Genital self-mutilation in an attempt of suicide by a patient with a borderline personality
Our male patient was 25-years-old, he was hospitalized in March 2003 in the department of psychiatry of the university hospital of Fez (Morocco) for genital self-mutilation while attempting to suicide. The patient achieved the complete cutting of his genital organ using a razor cutter. This act was carried out during the incarceration stage in the civil prison of Fez. The patient was been jailed for a sentence following a premeditated murder.\nThe patient belongs to large family composed of 11 brothers and sisters; the family belongs to a low-income class of the rural area of Fez (Morocco). The patient received a severe family education from his father demonstrating a full use of authority, power and violence. The patient has spent seven years to learn the holly book of “Koran”. Then he practiced several jobs such agriculture and shoemaker at early age without achieving any professional stability.\nThe patient interpersonal relationships demonstrated instability and frequent ruptures. He believed that people do not try to understand him; they do not identify his concerns, issues and needs; and he believed that he might be rejected any time. The relationship of the patient with women was restricted and limited since he feared to be abandoned. Concerning the sexuality, the patient declared that he has had three successful sexual interactions before. However, the patient expressed that his not confident about his sexual identity and virility. Nonetheless, no physical or sexual abuse was revealed during his childhood. In addition, neither familial psychiatric history disorders or mood disorders nor suicidal behaviors or addiction behavior were recorded.\nThrough his 15 years old, a succession of various psychiatric symptoms occurred in the patient with collection of clinical aspects. Evermore, the patient reported episodically fluctuating anxiety in abandoned or accompanied contexts and sometimes-associating periods of depersonalization and derealization. The patient revealed also episodes of a permanent feeling of emptiness and lack of goals in life, with a frequent feeling of uselessness and underestimation. An excessive and abusive consumption of cannabis and alcohol was reported during episodes of anxiety and distress.\nDuring his 19-years old, the patient attempted to commit suicide using organo-phosphorics chemicals, this required hospitalization in the intensive care department along ten days. This suicidal behavior was considered secondary to a major depressive disorder. A year later, the patient demonstrated a brief psychotic disorder associating persecuting delusions, hypochondria and a diabolic possession. These disorders regressed after a three weeks of antipsychotic treatment.\nAt 21-years old, our patient committed a murder in an impulsive context. Thus, while he was walking with his girlfriend, two young men from his village tried to humiliate him and captivate the girl away with them. The patient could not control his aggressive behavior and he wounded one of his aggressors that died in the emergency department of the hospital. He was condemned guilty and sentenced for ten years of jail.\nSince his incarceration, the anxiety disorder, emptiness and abandon feelings were worsening. The patient was self-isolating in the prison cell and established very few relationships with the prison colleagues. The feeling of abandon has increased by the incarceration circumstances and the rare family visits.\nThe patient started the self-mutilation in the prison iteratively commencing with the left arm and the thorax [Figures and ]; these occurred in a context of infringement of impulsion, abandon and anxiety. He reported that these self-destructive acts allowed him to discard fear and tension feelings without being determined to suicide. Two weeks earlier the GSM, the patient has acquired a massive anxiety, a feeling of emptiness and uselessness. Accordingly, a strong desire to die was subsequent. Subsequently, he began to think ending his life. The patient decided to cut his genital organ since he always believes that this organ is the center of his existence. He started to organize the means to accomplish his act with a complete dissimulation of his suicidal intention. By the day of the GSM act, our patient borrowed a razor cutter from another detainee in the prison pretending that he wanted to shave. The patient took the opportunity of the absence of other detainees and prison guards who were in their morning break, he has hided himself in a corner of the prison cell and proceeded to completely cut his genital organ using the razor cutter around 10 AM [].\nThe patient was transferred to the surgical unit of the emergency department, where he immediately followed a re-implantation of the genital organ with a realignment of the urethra. However, necrosis was been noticed and treated during the control of the implant. Unfortunately, the necrosis caused tissues shrinking, and the urological surgery team removed the necrotized graft and proceeded to a plastic surgery of the remaining base of the genital organ []. However, the patient completely refused any surgery and therapeutical approach despite all explanations provided about the consequences including the vital prognosis.\nAfterward, the patient was hospitalized in the psychiatric department where he showed a clear depressive syndrome, a self-culpability regarding the execution and declared that he has lost his virility. Our case adopted a desperate vision of his future but he did not reveal any intention to recommit suicide. In addition, none of symptoms such disorganized speech, delusional, or perceptive disorders were noticed. The somatic examination was without particularity besides a routine biological assessment that was conducted and was negative.\nThe psychometric test DIBR (diagnostic interview for borderline-revised) revealed a borderline personality. During the admission in the psychiatry department, the patient demonstrated a progressive improvement of the symptomatology while using anxiolytic and antidepressant treatments including Clomipramine at 150 mg/day and Diazepam 20 mg/day. The patient showed an attenuation of the psychomotor reduction within 4 weeks of treatment. Additionally the desperate, hopeless and self-culpability feelings have decreased within 6 weeks. During the hospitalization stage, the patient developed washing compulsions, which regressed after one month of treatment. The patient left the hospital after the stabilization of his clinical state lasting 64 days of hospitalization.\nSix months later, the psychiatric test revealed a significant recovery of depressive disorder. In addition, the patient refused to talk about his self-destructive act and declared that he does not want to remember it again. One year later, the patient was examined in the jail and neither self-mutilation nor suicidal behavioral signs were recorded. Since he left hospital, he declared that his act was committed without his determination and God would forgive him. He superficially mentioned the self-mutilation with avoiding to talk about the circumstances again.\nIndeed, the GSM of a borderline personality diagnosis was evoked first considering the omnipresent fear of being abandoned, the permanent dysphoria, the instability characterizing the interpersonal relationship, the life sentimental, the recurrent suicidal behaviors, the psychiatric disorders alternation of varied categories and the significant values recorded in psychometric tests.\nVarious facts allowed suggesting recurrent major depressive disorders including the re-occurrence of episodic suicidal attempt during depressive state and the suicidal goal behind the genital self-mutilation. However, a combination of depressive episodes with fear of abandon and the occurrence of psychiatric disorders such psychotic, obsession, substance abuse and substance dependence disorders were not supporting this hypothesis. The atypical GSM of the borderline personality might suggest a schizophrenia diagnosis, which was discarded considering the absence of any element of disorganization and the preservation of a good lucidity toward reality. An antisocial personality diagnosis was also envisaged considering the relational and professional instability, the impulsivity of repetitive self-mutilations. However, the biographical data, the interaction of the patient with events and the prevalence of fear of separation allowed withdrawing this diagnosis.