Self-mutilation in antisocial personality (disorder)

Penile implants and other high risk practices in French Guiana's correctional facility: A cause for concern

Background

Prisoners in French Guiana, a French territory located in South America, have a HIV and hepatitis B prevalence of 4%. Body modifications such as penile implants, tattoos, and body piercings are common among detainees, increasing the risk of blood-borne virus transmission.

Methods

We conducted a cross-sectional randomised survey in which the primary objective was to estimate the prevalence of high risk ‘bloody practices’ (penile implants, tattoos, body piercings) in French Guiana’s only correctional facility. The secondary objective was to describe the risk factors for penile implants, the procedures and motivations for insertion, the reported complications, their risk factors and adverse impact on condom use.

Results

Of the 221 male inmates interviewed, 19% had tattoos or body piercings while incarcerated, and 68% had penile implants, of which, 85% had been inserted inside the correctional facility. Addictive behaviors such as cannabis use and alcohol addiction (positive AUDIT-C score), early age at first sexual intercourse, and the number of incarcerations correlated positively with having inserted one or more penile implants while incarcerated. In contrast, having reported previous psychiatric hospitalizations and having a high knowledge score for HIV/AIDS and sexually transmitted infections (STIs) were negatively correlated with the insertion of penile implants while incarcerated. Penile implants were inserted in poor hygienic conditions, usually using the sharp lid of a canned food container, with 18% of early complications, mostly haemorrhage and edema. Condom use was negatively impacted for 52% of men with penile implants.

Conclusions

Our results highlight the need for prevention interventions which should aim at increasing knowledge levels and at implementing comprehensive risk-reduction measures.

Possible role of a dysregulation of the endogenous opioid system in antisocial personality disorder

Around half the inmates in prison institutions have antisocial personality disorder (ASPD). A recent theory has proposed that a dysfunction of the endogenous opioid system (EOS) underlies the neurobiology of borderline personality disorder (BPD). In the present theoretical paper, based on a comprehensive database and hand search of the relevant literature, this hypothesis is extended to ASPD, which may be the predominant expression of EOS dysfunction in men, while the same pathology underlies BPD in women. According to evidence from human and animal studies, the problematic behaviours of persons with antisocial, callous, or psychopathic traits may be seen as desperate, unconscious attempts to stimulate their deficient EOS, which plays a key role in brain reward circuits. If the needs of this system are not being met, the affected persons experience dysphoric mood, discomfort, or irritability, and strive to increase binding of endogenous opioids to receptors by using the rewarding effects of aggression by exertion of physical or manipulative power on others, by abusing alcohol or substances that have the reward system as target, by creating an "endorphin rush" by self-harm, by increasing the frequency of their sexual contacts, or by impulsive actions and sensation seeking. Symptoms associated with ASPD can be treated with opioid antagonists like naltrexone, naloxone, or nalmefene.

Does unstable mood increase risk of suicide? Theory, research and practice

BACKGROUND

Suicide represents a substantial problem, with significant societal and personal impact. The identification of factors influencing suicide risk is an important step in preventing self-harming behaviour. In this article the authors explore whether emotional instability increases risk of suicide, beyond that of mood intensity.

METHOD

This article provides a summary of existing theory and indirect evidence in support of an association between emotional instability and suicidality. A systematic literature search (Embase, Medline, PsychInfo) was carried out on literature conducted up to October, 2011. Meta-analysis was used to assess the strength of the proposed association.

RESULTS

The systematic search identified 20 journal articles meeting the inclusion criteria, including retrospective questionnaire design studies and research conducted across several time-points. Meta-analysis revealed a moderate association, which remained statistically significant even when only including studies conducted over multiple time-points. This effect was attenuated, but remained significant, when controlling for study selection bias.

LIMITATIONS

Retrospective questionnaire studies failed to adequately control for mood level. Little is still currently understood about the types of emotional instability (e.g., dysoria, anxiety) most associated with suicidality.

CONCLUSIONS

Future avenues of investigation include micro- to macro-longitudinal research and the differentiation of emotion subtypes and instability metrics. Momentary assessment techniques may help to detect subtle fluctuations in mood leading to more effective and immediate intervention. Psychosocial intervention strategies for treating unstable emotions are discussed.

