Imaging Study Sheds Light on New Type of Self-Injury

Megan Brooks

September 15, 2010

September 15, 2010 — Teenagers may deliberately and often discretely cut themselves and then embed foreign objects under their skin, researchers from Nationwide Children's Hospital in Columbus, Ohio, have found.

From a database of 600 patients treated with image-guided foreign body removal, the researchers identified 11 patients (1.8%) "who didn't get these foreign bodies by accident; they embedded them themselves," senior author William E. Shiels II, DO, chairman of the Department of Radiology at Nationwide Children's Hospital and president of the Children's Radiological Institute, told Medscape Medical News.

In a study published online September 7 and appearing in the October issue of Radiology, Dr. Shiels and his colleagues report that they identified a total of 21 episodes of self-embedding behavior (SEB) in 9 girls and 2 boys between 14 and 18 years of age.

The embedded objects, including metal, glass, wood, plastic, graphite, crayon, and stone, had been present for time periods between 2 days and an unknown number of years. They were embedded in the arms, ankles, feet, hands, and neck. One patient, an 18-year-old, had self-embedded 35 objects, including staples, a comb tooth, a fork tine, a cotter pin, and nail polish, during a period of 2 years.

Ten (91%) of the 11 subjects with SEB had multiple confirmed comorbid behavioral health diagnoses, such as posttraumatic stress disorder, dissociative disorder, borderline personality disorder, bipolar disorder, and depression, the authors report. "The psychological diagnoses identified in our patient population are largely consistent with the comorbid disorders noted in association with other forms of self-injurious behavior reported in the literature," they write.

SEB is most likely an attempt to covert intense emotional pain to more acceptable physical pain, which may temporarily reconcile these emotions, Dr. Shiels and colleagues say.

"There is little empirical research" regarding the motivation for this type of nonsuicidal self-injury, but it is likely multifaceted, John V. Campo, MD, chief of child/adolescent psychiatry at Nationwide Children's Hospital, who was not involved in the study, told Medscape Medical News.

"Affected individuals describe internal motivations such as interrupting or distracting from an unpleasant feeling state (such as might be associated with a traumatic memory) or generating some 'positive' sensations (eg, 'just to feel something,' 'to feel alive')," he said.

"Social motivations are also likely in many individuals, with the [behavior] sometimes 'keeping others away from me' or, more commonly, serving a care-eliciting or communicative function ('to let people know how I feel')," Dr. Campo added.

Most Common in Girls

Other unique features of SEB include a high prevalence of girls (n = 9), a high prevalence of repetitive behavior (7 patients, 64%), and a high prevalence of suicidal ideation (10 patients, 91%), the authors note.

Although SEB usually is not a suicide attempt, Dr. Shiels and colleagues point to a recent study that found that patients who perform self-injury are 18 times more likely to commit accidental or intentional suicide.

"[SEBs] appear to be relatively rare, and it is best they remain so," said Dr. Campo.

He added that it is "especially important for professionals and the media to be aware of the risk of contagion with such behaviors, making it critical to avoid presenting [SEBs] in a dramatic, sensational, or romanticized fashion."

In the current series, the metal, graphite, glass, and dense plastic objects were successfully depicted on radiography, whereas ultrasound was required to detect (incidentally) embedded nonradiopaque objects, including wood and crayon, and to localize a stone foreign body.

Interventional pediatric radiologists removed 68 of the 76 embedded foreign objects found in the patients, with no complications. There was 1 incident of fragmentation, but all pieces were removed.

"Just as radiologists are sometimes the 'first-responders' for child abuse, we can take one look at an x-ray and say this is a self-embedding patient, call the [emergency department], mobilize the behavioral health team, and hopefully interrupt this cycle," Dr. Shiels said.

The study was supported by the Dorothy M. Bennett and Clark L. Bennett Medical Research Scholarship. Dr. Shiels and colleagues and Dr. Campo have disclosed no relevant financial relationships.

Radiology. Published online September 7, 2010.

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