Self amputation of the female breast

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					                                                                                                   CASE              REPORT

PHILIP          M. COONS,                    M.D.

HAYA        ASCHER-SVANUM,                                    Ph.D.

KIRK        BELLIS,              DO.

S elf- amputation
of the female                                                                                      breast
The     incidence             of self-mutilation                  in psychiatric               populations             committed        suicide. Subsequently,                the patient drank heavily
has been reported’        to range from rare to 40%. Self-mutilat-                                                     and was unableto              work. A year later she was hospitalized                    af-
ing behavior     includes    wrist-cutting, eye enucleation,       ampu-                                               ter becoming           drunk and combative.                She was treated for a
tation  of digits or ears, skin carving,       biting,    burning,    and                                              schizophreniform              illness, which consisted               of symptoms           of
                                                                                                                       withdrawal,        hostility,      paranoia,     and auditory          hallucinations.
genital        mutilation.       Self-mutilation                     of the sexual and repro-
                                                                                                                       Following       discharge           she stopped         hen medication,            contin-
ductive        organs      is quite unusual.                     Only 53 cases in men as of
                                                                                                                       ued to drink heavily, became                   increasingly         hostile, and was
19792       and only           four       cases            in women        have       been      reported        in
                                                                                                                       unable to support              herself without being subsidized                     by her
the United States                  and England.36                 This is the first case               report
                                                                                                                       parents and a male friend.
of self-amputation                   of the female               breast.                                                   Although      surgeons           were able to reattach            her breast, she
                                                                                                                       refused further reconstructive                   procedures.          Eventually        she
Case report                                                                                                            admitted       propositioning            her landlord        immediately          prior to
A 31 -year-old       pregnant       woman was hospitalized          after hay-                                         the amputation,          but she refused to link the amputation                      to her
ing amputated         her right breast. Her parents had discovered                                                     landlord’s      rejection.        Under amobarbital           sodium she nemem-
her after that action naked in bed and nonchalantly                  smoking                                           bered the details of the self-amputation,                       but was lacking in
a cigarette.    Initially she confabulated          a story about an attack                                            insight.
by a male intruder.          Later saying that “It didn’t seem like me,”                                                   Initially the patient was sarcastic,                    hostile,     and evasive,
she admitted       to amputating         her breast but was amnesic          for                                       and she denied psychotic                    symptomatology.             Subsequently
removing     her clothes, the actual cutting, and the pain.                                                            she admitted         hearing command                hallucinations,         was placed
    She had developed            normally until as a high school sopho-                                                on antipsychotic            medication,        and her hostility and auditory
more she began abusing               drugs and alcohol, and her school                                                 hallucinations         ceased.         During a prenatal           examination          she
performance        deteriorated.        A brief attempt with family then-                                              experienced         a brief episode of amnesia and depersonaliza-
apy provided          little improvement        so she was placed          in a                                        tion when she was unaware of her identity or whereabouts.
boarding     school where she graduated               with average grades.                                                 Despite some improvement,                     she was unable to plan ap-
Following     a year of college,         she drifted from one temporary                                                propriately      for hen baby’s birth. During a home visit she be-
job to another,          drank heavily,     and was promiscuous.           She                                         came highly intoxicated                   and subsequently              failed to gain
was raped and also had two abortions.                  There was no family                                             weightduning          the lasttwo months of gestation.                   Following      de-
history of emotional          disorder.    Her parents were profession-                                                livery she was unable to bond with or care for hen infant. She
als and her older siblings were successful.                                                                            resisted      suggestions             about    infant care and during                  one
   Two years prior to the self-amputation,                 a boyfriend     had                                         chaperoned          visit pulled out part of the baby’s eyebrow.                        The
                                                                                                                       infant was subsequently                 placed in a foster home. The patient
From     the     departnent              of psychiatry,          Indiana          University       School of           repeatedly       engaged           in drinking     sprees while away from the
Medicine.         Reprint         requests          to Philip     M. Coons,            M.D.,      1315 West            hospital and on one occasion                   nearly died after hen car land-
10th St.,       indianapolis,             iN 46202.                                                                    ed upside down in a stream. Hen alcoholism                           was treated with

SEPTEMBER              1986        VOL
                                #{149}      27      NO 9
                                                  #{149}                                                                                                                                                       667
Case       report