Clinical characteristics of self-mutilating behavior in Turkish male subjects with antisocial personality disorder: relationship to psychopathy

AIMS

The aims of this study were to determine the characteristics of self-mutilation (SM) and examine the relationship between SM and psychopathy in male subjects with antisocial personality disorder (APD).

METHODS

APD diagnosis was established by the Structured Clinical Interview for DSM-III-R Axis II Disorders. Subjects (N = 116) were assessed using the Psychopathy Checklist-Revised and a semi-structured self-mutilation questionnaire form.

RESULTS

In males with APD, the percentages of psychopathy and SM were 48.3% (N =56) and 96.6% (N = 112), respectively. There were positive correlations between severity of psychopathy and severity, number, and frequency of SM.

CONCLUSION

Considerably high rates of SM and psychopathy were found in Turkish males with APD. The features of SM were associated with comorbidity of psychopathy. These results showed the importance of exploring the self-injurious behavior and psychopathy when diagnosed with APD.

Risk factors for deliberate self-harm among female college students: the role and interaction of childhood maltreatment, emotional inexpressivity, and affect intensity/reactivity

Despite the clinical importance of deliberate self-harm, research on the risk factors for self-harm among nonclinical populations has been limited. This study examined the role of childhood maltreatment, emotional inexpressivity, and affect intensity/reactivity in the self-harm behavior of 249 female college students. Childhood maltreatment and low positive affect intensity/reactivity reliably distinguished women with frequent self-harm from women with no history of self-harm, as did the combination of greater maltreatment, greater inexpressivity, and higher levels of affect intensity/reactivity (global and negative). Among women with a history of self-harm, emotional inexpressivity was associated with more frequent self-harm, as was the combination of greater maltreatment, greater inexpressivity, and lower levels of positive affect intensity/reactivity.

Risk factors for deliberate self-harm among college students

This self-report study examined the risk factors for deliberate self-harm among college students. Results indicated that insecure attachment, childhood separation, emotional neglect, sexual abuse, and dissociation were significant predictors of self-harm. Substantial gender differences in the risk factors for self-harm behavior were also revealed. Suggestions for future research are provided.

Clinical and theoretical issues in self-injurious behavior

This article presents an overview of pathological self-injurious behavior (SIB). Historical and cultural aspects, epidemiology, classification and clinical aspects and pathogenesis are described. The importance of comprehensive assessment of symptomatology and functions of SIB for treatment planning are discussed.

The coming of age of self-mutilation

Self-mutilation (SM), the deliberate, nonsuicidal destruction of one's own body tissue, occurs in such culturally sanctioned practices as tattooing; body piercing; and healing, spiritual, and order-preserving rituals. As a symptom, it has typically been regarded as a manifestation of borderline behavior and misidentified as a suicide attempt. It has begun to attract mainstream media attention, and many more who suffer from it are expected to seek treatment. This review suggests that SM can best be understood as a morbid self-help effort providing rapid but temporary relief from feelings of depersonalization, guilt, rejection, and boredom as well as hallucinations, sexual preoccupations, and chaotic thoughts. Major SM includes infrequent acts such as eye enucleation and castration, commonly associated with psychosis and intoxication. Stereotypic SM includes such acts as head banging and self-biting most often accompanying Tourette's syndrome and severe mental retardation. Superficial/moderate SM includes compulsive acts such as trichotillomania and skin picking and such episodic acts as skin-cutting and burning, which evolve into an axis I syndrome of repetitive impulse dyscontrol with protean symptoms.

Suicidal behavior among Finnish fire setters

Histories of serious suicide attempts and slashing were investigated among Finnish fire setters. Medical and criminal records of 304 fire setters were examined to compare those who had attempted suicide with those who had not, and those who had slashed themselves with those who had not using biological, diagnostic, and demographic variables. Major mood disorders, father's alcoholism, and suicidal motive of fire setting (self-immolation) were significantly associated with suicide attempts. Paternal violent alcoholism, father's criminality, and suicidal motive of fire setting were significantly associated with slashing. Among fire setters, non-lethal slashing is a predictor of serious suicidality. Associations between psychiatric diagnoses, family history, and suicidality among fire setters are similar to those reported for suicidal patients with mood and substance abuse diagnoses. Therefore, studying fire setters, who exhibit an extremely high incidence of suicidal behavior, is an effective way to elucidate psychobiology of suicidal behaviors.

