What Is Self-Embedding Disorder?

 

Self-embedding is an extreme form of self-injury, in which people (typically adolescents) insert objects into their body parts to deliberately hurt themselves or mutilate their bodies without intending suicide.

In a recent paper from Nationwide Children's Hospital, Columbus, Ohio, evaluating self-embedding behavior, researchers described 11 adolescent patients with a mean age of 16 years. Seventy-six foreign bodies were inserted into the arm (n = 69), neck (n = 4), ankle (n = 1), foot (n = 1), or hand (n = 1) in the 11 patients. The number of foreign bodies per case ranged from 1 to 15 and included metal, plastic, graphite, glass, wood, crayon, and stone. [1]

Self-embedding is a form of self-mutilation. Although it is a symptom of a larger underlying problem, it is often overlooked because it occurs in many diverse settings, is hidden or underreported by adolescents and parents, and is underdiagnosed in healthcare settings. [2]

Self-Mutilation in Adolescents

Little is known to date about self-embedding; however, the literature does address self-mutilation, also known as self-harm and cutting. The incidence of self-mutilation in adolescents has increased in recent years, with 1 survey of 8300 college students revealing that 17% engaged in self-harm. [3] Yet self-mutilation remains difficult to diagnose. [4] This problem is classified as an Impulse Control Disorder Not Otherwise Specified in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, Text Revised (DSM-IV-TR, [5] ) but may be symptomatic of other disorders, including borderline personality disorder. A comparison study of 44 adolescents who reported current self-cutting and an age- and sex-matched control group showed that the following disorders were more common among self-cutting girls than among controls [6]:

• Major depressive disorder (63% vs 5%);
• Anxiety disorders (37% vs 12%); and
• Eating disorders (15% vs 0%).

Self-mutilation is viewed as a maladaptive form of self-relief from inner pain. Although not a suicidal behavior, it does come under the umbrella of deliberate self-harm (DSH), which includes suicide and parasuicide. [7]

DSH differs from suicide attempts in that the intent is not death but rather improvement of a distressing psychological state. [8] Self-injurious behaviors performed in response to delusions, hallucinations, or serious mental retardation are not considered forms of DSH. [9]

Common Triggers for Self-Mutilation

Regardless of the underlying disorder, teens who engage in DSH tend to do so in response to a trigger. Mangnall and Yurkovich [10] describe common triggers:

• Tension and Anxiety: Although both depression and anxiety are found in persons who self-harm, anxiety and tension have a unique relationship with these behaviors. Self-cutters report more anxiety than those who engage in other forms of self-harm, although the relationship with self-embedding has not been established;
• Hostility and Impulsivity: Adolescents may turn to self-harm because of their inability to express anger. They are easily angered, yet they experience self-dislike and guilt, which may result in their directing these feelings against themselves;
• Feelings of Derealization and Depersonalization: Feelings of unreality or the lack of a feeling state are triggers for DSH. Cutting seems to end these states, returning the adolescent to a sense of "realness"; and
• History of Childhood Trauma: In self-harmers with a history of childhood trauma, the behavior sometimes begins in childhood. When it does, it may be particularly malignant.

The most frequently reported form of self-injury is cutting of the subdermal tissue. Severity ranges from superficial cutting to long-term disfigurement. The consequences of self-embedding can be quite serious. Wounds can become infected, and this is worsened when foreign objects are inserted deep into the tissue. Infection can travel to bone or muscle, and further damage can be caused if the adolescent hits blood vessels, nerves, or tendons. An object can also break, form an embolism, and travel to a vital organ. [11,12]

The Patient Who Self-Embeds: The Clinician's Role

As with other adolescent issues, early assessment and intervention are best. Nurse practitioners (NPs) and other pediatric providers should assess for all forms of DSH, including self-embedding, during routine assessments, and when adolescents present with suspicious symptoms, such as unexplained wounds and infections. Although DSH and self-embedding are not typically suicidal behaviors, clinicians should still ask about suicidal ideation and if present, assess lethality. Given that this problem may begin during childhood, it is important to also use these assessment strategies with the pediatric population, especially with patients who have experienced childhood trauma.

Intervention requires referral. Children and adolescents who engage in DSH and self-embedding should be referred for counseling to explore the root of this behavior and to determine if there is an associated mental health disorder. Patients who self-embed should also be referred to a radiologist. Using ultrasound diagnosis and ultrasound or fluoroscopic guidance, interventional pediatric radiologists have been able to successfully remove embedded foreign objects found in many parts of the body including the arms, hands, neck, ankles, and feet. Objects have included glass, graphite, and metal, as well as objects typically undetectable with radiographs, such as wood, crayons, and plastic. More unusual objects included a nail polish wand and a fork tine.

