, belly 10%, hands 6.9%, face 6.9%, arms 6.7%, and feet 3.3%). Addictive disorders, such as substance abuse (tobacco 46.7%; alcohol 23.3%; illicit drugs 16.7% mostly cannabis or cocaine) and eating disorders (33.3% and among them 50% of cases were restrictive anorexia nervosa) were often associated with a deliberate self harm syndrome. Three psychiatric diagnoses were often observed in our cohort: depressive disorder 36.7%; personality disorder 20%; psychosis 10% and depressive disorder associated with personality disorder 33.3%. In our sample, psychotic patients differed on several clinical aspects: the atypical location (abdomen, nails) and method (needles) of self-mutilating behaviour. None of them had been abused during childhood and none was suffering from addictive disorders.

Nicotine dependence is associated with suicide attempts and self-mutilation among adolescent females.

OBJECTIVE: There are no studies investigating the degree of nicotine dependence (ND) and suicidality among underage adolescents. Our aim was to investigate the relationship between ND and various forms of suicidal behavior among adolescent psychiatric inpatients in Finland. METHODS: Data were collected from 508 patients (age, 12-17 years) admitted to inpatient psychiatric hospitalization between April 2001 and March 2006. The level of ND was assessed by the modified Fagerström Tolerance Questionnaire. Information on adolescents' suicide attempts and self-mutilation as well as psychiatric Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, diagnoses was obtained by using the Schedule for Affective Disorder and Schizophrenia for School-Age Children. RESULTS: After adjusting for adolescents' age and psychiatric diagnoses, a more than 4-fold risk for suicide attempts (odds ratio [OR], 4.7; 95% confidence interval [CI], 1.3-17.2) and self-mutilative behavior (OR, 4.5; 95% CI, 1.6-13.3) was found among female adolescents with a high level of ND compared to nonsmoking adolescent females. In addition, the risk for suicide attempts was only increased by a high level of ND, whereas the risk for self-mutilation was increased among females with mild ND as well. Among males, the level of ND was not associated with suicide attempts or self-mutilative behavior. CONCLUSIONS: The level of ND should be taken into account when evaluating adolescent suicidality. Further sex-specific studies with accurate measurements of nicotine and its metabolites in relation to various suicidal and self-destructive behaviors are needed.

Periocular dermatitis artefacta in a child.

Dermatitis artifacta is a factitious dermatological disorder with many forms of presentation in any part of the body. It is commonly documented in dermatological cases but rarely presented as an ophthalmic condition. The diagnosis of dermatitis artifacta is often concluded after rigorous and repeated investigation. Histological sampling of skin lesions is usually required in these cases to exclude masquerading skin lesions such as basal cell carcinoma, vasculitis, or herpetic skin lesions.

The unbreakable bladder stone--Munchhausen's tale.

A wide range of intra-vesical foreign bodies have been described in the literature. Causes include iatrogenic, migration from adjacent organs, penetrating injuries and self-insertion, either due to eroticism, inquisitiveness or as a result of a psychiatric illness. We present an unusual case of fictitious bladder stones that proved unbreakable using all standard endourological techniques.

Self-inflicted garlic burns: our experience and literature review.

BACKGROUND: Throughout history, garlic has been used to treat a large variety of illnesses. One of garlic's adverse local effects is contact dermatitis. METHODS: We present three patients treated in the Department of Plastic Surgery for suspected self-inflicted lower extremity burns. RESULTS: The burns had unique features, not consistent with the etiology first claimed by the patients. All were soldiers with low motivation who confessed to using garlic to cause the burns. CONCLUSIONS: Garlic application usually results in local inflammation, but, if applied under a pressure bandage, or if there is poor wound care or a secondary infection, it can cause a severe dermal reaction and a deep chemical burn. We present these cases to increase physician awareness of the characteristics of self-inflicted garlic burns, and review the dermatotoxic effect.

Self-amputation of a healthy hand: a case of body integrity identity disorder.

A case report is presented of self-amputation of a healthy hand. We have reviewed the literature and seek to broaden the scope of understanding of Body Integrity Identity Disorder. This rare condition can constitute a pitfall for the unsuspecting hand surgeon.

Reported childhood onset of self-mutilation among borderline patients.

The purpose of this study was to determine the percentage of borderline patients who first engaged in self-mutilation as children and to compare the parameters of their self-harm to those of borderline patients who first harmed themselves at an older age. Two hundred and ninety inpatients meeting both Revised Diagnostic Interview for Borderlines (DIB-R; Zanarini, Gunderson, Frankenburg, & Chauncey, 1989) and Diagnostic and Statistical Manual of Mental Disorders (3rd ed. ref.) (DSM-III-R; APA, 1987) criteria for borderline personality disorder were interviewed about their history of self-mutilation. Of the 91% with a history of self mutilation, 32.8% reported first harming themselves as children (12 years of age or younger), 30.2% as adolescents (13-17 years of age), and 37% as adults (18 or older). Using logistic regression analyses and controlling for baseline age, it was found that those with a childhood onset reported more episodes of self-harm, a longer duration of self-harm, and a greater number of methods of self-harm than either those with an adolescent or adult onset to their self-mutilation. The results of this study suggest that a sizable minority of borderline patients first engage in self-harm as children and that the course of their self-mutilation may be particularly malignant.