Self mutilation disorder

Self mutilation disorder is a common problem amongst people with psychiatric illnesses. Self mutilation is not actually classified as a disorder in its own right - it usual forms a symptom of a psychiatric illness. (For the sake of my SEO I'll refer to it as a disorder.) Recently, an Italian man gouged his eyes out whilst attending a church service. It was reported that he stood up during mass in front of ther congregation and proceded to rip out both his eyes. The man, Aldo Bianchini, said that he was instructed by voices telling him to do this.

This happened in the Italian town of Viareggio in Northern Tuscany, but it could happen anywhere in the world. Self mutilation disorder can be part of many psychiatric disorders. These include schizophrenia, bipolar disorder, major depressive disorder, obsessive compulsive disorder, body dysmorphic disorder and personality disorder, post traumatic stress disorder, and epilepsy. I'm sure this is not an exhaustive list.

The commonest form of self mutilation, which is seen multiple times a day all ove the world is cutting. This involves cutting one's skin with a knife, or any sharp instrument eg piece of glass, scissor even a paper clip.

What are the reasons for self mutilation disorder.

Probably the commonest association with self mutilation is someone who is suffering from borderline personality disorder. The cutting usually is a dysfunctional mechanism for coping with painful and uncomfortable emotions. It is less likely to be a suicide attempt.

In schizophrenia self mutilation usually occurs in response to command hallucinations, which are voices instructing the person to hurt themselves. They then do it because they feel compelled to do it, or they do it out of desperation just to get the voices to stop. It can also serve as a means of distraction from the voices or, as with the borderline patient, it is a dysfunctional way of dealing with uncomfortable emotions. Schizophrenia patients might also hold delusional beliefs that for some or other reason, they NEED to self mutilate - eg God wants them to do it, or they need to do it to prevent something awful from happening, or they need to do it because they are bad. There are any number of wrongful beliefs which might lead them to self mutilate.

Similarly to schizophrenia, drug-induced psychosis can also lead to self harming. Often self mutilation can result from somatic delusions and can result in patients self mutilating in an attempt to extract something out from under their skin.

In depressive disorder, self harming is usually due to an attempt to self regulate dysphoric (unhappy) moods - similar to the borderline patient. It can also be a suicide attempt. It can be due the patient holding a nihilistic delusional, which is a belief that something bad has or will happen. eg the belief that their eyes are those of the devel, and therefore that it needs to be removed.

Self injurious behaviour can also occur in the context of a dementing illness and factitious disorder.

Autoenucleation

Autoenucleation is a particularly severe form of self mutilation disorder - it is the self removal of one's eye. One would think that the extreme pain would inhibit such an extreme degree of self mutilation, but incredibly, it does occur. Autoenucleation was first described in the medical literature in 1846 and was termed "Oedipism", which referred to Sophocle's Oedipus who self enucleated both his eyes ondiscovering that he had unwittingly murdered his father and married his mother. The prevalence rate is thought to be up to 4 per 100,000 people, and it occurs at the same rate in both sexes.

Autoenucleation is often associated with religeous and sexual delusions. Patients often make references to sin, guilt, evil and atonement as reasons for the self mutilation. Bilateral autoenucleation or self enucleation is not uncommon amongst schizophrenia patients.

But what about the pain?

An increased pain threshold, or perhaps a reduced pain perception, has been reported in schizophrenia patients on numerous occasions. This phenomenon has however not been vigorously investigated in the past. Neurophysiological tests have shown that there is sometimes an altered perception of pain in the pain processing regions of the brain in schizophrenia patients, which results in a greater pain tolerance. This effect can not be ascribed to the antipsychotic medications.

Various mechanisms for this increased pain threshold have been suggested.

  • An alteration in the pain receptors at a chemical level ie a change in the synthesis of the chemicals which allow the pain receptors to communicate with the nervous system
  • Abnormalities in the processing of information in the brain
  • A decrease in the behavioural expression of pain ie they feel the pain but do not express it as non-schizophrenia people.

The increased pain threshold is however a significant risk factor for self mutilation disorder and injuries. Pain has an important physiological function ie it protects the body against injury, and allows the detection of some physical conditions. Without this protective function, there may be delays in the diagnosis and treatment of diseases which could lead to higher mortality, morbidity and distress in the shizophrenia patient.

Treatment for self mutilation disorder starts with the recognition that this is always possible in someone who is acutely psychotic. Therefore diagnosis and treatment of the underlying disorder is the most important form of prevention. Even once patients are in hospital, nursing staff should remain vigilant for any type of self injurious behaviour. And once dischraged, regular monitoring of compliance and mental state is crucial.





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