Image-guided foreign body removal is safe, precise, and effective in removing foreign bodies, including those at risk for fragmentation during traditional operative removal techniques. Ultrasound-guided removal is performed through small incisions that leave little or no scarring -- a critical feature for adolescents who are already emotionally fragile. [13,14]

Resources for Clinicians

American Self-Harm Information Clearing House
http://www.selfinjury.org/

Cornell Research Program on Self-Injurious Behavior in Adolescents and Young Adults
http://www.crpsib.com/

Understanding and Responding to Students Who Self-Mutilate
http://www.nasponline.org/resources/principals/nassp_cutting.aspx

Resources for Parents and Teens

Severe Self-Injury a Threat to Teens WebMD
http://www.webmd.com/mental-health/news/20081202/severe-self-injury-a-threat-to-teens

Cutting
http://kidshealth.org/teen/your_mind/mental_health/cutting.html

Self Injury in Adolescents
http://aacap.org/page.ww?name=Self-Injury+in+Adolescents&section=Facts+for+Families

Teens, Cutting and Self-Injury
http://www.webmd.com/anxiety-panic/cutting-self-injury

References

1. Young AS, Shiels WE 2nd, Murakami JW, Coley BD, Hogan MJ. Self-embedding behavior: radiologic management of self-inserted soft-tissue foreign bodies. Radiology. 2010;257:233-239. Epub 2010 Sep 7.
2. Derouin A, Bravender T. Living on the edge: the current phenomenon phenomenon of self-mutilation in adolescents. J Matern Child Nurs. 2004;2:12-19.
3. Whitlock J, Eckenrode J, Silverman D. Lifetime prevalence of self-injurious behavior among US college students is 17%. Evid Based Ment Health. 2007;10: 30.
4. Williams K., Bydalek K. Adolescent self-mutilation diagnosis & treatment. J Psychosoc Nurs Ment Health Serv. 2007;45,1219-1225.
5. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed., Text Revised. Washington DC: American Psychiatric Association, 2000.
6. Hintikka J, Tolmunen T, Rissanen M, Honkalampi K. Kylma J, Laukkanen E. Mental disorders in self-cutting adolescents. J Adolesc Health. 2009;44,464-467.
7. Favazza AR. Self-injurious behavior in college students. Pediatrics. 2006;117: 2283-2284. Abstract
8. Roth D, Presse L. Nursing interventions for para suicidal behaviors in female offenders. J Psychosoc Nurs. 2003;41:20-29.
9. Favazza A. The coming of age of self-mutilation. J Nerv Ment Dis. 1998;185:259-268.
10. Mangnall J. Yurkovich E. A literature review of deliberate self-harm. Perspect Psychiatr Care. 2008;44:175-184. Abstract
11. Favazza A, Conterio K. Female habitual self-mutilators. Acta Psychiatrica Scand. 1989;79:283-289.
12. Sharples T. Teens' latest self-injury fad: self-embedding. Time Magazine. Available at: http://www.time.com/time/health/article/0,8599,1865995,00.html Accessed on October 14, 2010.
13. Goodwin, J. Self-embedding takes teen self-injury to the extreme: Radiologists recommend minimally invasive procedure to remove staples, paper clips and more. Available at: http://health.usnews.com/health-news/family-health/brain-and-behavior/articles/2010/09/07/self-embedding-takes-teen-self-injury-to-the-extreme.html Accessed October 14, 2010.
14. Shiels W. Embedded foreign bodies: new challenges, new solutions. Nationwide Children's Hospital. Available at: http://www.nationwidechildrens.org/medical-professional-publications/embedded-foreign-bodies-new-challenges-new-solutions?contentId=54039&orgId=5492 Accessed October 14, 2010.

Author

Mary E. Muscari, PhD, CPNP, APRN-BC

Associate Professor, Decker School of Nursing, Binghamton University, Binghamton, New York; Pediatric Nurse Practitioner, Psychiatric Clinical Specialist, and Forensic Clinical Specialist, Sex Offender Assessment Board / Pennsylvania Board of Probation & Parole, Harrisburg, Pennsylvania

Disclosure: Mary E. Muscari, PhD, CPNP, APRN-BC, CFNS, has disclosed no relevant financial relationships.

-From “What Is Self-Embedding Disorder?”, by Mary E. Muscari, PhD, CPNP, APRN-BC, http://www.medscape.com/viewarticle/731122_2, posted 11/02/2010, retrieved 11/10/11; linked from Medscape Psychiatry, November 09, 2010.

 

11/10