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Self-Mutilation of Fingers After Cervical Spinal Cord Injury

TO THE EDITOR: The psychiatry consult service was asked to evaluate a patient for anxiety and a 10-year history of finger-biting after a spinal cord injury that resulted in what appeared to be auto-amputation of some or all of eight of his fingers. The objective of this case report is to report a relatively unusual complication of spinal cord injury, to review other available case reports in the literature, and, we hope, stimulate research as to the cause and treatment of this type of self-mutilation.

Case Report

Mr. B is a 33-year-old single Caucasian man with quadriplegia and delirium, admitted 4 days before the psychiatric consultation, for intracranial hemorrhage. The patient had had a cervical spinal cord injury 11 years earlier. After his motor vehicle accident, the patient resumed a previous nail-biting habit, which progressed to chewing on scabs that formed on the fingertips and resulted in extreme resorption of most of his digits. The resulting acro-osteolysis, with loss of all or part of eight of his fingers was disturbing to him. The patient’s family attempted, unsuccessfully, to prevent further mutilation by applying mittens to both his hands. He had attended three or four counseling sessions about 3 years after the MVA but did not find it helpful. He was previously treated with sertraline, 50 mg daily, for anger outbursts, and was also diagnosed, post-MVA, with "anxiety attacks." Family history was notable for a stress-related "nervous breakdown" in a grandmother. We recommended a trial of ziprasidone and individual psychotherapy. The patient agreed to the medication trial but was not amenable to counseling.

Discussion

A review of the literature revealed nine case reports of self-injurious behavior after spinal cord injury in the past 20 years. The majority of the individuals were male (seven of the nine reported cases). Age at onset of self-mutilation behavior ranged from 9 months to 36 years. The most commonly affected areas were the nails, fingers, and hands. Six of the seven cases involved damage to the cervical region on the spinal cord. The other involved damage at the first-thoracic level. One case report involved biting the arms, and another involved "pinching and picking" of the nipples in a male child. In all but the latter case, the behavior was described as "biting." Anticonvulsants were reported as beneficial in five of the nine cases. Carbamazepine was used in four of the cases. Phenytoin and gabapentin were each utilized in two separate cases. Soft barriers (gloves, gauze wraps) were found to reduce or eliminate self-injurious behavior in two of the cases.

The etiology of self-injurious behavior is unclear. Various theories have been proposed, including biological and psychological causes. Research by Kasim et al.,¹ involving self-biting in mice, implicated the dopaminergic system. They found that drugs augmenting synaptic dopamine concentration increased self-biting, and drugs that depleted the dopamine stores decreased the behavior.

In the cases previously mentioned, anxiety, depression, social isolation, boredom, low frustration-tolerance levels, dysesthesias, a history of nail-biting, and attention-deficit hyperactivity disorder were reported. Carroll et al.² noted, in 1980, that "parental deprivation is commonly noted in the childhood histories of self-mutilating patients. Feelings of isolation or separation anxiety often trigger self-mutilation, and some patients seek physical or sexual contact when tension mounts." It was also pointed out that "intrafamilial hostility precipitates the self-mutilating syndrome, and physical abuse during childhood was another precipitating factor."

Mr. B had a history of anxiety, depression, pre-spinal cord injury nail-biting, social isolation, and low frustration tolerance, indicating that the etiology in this case may have been multifactorial and shared many commonalities with previous reports in the literature. In the previously mentioned case reports, anticonvulsants and soft barriers were found to reduce or eliminate the self-injurious behavior. Family therapy and behavioral therapy were also found to be beneficial in some of the above cases.

Ziprasidone was recommended in this case to make use of its dopamine-antagonism properties. Given the probable multifactorial etiology, it would seem logical that the optimal treatment for self-injurious behavior would require a combination of medication and psychosocial interventions, such as cognitive-behavior therapy and group therapy. Unfortunately, our patient was not amenable to the counseling that might have been helpful.

The prevalence of self-mutilation behavior after spinal cord injury is not known; however, several cases have been reported. More research needs to be done, investigating the cause and treatment of self-injurious behavior after spinal cord injury, with particular attention to the possible benefits of anticonvulsants and dopamine-antagonists.

REFERENCES

1. Kasim K, Jinnah HA: Self-biting induced by activation of L-type calcium channels in mice: dopaminergic influences. Dev Neurosci 2003; 25:20–25[CrossRef][Medline]
2. Carroll J, Schaffer C, Splensley J, et al: Family experiences of self-mutilating patients. Am J Psychiatry 1980; 137:852–853[Free Full Text]

Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Email this article to a Colleague Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to My Articles & Searches Download to citation manager Citing Articles via Google Scholar Articles by Couts, C. A. Articles by Gleason, O. C. Search for Related Content PubMed Citation Articles by Couts, C. A. Articles by Gleason, O. C. Syndromes Secondary to General Medical Disorders

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