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This page is a resource for Doctors to use to help them better understand self-mutilation

How a Doctor Can Better Understand Self-Mutilation

As a doctor, it can be hard to overcome the stigma that comes with having a patient who mutilates himself or herself. This can be especially true for someone such as a family doctor, who has little to no experience with psychiatric disorders. The above still applies, however, to a psychologist who may not often see patients who have illnesses with such "blatant" effects. It can, at times, be hard for a psychologist to get past the aforementioned stigma of seeing a patient with gory scars running alongside their arms. Although dismissed by many in the psychiatric field as being a "fad" used by teens to gain attention, there is an ever-growing number of doctors who are beginning to have genuine empathy for their self-mutilating patients' condition. A patient who goes to see a psychiatrist showing all visible symptoms of moderate-scizophrenia with acute schizophrenic episodes will most likely be prescribed one of the new atypical antipsychotics (including medications such as Zyprexa, Abilify, and Risperdal). What, however, can a doctor do for a patient who mutilates themselves? There is not a single medication approved by the FDA for the indication of self-mutilation, nor is there a drug used without the FDA's approval for the treatment of cutting (just as doctors often use the anti-seizure medications Neurontin and Klonopin to control psychosis and panic disorder, respectively). What, then, can a doctor do?
First of all, a patient who has been mutilating themselves should be seen as soon as possible by a psychologist. The most effective means of treating self-mutilation is by intense psychotherapy sessions. A self-mutilating patient who sees a psychologist for psychotherapy to treat their disorder is far more likely to achieve remission of the desire to cut than a patient who is seen by a family doctor and pushed aside as having depression.
It is important to mention, however, that psychiatry (including clinical psychiatry) can play an extremely important role in controlling the symptoms and desires toward self-mutilation. Usually, patients who mutilate-themselves are experiencing symptoms of depression, bipolar (manic-depressive) disorder, or mild-to-moderate psychosis. Patients can be effectively treated via medications and regular checkups from a psychiatrist, but due to the relatively short time slot granted to a patient from a psychiatrist ("medication checkups" are mandated by insurance companies in nearly every state to last "no more than fifteen minutes"), a remission of symptoms can only occur when that patient is also being seen by a psychologist who will help the patient better understand his or her symptoms.
This is an excellent time for psychology, psychiatry, and psychopharmacology. More and more doctors, clinical workers, nurses, and social workers are beginning to understand the symptoms of "atypical" psychiatric disorders such as self-mutilation, and as this continues to occur, more and more patients will find themselves receiving the treatment that they so badly need.

Choosing Therapy in the Present

As mentioned, any medical doctor not familiar with the treatment of self-injury, especially a family doctor, should refer his patient to another doctor (usually a psychiatrist first), and then seek progress information from that doctor.
Still, with today's ever-growing demand in the psychiatric field, it can be harder and harder for a patient, even in a semi-"emergency" situation, to see a specialist in a reasonable time frame. That having been noted, it is possible for even the most conservative family doctor to achieve efficacy for a patient who is mutilating.
In terms of medication, the biggest misconception in the uneducated medical field is that most "cutters" are suffering from the symptoms of Borderline Personality Disorder (BPD, pp. 707, DSM-IV-TR), which is not true in more than 90% of cases. Although one of the key characteristics of self-mutilating behavior is impulsivity, this generally doesn't pervade other aspects of the patient's lifeDo not treat your patient as having BPD unless it is clear by the DSM criterion that they are, indeed, suffering from the deeply pervasive patterns of instability in relationships and self-image. Note that self-injury should not be considered as meeting (and certainly not defining) the criteria for BPD. That having been said, most self-mutilators can be treated as majorly depressed, atypical-depression patients, many of whom have Generalized Anxiety Disorder (GAD).
It is most routine to titrate a patient (without prior history of DSM-defined major depression) on an SSRI over a two week period, then attempt to achieve efficacy over an eight week period and maintain dosage from there. Most self mutilators, however, don't respond to such conventional treatments. Staying in the realm of antidepressants, doctors can find more long-term efficacy for average to atypical patients with structurally unrelated antidepressants.
Whereas standard treatment of a typical patient would frequently warrant sertraline HCl 50mg taken QA.M., or escitalopram HBr 10mg QD, attempt treating a patient with a drug like venlafaxine XR, titrated in dose from 37.5mg for four days, to 75mg for four days, to 112.5mg for three days, and the stable dose of 150mg. Obviously, titration can be adjusted according to patient, but the doses should always stay QD due to the extended-release form of venlafaxine. Also, venlafaxine is one of only two drugs approved by the FDA to treat GAD, which patients who self-mutilate are far more likely to have the symptoms of than BPD.
If an SSRI is absolutely preferred, the most reliable is escitalopram HBr 10mg taken 1QD. Escitalopram happens to the other drug approved by the FDA for treatment of GAD, and titration isn't usually neccesary with the drug because of it's relatively stable and tolerable state. Still, efficacy can take up to a month or more with escitalopram.
Tricyclics, although riddled with side-effects, are also quite effective in treating the chronic depressive symptoms and anxiety that accompany self-mutilation.
Do NOT treat the GAD symptoms that your patient has with a benzodiazepine unless it is absolutely clear that the patient is suffering from Panic Disorder. Even short-acting BZD's such as alprazolam are oftentimes unneccesary and addictive for the bulk of patients.
With respect to age, most persons age 13 or older should be safe and respond well to any of the aforementioned treatment methods. Although little clinical data exists in support of venlafaxine use in juveniles, it has been proven time and again to be successful.
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