Klingsor Syndrome: Genital Self-Mutilation in a Psychotic Patient. / Klingsor Sendromu: Psikotik Hastada Genital Self Mutilasyon.

Self-mutilation attempts are common in psychiatric practice. One form of self-harm, genital self-mutilation (GSM), is less common but may have severe consequences. GSM acts can occur in different diagnoses such as personality disorders, substance abuse disorders, obsessive-compulsive disorders, and psychotic disorders. When GSM is performed due to psychotic symptoms, the clinical picture is called Klingsor Syndrome. GSM is often associated with severe psychosis and often accompanied by religious delusions. In our article, we discussed a case of schizophrenia with penile autoamputation due to religious delusions. A 28-year-old male patient was admitted to our hospital after penile autoamputation. After surgical interventions, the patient's follow-up continued in our clinic. The patient had auditory hallucinations, delusions of persecution, and sinfulness. His symptoms improved after antipsychotic treatment. It is important to identify the risk factors of Klingsor Syndrome, which is a rare but serious condition, and to intervene early in these patients. Keywords: Self-mutilation, Psychosis, Self-injurious Behavior.

Genital Mutilation in Males.

PURPOSE OF THE REVIEW: Genital mutilation in males can range from minor injuries (cuts from a blade) to severe urological emergencies (testicular or penile amputation). Due to the rarity of these events, there is a lack of extensive reports, as most of the available literature is regarding single cases. Genital mutilation has been associated with psychotic and non-psychotic causes, psychiatric conditions, drug consumption, sexual practices, or even cultural or religious beliefs. It is crucial to perform a psychiatric evaluation of these patients to obtain the best therapeutic approach. This manuscript serves as a review of the currently available knowledge regarding male genital mutilation. RECENT FINDINGS: A great variety of reasons have been associated with genital mutilation. Previous authors have distinguished between those that present with a clear mental health precursor from cases with no psychotic background. Nevertheless, sometimes, it is difficult to make this distinction. Recently, reconstructive techniques for amputation cases have moved towards a microsurgical approach in order to improve outcomes. A holistic therapeutic approach must be performed to increase the chances of effective treatment. Close collaboration between urologists, psychiatrists, and emergency doctors is essential to ensure the best care for patients performing genital mutilation. Future publications must evaluate differences in treatment options and the impact that these have on the long-term well-being of patients undergoing genital self-mutilation.

[Tear your eyes out ! A case of bilateral auto-enucleation]. / «Arrache-toi les yeux !¼ À propos d'un cas d'auto-énucléation bilatérale.

Bilateral autoenucleation is an extremely rare form of ocular self-mutilation. This gesture usually occurs in psychotic patients. In a moment of madness, a 28-year-old man brutally tore out both of his eyes. He was in acute relapse of schizophrenia after having interrupted all neuroleptic treatment for 6 months. Four days after admission, surgical enucleation was the only possible outcome. Facing the complexity of this clinical case, the ophthalmologist has a central role in the organization of long-term surgical, neurological and psychiatric care.

L'auto-énucléation bilatérale est une forme d'automutilation oculaire rarissime. Ce geste est observé presque toujours chez des patients psychotiques. Dans un moment de folie, un homme de 28 ans, s'est brutalement arraché les deux yeux. Il se trouvait en rechute aiguë de schizophrénie après avoir interrompu tout traitement neuroleptique depuis 6 mois. Quatre jours après son admission, l'énucléation chirurgicale fut la seule issue possible. Face à la complexité de ce cas clinique, l'ophtalmologue aura un rôle central dans l'organisation des soins chirurgicaux, neurologiques et psychiatriques au long cours.

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.

Rudy and Borden technique for penile self-mutilation in Klingsor syndrome: a case report.

