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CNS Spectr. 2008;13(4):273-274
Faculty Affiliations and Disclosures
Dr. Giusti is clinical researcher at the Impulse Control Disorder Unit in the Department of Psychiatry, Faculty of Medicine, University of São Paulo in Brazil. Dr. Tavares is the coordinator of the Impulse Control Disorder Unit in the Department of Psychiatry, Faculty of Medicine, University of São Paulo. Dr. Miquel is associate professor in the Department of Psychiatry at the University of São Paulo Medical School. Dr. Scivoletto is professor at Post-Graduation Course of Department of Psychiatry, Faculty of Medicine, at the University of São Paulo and chief of Adolescent Outpatient Unit at Institute of Psychiatry from Hospital das Clinicas, Faculty of Medicine from University of São Paulo.
Disclosure: This study was supported by grants from the FAPESP (Foundation for the Support of Research in the State of São Paulo), n. 2005/55628-8.
Communique
March 4, 2008
To the Editor:
Self-mutilation behaviors (SMBs) are becoming increasingly more frequent, especially among youths, causing considerable suffering.1 In a similar manner with obsessive-compulsive disorder (OCD) patients with SMB report previous intolerable affects followed by short-lived emotional relief after they hurt themselves, despite ashamed feelings and attempts to hide the injuries.2 Conversely, sometimes the same patients describe self-mutilation as an irresistible urge when under a stressful situation, hinting impulsive traits. Later, some of them realize they cause a great impact on friends and relatives and begin to use self-mutilation to manipulate others, in a similar way as patients with borderline personality disorder (BPD). SMB is considered under one of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition3 criteria for BPD. SMB seems to play different roles among the impulsive-compulsive spectrum of behaviors and, until now, SMB has not a defined classification as a symptom of psychiatry disorder or a nosological entity.
In order to achieve a deeper knowledge of the characteristics of those patients with SMB, five patients who sought treatment primarily due to SMB were assessed and compared to five patients with primary OCD. The internal ethics committee of the Department and Institute of Psychiatry—School of Medicine—University of Sao Paulo approved this study. Informed consent was obtained from each patient and the patients were compared regarding clinical and demographic characteristics. The following instruments were administered: Yale-Brown Obsessive-Compulsive Scale, University of São Paulo Sensory Phenomena Scale,4 Functional Assessment of Self-Mutilation,5 Structured Clinical Interview for DSM-IV Axis I Disorders-patient edition, Structured Clinical Interview for DSM-IV Axis II Disorders-Patient Edition (SCID II/P),6 only the questions about BPD,7 and Barratt Impulsiveness Scale.8
SMBs were deliberate infliction with predicted consequences without aesthetic or suicidal intentions, resulting in relief of bad feelings, and patients report mild or no pain associated to the behavior. They were also ashamed of the scars and spent some time planning the act, especially when surveillance of relatives and friends had to be circumvented. The most frequent behaviors found in this population were skin cutting (80%), beating (60%) and biting oneself (60%), most presented with more than one kind of SMB (80%). The most frequent reasons for self-mutilating were: to relief sensations of “emptiness” or indifference (80%); “to punish themselves” (80%), “to feel relaxed” (80%) and “to avoid bad feelings or sensations” (80%). There were no differences between groups regarding demographics.
We found that all patients who self-mutilated also presented OCD and reported sensory phenomena (mental and physical subjective sensations associated to repetitive behaviors) preceding their SMB. No patients in both groups presented diagnostic criteria for BPD according to the SCIDII/P. The Table shows the main results found through the comparison of both groups.
The sample size does not allow generalizations, studies involving larger populations are necessary to confirm these findings. However, it was possible to observe that SMB patients present symptoms of impulsivity and compulsivity, observed through the comorbidities with others impulsive-control disorders and OCD, respectively. Different from previous studies, association between SMB and BPD was not observed.
Would self-mutilation presented by these patients be a symptom of the OCD or a related nosological entity with its own characteristics? Or would the association between these disorders be a coincidence determined by selection bias? Therefore, future studies investigating the relationship between patients with SMB and the patients with OCD are warranted.
Sincerely,
Jackeline Suzie Giusti, MD
Hermano Tavares, MD, PhD
Eurípides C Miguel, MD, PhD
Sandra Scivoletto, MD, PhD
References
1. Nock MK, Prinstein MJ. Contextual features and behavioral functions of self-mutilation among adolescents. J Abnorm Psychol. 2005;114:140-146.
2. Favazza A. Self-injurious behavior in college students. Pediatrics. 2006;117: 2283-2284.
3. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Press; 1994.
4. Rosário-Campos MC, Prado HS, Shavitt RG, et al. University of São Paulo Sensory Phenomena Scale (USP-SPS), 10th version. In: Miguel EC, Rosario-Campos MC, Mathis ME, et al, eds. First Assessment Interview (APA) From OCD Spectrum Disorder Project. 2007;44-51.
5. Lloyd EE, Kelley ML, Hope T. Self-mutilation in a community sample of adolescents descriptive characteristics and provisional prevalence rates. Poster presented at: Annual Meeting of the Society for Behavioral Medicine. New Orleans, La; 1997.
5. First MB, Spitzer RL, Gibbon M, Williams JBW. Structured Clinical Interview for DSM-IV-TR Axis I Disorders, Research Version, Patient Edition. (SCID-I/P). New York, NY: Biometrics Research, New York State Psychiatric Institute; 2002.
6. First MB, Spitzer RL, Gibbon M, Williams JBW. Structured Clinical Interview for DSM-IV Personality Disorders. Washington, DC: American Psychiatric Press, Inc.; 1997.
8. Patton JH, Stanford MS, Barrat ES. Factor structure of the Barratt Impulsiveness scale. J Clin Psychol. 1995;51:768-774.
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