Anatol J Clin Investig 2009:3(1):94-96

A CASE OF DEPRESSION WITH NAIL EXTRACTION AND AN OVERVIEW OF

SELF-MUTILATION
TIRNAK EKME DAVRANII LE BRLKTELK GSTEREN BR DEPRESYON OLGUSU
VE KENDNE ZARAR VERME DAVRANII ZERNE GENEL BR BAKI
Recep TTNC1, Betl ONAT1
1

Etimesgut Army Hospital, Psychiatry Service, Ankara, Turkey

Abstract
Self-mutilation is defined as the deliberate harming or alteration of ones body tissue without consciously intending
tocommit suicide.Numerous psychological mechanisms contribute to the etiology and persistence of selfmutilation . In this paper a case of very unusual self mutilating behavior nail extractionwith depression is
reported and a short overview of self mutilation is made. (Anatol J Clin Investig 2009:3(1):94-96).
zet
Self mutilasyon kiinin beden btnlne bilinli zkym niyeti olmakszn verdii zarar olarak tanmlanr. Self
mutilasyonun etyolojisine ve devam etmesine birok psikolojik mekanizma katkda bulunmaktadr. Bu yazda
olduka nadir grlebilecek trnak ekmeeklinde kendine zarar verme davran ile giden depresyon vakas
bildirilmekte ve self mutilasyon ksaca gzden geirilmektedir. (Anatol J Clin Investig 2009:3(1):94-96).

Introduction
Pathological self mutilation is direct and socially
unacceptable, even within general social
subcultures; it is differentiated from direct selfharm such as drinking and driving, and from
more socially acceptable bodily harm such as
ear piercing and tattooing.
It is important to note that numerous
psychological mechanisms contribute to the
etiology and persistence of self-mutilation. These
include religious and sexual delusions, response
to command hallucination, resolution of
unconscious conflicts (implicated primarily in
major
self-mutilation),
attention
seeking,
autoerotic self-mutilation, frustration, turning
inward of anger, tension release, termination of
depersonalization,
euphoria,
depression,
loneliness or distressing sexual feelings, anger
release, self-punishment, attempt to gain feelings
of security or uniqueness, and manipulation of
others [1-6].
Self-mutilation have many features similar to
impulse control disorders. All of the disorders in
this grouping are characterized by the failure to
resist an impulse, drive, or temptation to perform
some act that is harmful to the patient or others.
In most cases the person senses increasing
tension or arousal prior to the act and
experiences pleasure, gratification, or relief
during or following the act. For this reason some
researchers discuss self-mutilation as a separate
disorder under the title of impulse control
disorders [5,7].
Recep TTNC
Etimesgut Army Hospital, Psychiatry Service, Ankara, Turkey
E-mail: drtutuncu@yahoo.com

Here we report a case of very unusual self

mutilating behavior with a major psychiatric
disorder. To the best of our knowledge this is the
first case, reporting self mutilation by nail
extraction.
36 year-old, married woman was admitted to our
psychiatry clinic voluntarily with the complaints of
anhedonia, loss of interest, social withdawal,
irritability and anger bursts. She was self
mutilating by nail extraction. She was extracting
her nails with no pain. She was totally amnestic
about the act. After the mutilation she was
feeling herself very relieved. As her children told
at that time she was wandering in the house like
searching something, and then she was
destructing her needles into small pieces and
extacting them. This self-mutilation was occuring
usually everyday especially in the evenings. Her
complaints had been started for six months and
increased significantly since last month.
Also she had been never sewing for two years
because whenever she had intended to do, she
felt so tensive and tore all the clothes. In addition
she had been eating 100 mg/day dry tea for 20
years.
According to psychiatric examination her mood
was depressive. She was thinking about death
but no suicidal ideation detected. There were
dissociative amnestic periods. There were
lesions due to self mutilation. In psychological
assessment MMPI and Beier tests were given

A case of depression with nail extraction and an overview of self-mutilation

and IQ test was performed. IQ was in normal

ranges.

repetitive, clearly more severe, and generally

associated with psychosis [4].

Laboratary test results were normal. Neurology

consultation was requested and no neurological
disorder was found.

Self-mutilation is most associated with a

diagnosis of borderline personality disorder.
Other diagnoses, such as major depression,
minor depression, dissociative identity disorder,
obsessive-compulsive disorder, alcoholism and
other substance abuse, anxiety disorders,
adjustment disorders have been associated with
self mutilation [4,10-12].

According to history, psychiatric examination,

psychological
and
organic
assessments;
depressive signs and symptoms eating dry tea
and self-mutilation behavior were prominent.
Herein our patient had significant functional
disability with depressive signs and symptoms.
Acording to DSM-IV all criteria were met for
major depressive disorder. The other possible
diagnoses were all excluded.

In our case nail extraction is not so severe as the

examples mentioned above for psychoses. But it
is very unusual and painful self-mutilation
behavior. And psychosis is excluded according
to DSM-IV criteria. Due to normal IQ testing
result, this behavior cannot be explained by
mental retardation.

She had been followed for six months with

regular visits. After pharmacotherapy as
depressive signs and symptoms approved, her
self mutilating behavior also disappeared.

Self mutilation and dissociative symptoms lead

us to possible diagnosis of personality disorders
specifically borderline personality disorder. But
as the patient does not have an enduring pattern
of inner experience and behavior that deviates
markedly from the expectations of the
individuals culture, we cannot diagnose
personality disorders.

Favazza et. al. defined three subgroups of selfmutilation.

1. Major self mutilation: Self mutilation
behavior is severe and it is associated with
psychoses.
2. Stereotypical self mutilation: Self mutilation
is repetitive with equal severity
3. Superficial or moderate self mutilation:
Frequency and severity is low [8].
Self-mutilation has also been associated
with a wide variety of axis I and axis II disorders.
A self-mutilative behavior is common among
people with severe mental retardation, borderline
and other personality disorders, schizophrenia,
gender identity disorders, eating disorders. It is
generally agreed that psychosis is a basic factor
in major self-mutilation [9]. Major self mutilation
or grave self-inflicted bodily harm such as eye
enucleation or self-castration are usually not

Acording to DSM-IV all criteria were met for

major depressive disorder. There are similar
findings in the literature that depression, suicide
and self mutilation may be interrelated [4,13-19].
As a conclusion we have to emphasize that
unusual patterns of self mutilating behavior can
be the signal of severe mental disorders.
Physicians have to be careful in differential
diagnosis. As in our case some patients do not
tell the self mutilating behavior. They usually
admit other physicians other than psychiatrists.
We think that it is important to detect these
patients and refer them to psychiatry.

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