Penile self-mutilation is a challenging situation that often jeopardizes sexual and voiding functions. Surgical treatment is currently based on penile replantation, nevertheless its requirements of time, conservation, and quality of amputated phallus and microsurgical expertise are not constantly available. Here, we present a case of penile self-inflicted amputation in a 28-years-old patient suffering from a psychotic disorder, who did not preserve the amputated phallus. In the first clinical examination, we have attested a hemorrhagic total penile section, 6cm from the penoscrotal angle. We performed immediate surgical management. Rudy and Borden technique is a reconstructive surgery procedure with interesting functional results, by performing a dorsal vascularized split-thickness skin flap to cover the penile shaft. The aim of this technique is to avoid perineostomy which compounds significantly the quality of life.

Self-inflicted injuries: The intersection of mental health and traumatic injury in Malawi.

Self-inflicted injury, the most common form of intentional injury, disproportionately affects low-income countries, but is poorly described in this setting. This retrospective review of the 2008-2018 trauma registry at a referral hospital in Malawi included all victims of intentional injury ≥10 years. Self-inflicted injuries were compared to assaults. The primary outcome was in-hospital mortality. Common mechanisms of self-inflicted injuries were fall from height, poisoning, and penetrating injury. In-hospital mortality from self-inflicted injury was 8.8% vs. 1.9% for assault. Those who died from self-inflicted injury were more often older (median 34 vs. 26 years, p < 0.001), male (91.9% vs. 67.8%, p < 0.001), unemployed (32.8% vs. 6.4%, p < 0.001), and most commonly died by hanging (60%). The odds of in-hospital mortality after self-inflicted injury was four times assault (OR 4.0 [95% CI 1.4-11.5], p = 0.01). The trauma registry proved useful for describing self-inflicted injury in this setting.

Automutilações na adolescência: reflexões sobre o corpo e o tempo / Automutilaciones en la adolescência: reflexiones sobre el cuerpo y el tiempo / Self-mutilations in adolescents: reflections on the body and time / Les automutilations à l'adolescence: réflexions sur le corps et le temps

O objetivo deste artigo é analisar o fenômeno das automutilações na adolescência a partir da articulação do registro do corpo à dimensão arcaica do tempo. As automutilações se caracterizam pelo ato de ferir o próprio corpo voluntariamente, sem intenção consciente de morte. É através do corpo que se manifesta um sofrimento que ultrapassa os limites psíquicos do sujeito, encontrando uma via de expressão radical daquilo que o faz sofrer. O caráter radical desta resposta aponta para a complexidade dos primórdios da constituição psíquica. Neste cenário, propõe-se compreender as automutilações na adolescência como uma via atual através da qual algumas vivências da ordem do arcaico se apresentariam. Elas conjugariam, em um curto-circuito do tempo, passado e presente, abrindo caminhos para a ressignificação de vivências irrepresentáveis.

El objetivo de este artículo es analizar el fenómeno de las automutilaciones en la adolescencia a partir de la articulación entre el registro corporal y la dimensión arcaica del tiempo. Las automutilaciones se caracterizan por el acto de lesionar voluntariamente el propio cuerpo, sin intención consciente de muerte. Es a través del cuerpo que se manifiesta el sufrimiento que traspasa los límites psíquicos del sujeto, encontrando una forma de expresión radical de lo que le hace sufrir. El carácter radical de esta respuesta apunta a la complejidad de los inicios de la constitución psíquica. En este escenario, se propone entender las automutilaciones en la adolescencia como una ruta actual por la que se presentarían algunas experiencias del orden de lo arcaico. Combinarían, en un corto circuito de tiempo, pasado y presente, abriendo caminos para la reformulación de experiencias irrepresentables.

The aim of this article is to analyze the phenomenon of self-mutilations in adolescents proposing an articulation between the body and the archaic dimension of time. Self-mutilations are characterized by the act of voluntarily injuring one's own body, with no conscious intention of death. The body manifests suffering that goes beyond psychic limits, finding a radical way to express what makes him suffer. This radical answer shows the complexity of the beginnings of the psychic constitution. In this scenario, self-mutilations in adolescents are understood as a current route through which some archaic experiences present themselves. The self-mutilations combine, in a short circuit of time, past and present, opening new paths for the reformulation of unrepresentable experiences.