The psychopathology of incarcerated self-mutilators

OBJECTIVE

To investigate the symptomatology of severe psychopathology reported by male incarcerated self-multilators.

METHOD

Comparisons were made with a nonmutilating incarcerated group and a nonincarcerated, nonmutilator group.

RESULTS

A distinctive pattern of symptomatology emerged. Self-mutilators evidenced a wide range of elevated scores on general measures of psychological/psychiatric symptoms, particularly depression and hostility. Aspects of hostility that distinguished self-mutilators for other groups included the urge to act out hostile feelings, critical feelings towards others, paranoid feelings of hostility and guilt. Self-mutilators demonstrated substantial problems with substance abuse, particularly alcohol.

CONCLUSION

A pattern of passive-aggressive, schizoid and avoidant personality styles distinguished self-mutilators from other groups.

Belief and behavior: the role of "folk psychology" in psychiatry

Most psychiatrists assume that belief is a basis for behavior. The validity of this assumption has been challenged by certain philosophers who assign the concept belief to the domain of "folk psychology." These philosophers contend that the discoveries of neuroscience will eliminate the ideas of folk psychology from scientific discourse and that behavior will eventually be accounted for in terms of brain states. In order to examine the relationship of belief and behavior, examples of self-mutilation by normal and abnormal individuals are reviewed. It is concluded that belief is a basis for behavior and that neuroscience, like folk psychology, is valid only within certain limits.

The deliberate self-harming behaviour of patients within a British special hospital

Within more conventional discourse amongst health-care professionals, 'deliberate self-harm' is largely conceived in pejorative terms. Unlike other so-called 'pathological' behaviour for which the 'sick' are not held wholly responsible, this particular behavioural mosaic carries within its very conception quite different connotations of 'intentionality'. This project constituted a retrospective survey of the phenomenon amongst patients resident within a British special hospital, over a 6-month period, in 1987, prior to the establishment of a unit for disturbed females in November of that same year. It illustrated that the scale, and nature, of the problem was comparable to any of the other much-publicized accounts that have emerged from other custodial establishments. It is the contention, here, that patient characteristics alone are an insufficient explanation for the level of self-harm that prevails and that significant, alternative considerations are available. It is intended that this paper should contribute to the evaluation of the clients' predicament, and the institutional management of their self-harm, within an environment such as a special hospital in the hope that a clearer understanding, and strategy, may be elaborated.

Deliberate Self-Injury: Management in a Psychiatric Setting

Self-injury is a significant clinical problem of psychiatric patients, although the prevalence of self-injury in specific disorders is unclear. Nurses can assess and intervene in the psychological causes and behavioral sequelae self-injury. Each patient's early history, dynamics, and motives for self-injury require evaluation. Behavioral techniques (eg, reinforcement) and psychodynamic techniques, such as exploring feelings and anxiety, can help patients understand their self-destructive tendencies. Patients can learn to anticipate anxiety-provoking situations, plan strategies to manage anxiety, cope with feelings, and reduce self-injury.

Self-injurious behaviour and the Gilles de la Tourette syndrome: a clinical study and review of the literature

Thirty (33%) of 90 patients with the Gilles de la Tourette syndrome exhibited self-injurious behaviour. Fourteen were head bangers, of whom two had cavum septum pellucidum. Clinical correlates of self-injury were the severity of Gilles de la Tourette syndrome symptoms and psychopathology, with special reference to obsessionality and hostility. We discuss an additional patient who died from a subdural haematoma as a result of head banging, and three who had permanent vision impairment from self inflicted eye injuries.

The challenge of self-mutilation: a review

The challenge of self-mutilation among humans arises from the imprecision of much of the existing literature, as well as the countertransference such disturbing behavior mobilizes. Self-mutilation is defined as an individual's intentionally damaging a part of his or her own body apparently without a conscious intent to die. The importance of understanding this behavior is reflected in the frequency with which it is encountered among psychiatric patients, particularly those diagnosed with borderline personality disorder or schizophrenia. The distinguishing characteristics of dermal, ocular, and genital self-mutilation illustrate the diverse clinical settings in which mutilation arises. Numerous explanations with differing degrees of complexity and merit have been offered; yet, no clear consensus has emerged. Psychotherapy, behavior therapy, and chemotherapy, while controversial, remain the most compelling treatment options. Salient areas for further study include epidemiology both for specific groups and the general population, possible biologic bases for the behavior, and additional management options.

