Thursday, December 04, 2008

Deliberate self-harm by insertion of foreign bodies into the forearm

OR: Why is the RSNA Makin' Stuff Up?

First, we had the latest new scourge among teenage girls, as featured in yesterday's post:

Self-Embedding Disorder appears to be a newly-coined term described in a press release issued by the Radiological Society of North America (RSNA):
Radiologists Diagnose and Treat Self-Embedding Disorder in Teens

CHICAGO — Minimally invasive, image-guided treatment is a safe and precise method for removal of self-inflicted foreign objects from the body, according to the first report on "self-embedding disorder," or self-injury and self-inflicted foreign body insertion in adolescents. The findings will be presented today at the annual meeting of the Radiological Society of North America (RSNA).

A quick PubMed search shows that although "self-embedding disorder" resulted in zero hits, "self-harm, foreign" yielded 17 references, with the most relevant being:
Wraight WM, Belcher HJ, Critchley HD. (2008). Deliberate self-harm by insertion of foreign bodies into the forearm. J Plast Reconstr Aesthet Surg. 61:700-3. Epub 2007 Jun 20.

Deliberate self-harm is common. It is usually by drug overdose or ingestion of other noxious substances, but self-harm by cutting or burning often comes to the attention of plastic surgeons. We report three variant cases involving insertion of paperclips, a ballpoint pen cartridge and sewing needles into the forearm. We discuss the management considerations of each case and emphasise the importance of actively addressing the underlying psychiatric problems for all instances of deliberate self-harm.
OK, the case reports were from three adult women (not teen girls), but it's not exactly a new phenomenon. It's a form of self-injury, which has been widely reported in the literature (more broadly), and is well-known to clinicians.

Figure 2 (Wraight et al., 2008). Case A, dorso-palmar and lateral radiographs of left forearm.

Case A:
A 42-year-old woman with a history of depression, personality disorder and deliberate self-harm by drug overdose and cutting was referred for non-healing wounds of her left, non-dominant forearm (Fig. 1). Over the preceding five years the self-harm included subcutaneous insertion of straightened-out paperclips. Consequently, abscesses had formed intermittently and were managed by incision and drainage with removal of the causative paperclip. Nevertheless, numerous paperclips remained embedded in subcutaneous tissue (Fig. 2), engendering ferrous staining of the skin and overgranulating chronic ulcers. There was no functional deficit in the hand or forearm at the time of assessment.
Wraight and his colleagues are from Plastic Surgery and Psychiatry Departments (not Radiology Departments), so the emphasis of their short Case Report was different from that of the conference presentation by Young et al., and did not involve interventional radiology to assist in removal of the self-inflicted soft tissue foreign bodies. Nonetheless, their discussion notes that
Insertion of foreign bodies is an unusual form of deliberate self-harm. Most are inserted through existing orifices, and urologists, ENT surgeons and gastrointestinal endoscopists may be involved in their assessment, monitoring and removal. Breach of an epithelium is less common, but is reported with insertion of long thin objects through the nose into the brain, or through the urethra and bladder into the abdominal cavity. Foreign bodies may also be inserted directly through skin, for example into the orbit, breast and abdomen. The forearm is a common site of deliberate self-harm by cutting, but our report is the first to highlight the forearm as a site for foreign body insertion.
They also emphasize that medical management of these cases must take into account the underlying psychiatric problems, and ensure that the patients' emotional behavior doesn't compromise the standard of surgical care. The patients are often subject to stigmatization by health care providers, and psychiatry teams specializing in deliberate self-harm are recommended to improve the quality of care.

So to conclude: "self-embedding disorder" is not a new phenomenon, just a new term for a variant of self-injurious behavior.

Next on the agenda: Stay tuned for another [more egregiously] false press release from the RSNA...


W WRAIGHT, H BELCHER, H CRITCHLEY (2008). Deliberate self-harm by insertion of foreign bodies into the forearm. Journal of Plastic, Reconstructive & Aesthetic Surgery, 61 (6), 700-703 DOI: 10.1016/j.bjps.2007.04.004.

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At December 05, 2008 4:44 PM, Anonymous Anonymous said...

Neurocritic: you might need to reconsider your policy of displaying images of frank radiological findings without warnings or some kind of cloaking mechanism. I almost hurled back there at the left forearm picture. And that was _before_ I read the words "straightened paperclip. Gah!

At December 05, 2008 5:31 PM, Blogger The Neurocritic said...

Wound: I can appreciate your discomfort, but the title of the post is rather graphic. I thought it might serve as warning enough to those who are squeamish. The color photograph in Fig. 1 of the paper (not reproduced here) is much more disturbing than the x-ray.

At December 05, 2008 6:29 PM, Blogger The Neurocritic said...

OK, I posted a warning label.

At December 05, 2008 7:09 PM, Anonymous Anonymous said...

Thanks, Neurocritic! The warning label will be most helpful in the future!!

Note that I am not squeamish per se; I am most sensitive to pictures of things like invasive gliomas, functional MRI images depicting activations outside of the cortex of the skull and X-rays of dozens of straightened paperclips pushed into somebody's forearm. In other words, your hardcore bad stuff. I was vaguely nauseous earlier today when I noticed the cover illustration on some report I had to read showed a post mortem brain with quite noticeable sulcal widening over much of the temporal and frontal cortex. and then I noticed the saw marks. Gah! Gah!!

At September 30, 2009 4:24 PM, Blogger raven-rabbit said...

Maybe it's just because I'm a student radiographer, but why would you look at the xray or work in the medical proffession if you know you can't handle it? I believe it was right to withold the colour picture of the patient. They're the ones that hurt more to see; and believe me it's worse when it's you taking the images. A "difficult" patient can put you off for the rest of the day.
Also, good on you, Neurocritic, for pointing out that self harm is not new. So true.

At April 28, 2013 1:41 PM, Blogger Unknown said...

Thanks, Neurocritic! The warning label will be most helpful in the future!!
Glyn Willmoth


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