Self-Mutilation in Children
SELF-MUTILATION IN CHILDREN
In psychiatric usage the term "self-mutilation" (auto-mutilation), a combination of the Greek root autos (self) and the Latin verb mutilare (mutilate), refers to behavioral forms characterized by acts of physical injury initiated by the subject; such acts are subject to various interpretations. Some authors have suggested the use of the expression "unintentionally self-inflicted injury," which avoids the assumption of intentionality (Carraz, Yves, and Ehrhardt, Raymond, 1973).
The term "self-mutilation" was first used to describe physical injuries that schizophrenic patients or those suffering from melancholia sometimes inflicted on themselves. These were frequently directed at the genital organs, but the hands and eyes were also affected, especially in schizoid patients experiencing a period of mystical delirium. Karl A. Menninger in 1935 wrote a psychoanalytic study on the question. Menninger considered these signs of self-mutilation to be acts of self-punishment, which symbolized castration.
Self-mutilation has also been described in other psychopathological contexts: in relation to masochistic compulsions or within the context of some perversion; such behavior has also been described during states of heightened or chronic anxiety.
A particular and relatively frequent aspect is represented by the repetitive scarification or carving resorted to by some adolescents. The meaning of such behavior is difficult to interpret, especially since the subjects themselves do not associate any mental imagery with it. Aside from serving as a discharge designed to temporarily eliminate psychic suffering and short-circuit the activity of thought (Delarai-Chabaux, Catherine, and Roche, Jean-François, 1996) common to the majority of such behavior, this type of self-mutilation involves questions about the psychic status of the body in the adolescent.
In the infant, self-mutilation is observed in children who are severely mentally retarded or autistic, and especially when both types of pathological organization are combined. The most severe forms occur in children who cannot speak. In this clinical context, several authors have attempted to identify the different psychopathological interpretations of self-mutilation. Salem A. Shentoub and André Soulairac refer to motor discharges, possibly "self-offensive," that can arise during normal development, especially between the ages of twelve and eighteen months, during the activity of sensory-motor exploration, although these have no pathological value. This primitive self-mutilation decreases rapidly with the development of the bodily schema and the differentiation between ego and not-ego. The infant perceives the causality of the pain; aggressive behavior towards others may then appear. In infantile psychoses self-mutilation is associated with the inability to modulate relational distance and the failure of defense mechanisms, which leads to a massive regression to undifferentiated stages of psychic organization, where the ego is confused with the nonego.
F. Dumesnil attempted to differentiate self-mutilating behavior in different forms of autism and infantile psychosis. Referring to the work of Frances Tustin and Margaret Mahler, he distinguished between "internal shell autism," "external shell autism," the "regressive autistic position," "symbiotic psychosis," and "moderate retardation." In internal shell autism, self-mutilation appears to be a ritualized self-injurious gesture intended more for protection than destruction, in which the mutilatory aspects appear to be accidental. In external shell autism, self-mutilation, which is less mechanical but more violent than in the previous group, can be considered a self-destructive gesture without any specific intentionality. According to Dumesnil, its appearance is determined by an "experience of conflict" and must be understood as "the acting out of an intensely difficult emotion," probably of a depressive nature. In the regressive autistic position, self-mutilation corresponds to a "discharge of hostility and anxiety" that occurs in connection with an anxiety-causing situation of internal or external origin, and which can be directed, in an undifferentiated manner, towards others or the self, because of the absence of a defined bodily limit. In symbiotic psychoses, where the mechanisms of splitting are prevalent, self-mutilation appears in situations where hostility gives rise to an "intense discharge of hatred." Again, according to Dumesnil, these violent acts of self-mutilation, which specifically affect certain parts of the body, involve "an interplay of introjections and projections enabling the person to actualize the bad object within himself" and to maintain the feeling that the outside is completely good. Finally, in moderate retardation, self-mutilation results in a relatively disorganized discharge of anger triggered by some kind of frustration; it does not appear to be "directed" toward an object.
Some self-injurious behavior observed in cases of autism or mental retardation seems to fall within the framework of the auto-sensory phenomena described by Frances Tustin. These serve to maintain the child in a "constant bath of stimuli" that helps to form a "psychic skin" (Esther Bick), protecting the child from environmental discontinuities. The attempt to damage corporal integrity here appears to be an unintentional consequence of self-stimulation. The physiological phenomenon of habituation likely contributes to their gradual intensification. In other cases, the deliberate search for a more or less violent contact with hard objects evokes what Tustin has described as an "autistic object." The sensation of hardness serves to ensure a corporal limit while avoiding separation from the nipple. The distinction observed in clinical psychoanalytic work between the repetitive search for experiences of pure stimulation—which are aimed, well below the threshold of autoeroticism, at "feeling that one exists"—and a very real self-destruction can be compared with the opposition between life narcissism and death narcissism introduced by André Green.
Self-mutilating behavior can also occur when relations involve a form of partial object cathexis, which gives rise to attempts at omnipotent control of the object; separation then leads to violent displays directed toward another or toward the infant himself. The intentionality of self-mutilating behavior appears more clearly here since it reflects a form of aggression turned against the self, as a response to frustration, or because it represents an appeal or request, possibly reinforced by the responses provided by those in the subject's immediate environment.
On another level self-mutilation raises the question of pain and its perception in the autistic child. Is there an elevation in the threshold of pain perception in these infants, as some neurobiological theories claim (endorphins)? Or is this apparent insensitivity the expression of an "intractable interweaving of pleasure and pain," leaving the observer with the impression of a "desperate pleasure" (Jean Ochonisky)?
There also exist a number of forms of rhythmic behavior, most notably head banging, which can result in lesions of varying severity. It is known that these symptoms are particularly frequent in situations of separation or emotional deprivation. It can be hypothesized that for the infant rocking plays the role of maternal holding, or that the self-mutilation is a substitute, in the body of the child, for the missing object.
These attempts at psychopathological understanding are important for ensuring proper institutional care of such pathologies. Self-mutilating behavior arouses strong feelings of powerlessness and guilt, and sometimes even depression, in caregivers as well as parents.
See also: Autism; Infantile psychosis; Suicide.
Carraz, Yves, and Ehrhardt, Raymond. (1973). L'automutilation chez des enfants en institution. Revue de neuropsychiatrie infantile, 21, 217-227.
Delarai-Chabaux, Catherine, and Roche, Jean-François. (1996). Les coupures cutanées à l'adolescence: le carving. Sens et fonction du symptôme. Neuropsychiatrie de l'enfance et de l'adolescence, 44, 43-48.
Dumesnil, F. (1984). Analyse différentielle de cinq pathologies précoces et des automutilations qui en découlent. Neuropsychiatrie de l'enfance et de l'adolescence, 32, 183-195.
Ochonisky, Jean. (1984). L'automutilation a-t-elle un sens? Neuropsychiatrie de l'enfance et de l'adolescence, 32, 171-181.
Shentoub, Salem A., and Soulairac, André. (1961). L'enfant automutilateur. Psychiatrie de l'enfant, 3, 111-145.
Fowler, C., and Hilsenroth, M. (1999). Some reflections on self-mutilation. Psychoanalytic Review, 86, 721-732.
Fowler, J.C., et al. (2000). The inner world of self-mutilating borderline patients. Bulletin of the Menninger Clinic, 64, 365-385.