Dear Ali,

Facial self-injury is relatively uncommon and there is a really limited number of publications on the subject. The most rational think to make is to return to the basics of psychiatric phenomenology and psychopathology to assess this case as a whole. Being superficial, one could say there is a major impairment in executive functions and disinhibition. The age of the patient lead us to explore the possibility of frontotemporal degeneration and I would look for stereotypical or obssesive-compulsive behavior. Self-injurious behaviors in young people have been related to impairment in facial expression recognition, that could be an issue too.

In my curiosity I would like to explore her own sense of identity if possible. This is a really disorganized behavior that deserves a case-report.

This was more like a brainstorming, but I hope it can lead to a discussion.

Hi, spontaneously I would also tend to explore, whether she has a history of OCD or an OCD-spectrum disorder. Sergios suggestion into the FTD direction is also worth to be considered, as well as Munchausen´s disorder or even a borderline spectrum disease. In elderly patients (very rarely) delusional parasitosis may lead to such clinical pictures (attempting to remove an imaginary parasite with an instrument, e.g. the needle.

Hope you can help the old lady!

Just Genius, are you calling a 45 year-old lady old?  Oh my!  I agree with you in that I would look for some underlying causes as to why she is doing this to herself such as the parasitic delusional thought...

That is a large wound, a large part of her cheek is affected. Proper wound care is essential, to prevent infection (it is also close to the eye) and proper healing. Since it on a visible place and it will be visible the rest of her life. Hopefully it is possible to stop her from continuing this behavior.  

I agree with the others about exploring an underlying cause. I was wondering if there is a reason to rule out assault (since the title says the woman used the needle in secret)? And I would check (if possible) her medical history. The onset of such severe self injury on a later age is striking to me.  

Self injury such as this is remarkable because of the site chosen only, and unlikely to have just begun. There are many questions to be posed:

Duration, frequency, situational + emotional context??? History of physical/verbal/emotional/sexual abuse? History of other self injurious behaviour? Other maladaptic coping behaviours?"in secret"- does she hide she resulting wound? You need information about what she thinks and feels! Does she have thought or mood disturbances of any kind? Whatever the reasons, she has some, which would need to be addressed.. Yes, it could be obsessive behaviour by now.  Too many other possibilities given the information provided:recreating or obliterating previously experienced trauma, for example. How desirable/undesirable are the consequences of this wound to her? How does her environment react?

I look forward to seeing more information, thank you.

I think that is a rare phenomenon, this may be due to a psychotic or dissociative symptom. That may be refer to traumatic experiences or abuse in childhood. As a result, this may be due to a separate self-states, a kind of self-punishment.

I would ask what secondary reinforcement does she receive in addition to the many sensible psychodynamic interpretations  including CSA?   When did it start and when did she report its onset?   Clearly earlier respondents recognise the distress caused by her actions and the need for clinical input 

While most have discussed the various aspects of care in the physical and mental aspects of this patient, just as a shock, I wish to add a new perspective to the wound - 

First question I would ask is "Is it really self injury?"

Second question I'd ask is "Is the self injury self motivated ?"

Even if she inflicted it upon herself, has it been rooted to some injury she had earlier or some experience she had earlier ?

The wound shows various stages of healing which obviously means she has been going from downwards up systematically injuring herself. Another question is why go up and not down ?

A bit late to this discussion, but I am curious regarding the follow up of this patient!

Regards,

Dr. Akilesh. R

India