disulfuram,     which was discontinued                  following     the develop-            ity, was her only                 way        ofcoping        with      these        losses.          Conflicts
ment of confusion         and hallucinations.              She was unwilling             to   about femininity     eventually     caused   her to reject her infant.
complete      vocational        therapy      assignments          and was trans-                 Although      she was alcoholic,       she denied    drinking  at the
ferred to another         psychiatric         facility for further treatment.                 time        she amputated               her breast,          and this           was          confirmed            by
She was discharged             from that location as improved                   but un-       her        parents       and      emergency              room       personnel.                She      had       not
fortunately    committed          suicide by carbon dioxide poisoning
                                                                                              abused   drugs for years. Therefore,  blackout    owing to alco-
three months later after losing her job.
                                                                                              ho! or drugs was ruled out as a cause of amnesia.      The amne-
    Psychological       testing had been administered                     five weeks
                                                                                              sia appeared              psychogenic              because          of the following:                        ( 1) its
after the self-mutilation          episode,     since the amobarbital              sodi-
um interview had failed to provide much ofdiagnostic                            signifi-      occurrence              after     sudden         psychosocial             stress,            (2) the initial
cance. Test findings          indicated       a verbal 10 of 1 19 and no or-                  inability            to remember,               followed           by retrieval                 of memory
ganic brain dysfunction.             Personality      testing revealed          a high-       with        amobarbital            sodium,          (3) indifferent              affect         concerning
ly defensive      woman claiming            to be free of psychopathology                     the self-mutilation,                  (4) the confabulated                      story         of an attack,
and to possess         robust ego strength.               Although       the clinical         (5) the statement                 that the self-amputation                      seemed              alien,      and
scales on the Minnesota                Multiphasic        Personality        Inventory        (6) the subsequent                   episode            of amnesia            and          depersonaliza-
were not elevated,         elevation      of the Lie Scale indicated               a de-      tion.7”        Unfortunately,                 her dissociation                proved           not to be an
liberate attempt to create a favorable                   impression.
                                                                                              adequate             defense      because          she subsequently                 became             blatant-
    The results of her projective          testing revealed      an insecure,                 ly psychotic             when       stressed        with     vocational             rehabilitation.
confused,        hostile woman hiding behind a facade of normal-
                                                                                                 Among              the exceedingly               rare reports of self-mutilation      of
ity. Owing to her guardedness,                more was learned from her
                                                                                              the sexual            and reproductive               organs in women     are the follow-
omissions        than her answers on this testing. She consistently
and selectively         avoided,    blocked,     or rejected  stimuli related                 ing After an
                                                                                                     .                 altercation   with her husband,     a woman     lacerat-
to relationships         with family members          as well as sexual be-                   ed her vulva             with a razor blade.3 In another       case, a 24-year-
havior,       needs,     and fantasies.       Her responses         conveyed                  old mutilated             her vagina with a knitting     needle and hatpin in
chronic and intense conflicts             with family members,         particu-               an effort     to         produce     an abortion.4     A 29-year-old      unwed
larly her mother and sister. Overall, thefindings               indicated      in-            mother    asked            for a hysterectomy      after gouging     her vagina
adequate        sexual adjustment,        rejection of femininity,      intense               with her fingernails                    in order        to produce            spotting.’  Finally, a
self-dislike,      and poor body image.                                                       22-year-old    woman                     slashed         her vagina            and breast in an at-
                                                                                              tempt         to deal      with     psychosexual                conflicts.6
Discussion                                                                                           Self-mutilation          may occur                during psychosis    but the latter
The results         of psychological        testing   were compatible     with                is    not always       present.    Pattison               and Kahar reported     a 41% in-
our clinical        impression      of paranoid     schizophrenia.    In addi-                cidence         of psychosis   with self-mutilation.                                   ‘    They       also re-
tion   ,   they corroborated      our psychodynamic              formulation.                 ported         a 36% incidence     of substance      abuse,                                  such       as with
The patient had been unsuccessful              compared       with her moth-                  PCP, by self-mutilators.                        It would        be unwise             forus         to present
er and sister,        and had experienced        considerable        envy and                 a generalized     conclusion     for such a rare event.      However,
hostility.      Relationships     with men were characterized                   by            several reports9’    ‘ have  drawn attention   to the dissociative    or
abuse and further failure.         The rejection     by her male landlord                     depersonalized       nature of self-mutilation.                                  All noted               a high
was the culmination           of a number      of unsuccessful        relation-               incidence      of depersonalization      during                               wrist-cutting.               This
ships,     two abortions,         a rape,       and an out-of-wedlock     preg-               depersonalization                  included    numbness,      emptiness,                              “out-of-
nancy.      Amputating         her breast,       or the denial of her feminin-                body separatedness                       and loss of control.
                                                                                                                                   , ‘ ‘                                                                         0

 1 . Pattison   EM, Kahar J: The deliberate      self-harm     syndrome.    Am J      Psy-        808-810,     1973.
     chiatry 140:867-872,     1983.                                                            7. Diagnostic     and Statistical    Manua/of       Menta/Disorders,         ed 3. Washington,
 2. Greilsheimer     H, Groves JE: Male genital self-mutilation.        Arch Gen      Psy-        DC, American        Psychiatric    Association,      1980.
     chiatry 36:441 -446, 1979.                                                                8. Ables M, Schilder       P: Psychogenic        loss of personal        identity. Arch Neurol
 3. French AP, Nelson HL: Genital self-mutilation          in women. Arch Gen         Psy-        Psychiatry     34:587-604,      1935.
     chiatry 27:618-620,    1972.                                                              9. Graff H, Mallin A: The syndrome                 of the wrist cutter. Am J Psychiatry
 4. Gerstle ML, Guttmacher       AF, Brown F: A case of recurrent malingered           pla-        124:74-80,     1967.
     centa previa. J Mt Sinai Hosp 24:641 -646, 1957.                                         10. Rosenthal      RJ, Ainzler c, Wallsh A, et al: Wrist-cutting                  syndrome:   The
 5. Goldfield    MD, Glick   ID: Self-mutilation of the female genitalia.     Dis    Nerv         meaning     ofa gesture. Am J Psychiatry            128:1363-1368,         1972.
    Syst3l    :843-845, 1970.                                                                 11. Akhtar 5, Brenner I: Differential        diagnosis      of fugue-like     states. J C/in Psy-
 6. Simpson      MA: Female   genital     self-mutilation   Arch    Gen Psychiatry      29:       chiatry 40:381-385,        1979.

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