many clinical cases of genital self - mutilation ( gsm ) were reported in the literature .
however , the voluntary cutting of the genital organ remains extremely rare . in this paper
, we report a case of genital self - mutilation committed in a jail while associating a depression episode .
, we will discuss the epidemiological and psychopathological aspects of the self - mutilation of the borderline patients with a focus on the genital self - mutilation .
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 .
this act was carried out during the incarceration stage in the civil prison of fez .
the 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 .
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
however , the patient expressed that his not confident about his sexual identity and virility .
in addition , neither familial psychiatric history disorders or mood disorders nor suicidal behaviors or addiction behavior were recorded . through 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 . during 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 .
a year later , the patient demonstrated a brief psychotic disorder associating persecuting delusions , hypochondria and a diabolic possession .
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 . since 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 .
the patient started the self - mutilation in the prison iteratively commencing with the left arm and the thorax [ figures 1 and 2 ] ; 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 .
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 [ figure 3 ] .
the image clearly demonstrates the self - mutilation at the thoracic level the image clearly demonstrates the self - mutilation at the neck level the image clearly demonstrates the self - mutilation at the neck level the 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 [ figure 4 ] .
however , the patient completely refused any surgery and therapeutical approach despite all explanations provided about the consequences including the vital prognosis .
the image clearly demonstrates the complete cut of the genital organ afterward , 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 .
the 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 .
additionally the desperate , hopeless and self - culpability feelings have decreased within 6 weeks . during the hospitalization stage ,
the patient left the hospital after the stabilization of his clinical state lasting 64 days of hospitalization .
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 .
indeed , 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 . various 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 .
the self - mutilation is an intentional injury committed by a patient on his / her body without an apparent intention to pass away .
this definition opposes the durkeim definition that considers these acts such a slight figure of suicide .
several denominations were used to describe the self - mutilation acts . the first scientific description of the self - mutilation act was given by strch in 1901 , and reported a case of a 27-year - old male that self - mutilated in because of success lack with women . according to joyce et al .
, the rate of self - mutilation in the general population is comprised between 0.75% and 4% , while it varies between 5.5% and 77% in hospitalized psychiatric population and between 50% to 80% in borderline personality patients .
patients used various means for self - mutilation and might select any part of their bodies .
zanarini et al . , studied 290 borderline patients during 10 years ; they reported high prevalence of self - destructive acts in this category of patients as well as large varieties of methods and means used for this purpose . hence , more than 70% of patients revealed a history of multiple sequences of self - mutilation and 60% have previously undergone a suicide attempt . in the same longitudinal study ,
a prospective periodical follow - up of two years revealed a significant decrease of self - destructive behavior in 75% of patients ; the improvement was mainly due to medical and psychotherapeutical treatments and to the maturation cumulated by the age increase of patients during treatment stage .
the gsm achievement circumstances correlated with long surgical treatment mostly combined to coordination lack between the surgical and psychiatric care departments . the most reported gsm cases in the literature are not associated to another mutilation form of the body .
generally , the masculine gsm concerns bourses including contents and the penis . lesions vary in intensity from the simple superficial cutaneous laceration to almost complete ablation of testicles and cutting of the penis . compared to males ,
the gsm of females is exceptional and the most frequent lesions are cuts or scarifications . the literature review of greisheiner and groves achieved on 52 gsm cases , demonstrated that 87% of gsm patients are caused by psychotic context including 28.5% schizophrenic .
literature review of 110 cases showed that most of patients have suffered of psychoses associating sexual conflicts and delirious disorder about mystic - religious topics ; while non - psychotic cases have presented sexual identity disorders .
the psychiatric disorders consisted of psychosis , erotomania , dysmorphophobia disorder , histrionic personality , munchausen 's syndrome , alcoholic dementia , temporal lobe epilepsy , and sexual identity disorders .
lennon et al . , reported a case of mood disorder during a manic episode .
however , tharoor et al . , reported a 72 years old patient that committed gsm secondary to familial conflicts without any remarkable psychiatric disorder history . to our knowledge ,
fayed et al . , reported a 17-year - old girl who was admitted in the gynecological emergency department for an acute hemorrhage resulting from a gsm using an electric knife .
the self - destructive act was accomplished during an episode of dissociation of a borderline personality .
three years earlier , this young girl was a victim of sexual abuse without penetration by three people ; and she kept the incident secrete .
the investigation of the risk factors of the self - mutilation behavior in borderline patients found factors counting loss of physical integrity , confusion , the feeling of guiltiness , self - underestimation , the dependence or the abusive consumption of a substance .
the presence of maltreatment during childhood including physical or effective negligence , sexual abuse is mostly mentioned as a predictive factor of the self - mutilation in borderline personality patients . in - contrast
, functions were attributed to these acts such coping with dissociative states , stress communication to others , symbolic expression of emotions especially guiltiness , regulation of dysphoric element such an anti - suicide role .
authors insisted on the addictive nature through deliverance of endorphin and dopamine in blood , and on the distractive function consisting of shifting patient attention from moral pain to physical pain .
subsequently , 60% of borderline patients did not report any pain feeling during the self - mutilation acts .
bohus has achieved two perception tests of cold and pain in 12 borderline patients and 19 witness women ( the cold pressure test , the tourniquet pain test ) .
results showed a significant decrease of pain perception in borderline patients compared to the witness group regardless of their stress state .
they noted that there was neither a modification of sensory discriminative component of the pain nor a deficit of attention .
this approach would involve either a serotoninergic dysfunction yielding impulsive and aggressive aspects or a low limit of excitability in the secondary limbic structure with repeated emotional trauma during a fast evolution .
indeed our clinical case illustrates the issue that is often raised in the literature such : what is the suicidal component in the self -mutilation behaviors ?
these included the patient suicidal intention , the physical damage resulting of the self - destructive act , the frequency or the chronicity of the act supporting the self - mutilation and used methods .
they found that these varied for the self mutilation acts and are identical for the suicide attempts .
fulwiter et al.,studied 31 self - mutilated prisoner patients and noticed that 15 cases reported their act targeting an attempt to commit suicide , while 16 patients simply targeted hurting themselves .
the suicide attempt was associated to affective disorders , while the mutilation injuries were related to a history of hyperactivity and dysthymia or to an anxiety disorder during childhood .
in addition , greilsheimer and groves reported a series of 53 patients of gsm including five cases with suicidal profile .
jason et al . , presented three chinese patients followed for psychotic disorder while they committed gsm for suicidal purposes .
recently , tharoor et al . , reported a 72 years old married patient without major medical or psychiatric history who tried to suicide using gsm .
in fact , it is believed in chinese and indian cultures that the penis is the source of the life . hence destroying this organ might lead to death .
in addition , it is to highlight that our patient does not have any associated delirious religious believes .
indeed the original aspects of the genital self - mutilation in a borderline personality of the psychiatric profile discussed have demonstrated almost unique case .
the suicidal aspect of this self - destructive act constituted another originality of our case study .
therefore , our paper might contribute to better understanding and clarification of unknown aspects of the profile of the borderline personality behaviors .
 self - mutilation acts are known to characterize the borderline personality disorders . 
 however , voluntary cutting of the male genital organ remains extremely rare . 
 the present paper reports a case of a 25-years - old young male with a borderline personality . 
 the patient committed a genital self - mutilation ( gsm ) targeting suicide during incarceration stage in jail . 
 in addition , a discussion of the epidemiological and psychopathological aspects of the self - mutilation of borderline patients was been conducted . 
 a particular interest is attributed to the genital self - mutilation and a review of the literature is presented . 
Introduction
Case Report
Discussion
Conclusion