Le but de cet article est d'analyser le phénomène de les automutilations à l'adolescence à partir d'une articulation entre le registre corporel et la dimension archaïque du temps. Les automutilations sont définies comme un dommage intentionnellement auto-infligé à une partie de son propre corps, sans l'intention consciente de se donner la mort. C'est à travers du corps que se manifeste la souffrance qui dépasse les limites psychiques du sujet, en trouvant un moyen d'expression radicale de ce qui le fait souffrir. Le caractère radical de cette réponse indique la complexité des débuts de la constitution psychique. Dans ce scénario, il est proposé de comprendre les automutilations à l'adolescence comme un moyen actuel par lequel certaines expériences de l'ordre de l'archaïque se présenteraient. Elles conjugueraient, dans un court circuit du temps, passé et présent, ouvrant des chemins à la redéfinition d'expériences irreprésentables.

A Case of Self-Cannibalism: An Extremely Rare Type of Self-Mutilation With Multiple Risk Factors.

ABSTRACT: Self-mutilation is a behavior often associated with various psychiatric diseases, and it has various risk factors. Self-cannibalism, an extremely rare form of self-mutilation, can also be observed in the absence of psychosis and substance abuse. This study reports a case of self-cannibalism with multiple risk factors including history of substance use, previous self-mutilation actions, suicidal attempts, antisocial personality disorder, imprisonment, and active symptoms associated with untreated schizophrenia.

Suicidality and self-injurious behavior among adolescent social media users at psychiatric hospitalization.

BACKGROUND: The current study sought to examine the relationship between documented social media use and suicidality and self-injurious behaviors in adolescents at the time of psychiatric hospitalization. METHODS: We retrospectively identified adolescents (aged 12-17 years) hospitalized on an inpatient psychiatric unit during 1 year. Abstracted information included documented social media use, demographic variables, documented self-injurious behaviors, the Patient Health Questionnaire-9, and the Suicide Status Form-II. Logistic regression was implemented to examine the effect of social media use on the risk of self-injurious behaviors and suicidality. RESULTS: Fifty-six adolescents who used social media were identified and matched with 56 non-social media users. Those with reported social media use had significantly greater odds of self-injurious behaviors at admission (odds ratio, 2.55; 95% confidence intervals, 1.17-5.71; P = .02) vs youth without reported social media use. Adolescents with reported social media use also had greater odds of increased suicidal ideation and suicide risk than those with no reported use, but these relationships were not statistically significant. CONCLUSIONS: Social media use in adolescents with a psychiatric admission may be associated with the risk of self-injurious behaviors and could be a marker of impulsivity. Further work should guide the assessment of social media use as part of a routine adolescent psychiatric history.

WebPalestra: suicídio na infância e adolescência, do que estamos falando?

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[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.

Early maladaptive schemas as common and specific predictors of skin picking subtypes.

BACKGROUND: Three distinct subtypes of Skin Picking (SP) have been identified in previous research: Focused, Automatic and Mixed. Early Maladaptive Schemas (EMS) were not investigated across the subtypes. Understanding which EMS are associated with the subtypes might suggest the evaluation of Schema Therapy for SP and guide clinicians using it according to subtypes. The current study explored the relationship between EMS and SP subtypes in community adults. METHODS: Five hundred ninety-six adults [mean age = 35.23 years, 66% females] self-reporting SP behaviours completed the Milwaukee Inventory for Dimensions of Adult Skin Picking and the Young Schema Questionnaire-Long form third version (YSQ-L3). RESULTS: Higher Dependence/Incompetence EMS was a common predictor of both Focused and Automatic subtypes, while lower Emotional Deprivation EMS and younger age predicted all three subtypes. Higher Approval/Recognition Seeking, Mistrust/Abuse and Failure to Achieve were specific predictors of Automatic, Focused and Mixed subtypes, respectively. Lower Social Isolation/Alienation and Enmeshment/Undeveloped Self were specific predictors of Focused subtype. Male gender was a specific predictor of Mixed subtype. CONCLUSIONS: The assessment and psychological treatment of individuals with SP behaviour may focus on specific EMS. Future longitudinal studies using clinical samples may clarify this association.