The plight of chronic self-mutilators

Self-mutilation is a more common behavior than generally realized; its prevalence may be 750 per 100,000. From the responses of 250 subjects to a Self-Harm Behavior Survey we have learned that self-mutilation typically begins in early adolescence and may assume a chronic course characterized by severe psychosocial morbidity. Some chronic self-mutilators already are heavy and generally dissatisfied users of mental health services. The number of them seeking help may increase as a result of heightened public awareness. Community mental health facilities may be hard-pressed to meet the needs and demands of these clinically vexing patients.

How many psychiatric patients in prison?

The paper compares the prevalence of psychiatric morbidity amongst sentenced prisoners and in the general population. Major psychosis was no more common in the majority of studies of criminal populations. Although prisoners have a higher level of neurotic symptomatology, this was mainly found to be secondary to imprisonment itself. Long term imprisonment was not found to be a precipitant of severe psychiatric morbidity or intellectual deterioration, and prisoners adopt elaborate coping mechanisms which may themselves be protective. However, there is a higher prevalence of mentally handicapped and epileptic prisoners, and doctors in the Prison Medical Service have to cope with frequent, serious behavioural problems. Prisons appear to be a particularly important area for future psychiatric research.

Significance of tattooes in narcotic abusers

Social aspects of tattooed compared to non-tattooed narcotic addicts attending a methadone maintenance programme were investigated. It was found that those who were tattooed reported greater current social instability and a more deprived background compared to those without tattooes. None of the tattooes specifically identified the subjects as belonging to the drug scene nor could the age at which the subject was first tattooed be used to predict subsequent drug abuse. The presence of tattooes was unrelated to the current dose of methadone and to the duration of attendance on the methadone programme.

The Bridgewater 100: an analysis of admissions to a hospital for the criminally insane

One hundred admissions to a hospital for the criminally insane are reviewed. Within this sample 20% were referrals from psychiatric hospitals and 30% were transferred from prison. The remainder were referred from the courts for evaluations. In 44 cases this was for an evaluation of competency to stand trial and in 6 cases the referrals were for evaluation prior to sentencing. An analysis of the subgroups and individual cases indicates that mentally ill patients are often referred to facilities for the criminally insane because the appropriate wards do not exist within the mental health system. This exposes them to a criminal population and results in negative social labelling. A large proportion of those referred from prisons have consciously manipulated their transfer in order to do "soft time". This also confers on them future advantage by virtue of being labelled more mental than criminal. The majority of those referred for competency evaluations could easily have been assessed in a non-inpatient setting. In these cases the referral appeared to be a covent request for treatment or a legal maneuver. Methods for solving these problems are briefly discussed.

Alcoholism and antisocial personality

The picture of alcoholism in criminals with an antisocial personality was compared with criminals with other personality disorders. Fewer of those who had an antisocial personality were physically dependent on alcohol than those with other personality disorders. They considered their alcoholism to be a problem and behaved as if it were only rare. However, they had a strong tendency to behave abnormally under the influence of alcohol over and over again. In these respects the situation among those who were below the age of 20 was similar. To a great extent, the fathers of those who had an antisocial personality had also had a tendency towards abnormal behavior under the influence of alcohol. This was not so often found in the control group.

WAIS performances in antisocial personality (disorder)

In the present study, the WAIS performances of subjects with antisocial personality disorder were compared with the performances of controls, who had other personality disorders and had usually only occasional criminality. It appeared that in all subtests the age-scaled scores of the controls were higher than those of the subjects. Statistically significant differences emerged in subtests Information, Comprehension and Arithmetic of the Verbal Scale, and in the picture Completion subtest of the Performance Scale, as well as in the Verbal, Performance and Total IQ. In the light of these results, one fundamental feature in antisocial personality could be the lack of general interest and intellectual curiosity, which is probably associated with a poor ability to "feel" (inadequacy of feelings of pleasure) in those predisposed to antisocial personality.