Self Wounding and Self Mutilation

Professional and self-administered body modifications (e.g., body piercings for insertion of jewelry in the tongue, nipples, and genital area) are coincidental observations at autopsy (56,92). Their presence is influenced by social, cultural, or religious customs (93-95).

Self-inflicted cutting can be part of either psychotic or nonpsychotic destructive behavior and is enhanced by alcohol or drug abuse (Fig. 29; refs. 56, 93, and 95-101). Self-cutting also occurs as a religious ritual or as a means for personal gain (e.g., malingering, insurance fraud [56,64,93,95,96]). Self-wounding of the skin of the extremities (e.g., wrist slashing) is common (56,99,101). Self-wounding injuries are usually relatively minor. Superficial skin wounds in less pain-sensitive areas are observed, and

Fig. 27. Homicide. Multiple stab wounds. Wounds on arm indicative of victim's attempt at protection ("defense" injury). (Courtesy of the Office of the Chief Medical Examiner, Chapel Hill, NC.)

Fig. 28. Defense wound. Victim reached for knife, sustaining cut across fingers. (Courtesy of the Office of the Chief Medical Examiner, Chapel Hill, NC.)

Fig. 29. Death during hospitalization from acetaminophen toxicity. Radial line insertion. Multiple linear and irregular scars on forearm from previous self-wounding.

evidence of repetition is indicative of reactive or habitual activity (95,96,98). Some individuals inject drugs (e.g., lidocaine) to achieve analgesia (102). These injuries are not necessarily suicidal, although they are seen in fatal suicides by various means (Fig. 30; refs. 10, 56, 95, and 97). Healed wrist incisions indicate past suicide attempts and alert the investigator that a death may be a suicide (Fig. 31; refs. 7 and 12).

More mutilating injuries, usually associated with psychosis, result in a major anatomical change affecting vital structures, require surgical intervention, and can cause death (Fig. 32; refs. 56 and 99). Some individuals have nonpsychotic disorders (94). People who are either intoxicated or demented can also self-mutilate (95,99). Self-mutilation can be part of Munchausen syndrome (56,95,96). Psychotic individuals can sustain unusual injuries: ocular trauma due to self-enucleation, sharp-force trauma or fingernail gouging, autoamputation, perforation of viscera by instrumentation, penetration of the skull, and castration (see Subheading 6.2. and refs. 53, 54, 56, 94, 99, 103, and 104). Autoamputation of an arm using either a kitchen knife or electric saw has been described (69,103).

Genital self-mutilators fall into three groups: psychotics (schizophrenics), transves-tites, and patients with complex religious or cultural beliefs (93). These cases typically involve men (93). Women may mutilate their genitals to achieve abortion (93). A case of self-inflicted trauma by the insertion of needles through the abdominal wall to trigger abortion has been described (105).

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