Dez anos de um CAPSi: comparação da caracterização de usuários atendidos / 10 years of CAPSi: comparing the characterization of users served / 10 ans dune CAPSi: comparaison de la caractérisation des utilisateurs du service / 10 años de un CAPSi: comparación de la caracterización de los usuarios atendidos

Resumo Estudo retrospectivo de caráter descritivo. Por meio de coleta em prontuários, objetivou-se caracterizar crianças e adolescentes atendidos em um Centro de Atenção Psicossocial Infantojuvenil (CAPSi) durante seu décimo ano de funcionamento e comparar com estudo análogo realizado no primeiro ano de funcionamento. Os dados foram analisados com auxílio dos softwares SPSS e Iramuteq. Identificou-se aumento de 51,85% ( n = 84 ) da demanda em relação ao primeiro ano. Observou-se aumento de usuários de sexo feminino, cuja marca foram queixas de automutilação. Manteve-se prevalência de usuários do sexo masculino, cuja marca foram problemas de comportamento, como agressividade e hiperatividade. Discute-se, neste estudo, as articulações entre CAPSi e demais serviços da Rede de Atenção Psicossocial (RAPS), especialmente acerca dos encaminhamentos. Também se discute sobre a medicalização sem registro de hipótese diagnóstica e os desafios de se exercer a clínica ampliada e a lógica do trabalho psicossocial, a qual se opõe ao paradigma exclusivamente biomédico, simplificador dos fenômenos do desenvolvimento infantil.

Abstract This descriptive retrospective study used medical records to characterize children and adolescents cared in a CAPSi during their tenth year of operation and to compare with an analogous study carried out in the first year of operation. Data were analyzed using SPSS and IRaMuTeQ. There was an increase of 51.85% ( n = 84 ) in demand compared to the first year. There was an increase in female users, whose complaints concerned self-mutilation. However, the prevalence of male users remained, whose complaints concerned behavioral issues such as aggression and hyperactivity. In this study, we discuss the articulations between CAPSi and other services of the Psychosocial Care Network, especially regarding referrals. It also discusses medicalization without record of prognosis and the challenges of exercising the "expanded clinical" practice and the logic of psychosocial work, which opposes the exclusively biomedical paradigm, simplifying the phenomena of child development.

Résumé Une étude rétrospective descriptive. L'objectif c'était de caractériser les enfants et adolescents traités dans une CAPSi au cours de leur dixième année d'activité et faire la comparaison avec l'étude analogue réalisée au long de la première année. Les données ont été analysées à l'aide des logiciels SPSS et IRaMuTeQ. Il a été identifié une augmentation de 51,85% ( n = 84 ) de la demande par rapport à la première année. Il y a eu une augmentation du nombre d'utilisateurs du sexe féminin, dont la marque était des plaintes d'automutilation. Cependant, la prévalence des utilisateurs du sexe masculin est restée, dont la marque était des problèmes de comportement, comme l'agressivité et l'hyperactivité. Dans cette étude, nous discutons des questions relatives aux articulations entre le CAPSi et les autres services du réseau de soins psychosociaux, particulièrement en ce qui concerne les renvois. Il aborde également la médicalisation sans enregistrement d'hypothèses diagnostiques et les défis de l'exercice de la "clinique élargie" et à la logique psychosocial, qui s'oppose au paradigme exclusivement biomédical simplifiant les phénomènes de développement de l'enfant.

Resumen Estudio retrospectivo, de carácter descriptivo. Por medio de recolección de datos en historiales, se objetivó caracterizar a niños y adolescentes atendidos en un CAPSi durante su décimo año de funcionamiento, y comparar los datos con un estudio análogo realizado en su primer año de funcionamiento. Para el análisis de datos, se utilizó los softwares SPSS e Iramuteq. Se identificó un aumento del 51,85% ( n = 84 ) de la demanda en relación al primer año. Se observó un aumento de usuarios del sexo femenino, cuya marca fueron quejas de automutilación. Sin embargo, se mantuvo la prevalencia de usuarios del sexo masculino, cuya marca fueron problemas de comportamiento, como agresividad e hiperactividad. En este estudio, se discuten las articulaciones entre CAPSi y otros servicios de la Red de Atención Psicosocial, especialmente sobre las remisiones. También se discute la medicalización sin registro de hipótesis diagnósticas y los desafíos de ejercer la clínica extendida y la lógica del trabajo psicosocial, que se opone al paradigma exclusivamente biomédico simplificador de los fenómenos del desarrollo infantil.

Emozioni, comportamenti e relazioni: uno studio caso-controllo sul self-cutting in adolescenza.

Scopo. Lo scopo del presente studio caso-controllo è di approfondire i correlati psicopatologici e alcuni tratti psicologici come alessitimia e impulsività inerenti al self-cutting. È stato anche approfondito il tema dell'ideazione suicidaria nei soggetti con tale forma di autolesionismo. Metodi. Lo studio caso-controllo ha coinvolto 55 pazienti con self-cutting non suicidario, di età compresa tra i 12 e i 18 anni, e un gruppo di controllo composto da 277 adolescenti di età compresa tra i 13 e i 19 anni. La batteria testale utilizzata è stata composta da YSR 11-18 anni, CBCL 6-18 anni, SCL-90-R, TAS-20, CDI e BIS-11. Risultati. Dalle analisi effettuate sono emerse differenze statisticamente significative tra casi e controlli in relazione alla maggioranza delle scale psicopatologiche considerate. È risultata una differenza significativa tra i due gruppi anche in merito all'ideazione suicidaria. Infine, tra i self-cutter si sono evidenziate differenze significative di alcune variabili psico-relazionali (alessitimia e competenze sociale) in relazione alla frequenza di attuazione dell'atto autolesivo. Conclusioni. Il self-cutting correla con un'ampia varietà di quadri psichiatrici, senza presentare legami specifici con una particolare categoria psicopatologica. Gli elementi di alessitimia, impulsività e difficoltà relazionali degli adolescenti self-cutter dicono di come la programmazione di interventi di prevenzione primaria e secondaria dovrebbero mirare alla psico-educazione all'affettività, all'autocontrollo e ai social skill. Nello specifico, i nostri dati suggeriscono che la focalizzazione dell'intervento, in termini di lavoro sull'emotività piuttosto che sulla socializzazione, dovrebbe tener conto della frequenza degli agiti. Nella gestione clinica di questi pazienti non va esclusa a priori la possibilità di passaggio all'atto suicidario, con relative attenzioni anamnestico-cliniche da avere sia al momento della valutazione diagnostica sia lungo il follow-up della presa in carico.

Automutilações na adolescência e suas narrativas em contexto escolar / Automutilaciones en la adolescencia y sus narrativas en contexto escolar / Self-mutilation in adolescence and its narratives in school context

O artigo tem por objetivo discutir a automutilação e suas narrativas por adolescentes em contexto escolar. Trata-se de uma pesquisa que envolve a psicanálise e o campo da educação, como um trabalho possível da clínica institucional. A partir de estudos de casos de uma escola privada em Fortaleza, são discutidos os seguintes aspectos: autolesão e os efeitos na escola, conflitos socio-familiares e processo de subjetivação adolescente. Conclui-se que a partir de uma escuta qualificada na escola é possível dar voz aos adolescentes para que possam produzir um saber sobre si, e ao seu modo sustentar seu mal estar.

El artículo tiene por objetivo discutir la automutilación y sus narrativas por adolescentes en contexto escolar. Se trata de una investigación que involucra el psicoanálisis y el campo de la educación, como un trabajo posible de la clínica institucional. A partir de estudios de casos de una escuela privada en Fortaleza, se discuten los siguientes aspectos: autolesión y los efectos en la escuela, conflictos socio-familiares y proceso de subjetivación adolescente. Se concluye que a partir de una escucha cualificada en la escuela es posible dar voz a los adolescentes para que puedan producir un saber sobre sí, ya su modo sostener su malestar.

The article aims to discuss self - mutilation and its narratives by adolescents in a school context. It is a research that involves psychoanalysis and the field of education as a possible work of the institutional clinic. From the case studies of a private school in Fortaleza, the following aspects are discussed: self-harm and effects in school, socio-familial conflicts and adolescents subjectivation process. It is concluded that from a qualified listening in the school it is possible to give voice to the adolescents so that they can produce a knowledge about themselves, and in their way to sustain their malaise.

The two faces of intentional self-inflicted injury: High in-hospital mortality, low postdischarge mortality, but high readmission rates.

BACKGROUND: Intentional self-inflicted injuries present unique challenges in treatment and prevention. We hypothesized intentional self-inflicted injuries would have higher in-hospital and postdischarge mortality than nonintentional self-inflicted injuries trauma. METHODS: Adult patients evaluated 2008 to 2012 were identified in our trauma registry and matched with mortality data from the National Death Index. Intentional self-inflicted injuries were identified using E-Codes. Readmissions were identified and analyzed. Intentional self-inflicted injuries patients who died in-hospital were compared with those surviving to discharge. Univariate analysis was performed using nonparametric tests. Kaplan-Meier curves were plotted to compare mortality ≤5 years postdischarge between intentional self-inflicted injuries and non-intentional self-inflicted injuries patients. RESULTS: In the study, 8,716 patient records were evaluated with 245 (2.8%) classified as intentional self-inflicted injuries. Eighteen (7.8%) patients with intentional self-inflicted injuries had multiple admissions, compared with 352 (4.4%) patients with nonintentional self-inflicted injuries with readmissions (P = .0210). In-hospital mortality was higher for intentional self-inflicted injuries compared with patients with non-intentional self-inflicted injuries (18.7% vs 4.9%, P < .0001). Survival analysis demonstrated that patients with intentional self-inflicted injuries had significantly lower postdischarge mortality at multiple time points. CONCLUSION: Patients with intentional self-inflicted injuries trauma have high in-hospital mortality, but low postdischarge mortality. We attribute this to high lethality mechanisms but appropriate psychiatric treatment and rehabilitation. However, the high intentional self-inflicted injuries readmission rate indicates further study of intentional self-inflicted injuries follow-up is warranted. Better prevention strategies are needed to identify and intervene in patients at-risk for intentional self-inflicted injuries.

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.

Referral of patients to plastic surgeons following self-harm: Opportunities for suicide prevention.

Self-harm is a common source of referral to plastic and hand surgery services. Appropriate management of these patients is complex and includes the need for close liaison with mental health services. Self-harm is the single biggest risk factor for completed suicide, thereby increasing the risk by a factor of 66.1 This study aimed to analyse the clinical pathway and demographics of patients referred to plastic surgeons following self-harm. This 6-year retrospective series included patients referred to plastic surgeons following self-harm within the Galway University Hospital group. Patients were identified through the Hospital inpatient enquiry system, cross-referenced with data from the National Suicide Research Foundation. Data collected included demographics, psychiatric history, details of self-harm injury, admission pathway and operative intervention. Forty-nine patients were referred to plastic surgery services during the study period, accounting for 61 individual presentations. The male-to-female ratio was 26 (53%) to 23 (47%). Mean age was 40 years (range 21-95 years). Alcohol or illicit substance use was recorded in 17 of 61 (28%) presentations. Mortality from suicide occurred in 4 patients (8%). Mental health assessment was not carried out in 9 presentations (15%). Documentation of need for close or one-to-one observation was made in 11 cases (20%) and was not referred to in 43 cases (83%) following mental health assessment. This study demonstrates significant diversity in the management of this vulnerable patient group and may inform development of referral pathways to improve the safety of transfer, surgical admission and discharge of patients following self-harm, in consultation with mental health services.