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Pilotstudie zur Evaluation eines strukturierten Behandlungsprogrammes (CTC - Cut the Cut) für selbstverletzende Jugendliche unter Einbezug der Patientenzufriedenheit

The case of a young woman with still ongoing incest and forced prostitution is presented. The criteria for a dissociative identity disorder (DID) were met. Due to persistent contact to the perpetrator she was repeatedly revictimized. Based on the model of trauma-related dissociation we discuss to what extent she was capable of self-determined decision making as well as therapeutic consequences resulting therefrom.

Factitious disorders are conditions which are unknown to many physicians but have a prevalence of 1-5 % in outpatient departments and hospitals. In order to avoid prolonged and complicated (false) treatment in surgery this article gives a review of the definition, epidemiology and pathogenesis of factitious disorders as well as clinical symptoms and therapy options. A focus is placed on the identification of patients, treatment strategies and the prevention of malpractice. Additionally, clinical features of the disorder are illustrated with the description of some characteristic cases.

Given the increasing demand for counselling in gender dysphoria in childhood in Germany, there is a definite need for empirical data on characteristics and developmental trajectories of this clinical group. This study aimed to provide a first overview by assessing demographic characteristics and developmental trajectories of a group of gender variant boys and girls referred to the specialised Gender Identity Clinic in Hamburg. Data were extracted from medical charts, transcribed and analysed using qualitative content analysis methods. Categories were set up by inductive-deductive reasoning based on the patients' parents' and clinicians' information in the files. Between 2006 and 2010, 45 gender variant children and adolescents were seen by clinicians; 88.9% (n = 40) of these were diagnosed with gender identity disorder (ICD-10). Within this group, the referral rates for girls were higher than for boys (1:1.5). Gender dysphoric girls were on average older than the boys and a higher percentage of girls was referred to the clinic at the beginning of adolescence (12 years of age). At the same time, more girls reported an early onset age. More girls made statements about their (same-sex) sexual orientation during adolescence and wishes for gender confirming medical interventions. More girls than boys revealed self-mutilation in the past or present as well as suicidal thoughts and/or attempts. Results indicate that the presentation of clinically referred gender dysphoric girls differs from the characteristics boys present in Germany; especially with respect to the most salient age differences. Therefore, these two groups require different awareness and individual treatment approaches.

The authors report on the suicide of a 27-year-old woman with extreme self-inflicted injuries. The victim suffered from schizophrenic psychosis with several stays in mental institutions and one previous suicide attempt. Autopsy revealed multiple cut and stab injuries in various body regions (51 stabs to the chest, cutting off parts of ears and nose, stab to the eye and transection of the scalp). Death was caused by exsanguination.

A 52-year-old woman was admitted for emergency treatment after traumatic enucleation. Because of the position of the avulsed eye and the acute mental condition of the patient a trauma caused by self-mutilation could not be excluded. There was even the suspicion of self-enucleation in a second case and in both cases a psychiatrist was consulted but ultimately a disastrous accident was clearly verified for both patients. Nevertheless, an interdisciplinary evaluation should be initiated in cases of patients with a suspicious traumatic injury as in cases of self-mutilation the danger of relapse is high in the first hours and weeks after the primary event.

Autoerotic fatalities in the Greater Dusseldorf area correspond to the relevant medicolegal literature. Our results included exclusively young to middle-aged, usually single men who were found dead in their city apartments. Clothing and devices used showed a great variety. Women's or fetish clothing and complex shackling or hanging devices were disproportionately frequent. In most cases, death occurred due to hanging or ligature strangulation. There was no increased incidence of underlying psychiatric disorders. In most of the deceased no or at least no remarkable alcohol intoxication was found. Occasionally, it may be difficult to reliably differentiate autoerotic accidents, accidents occurring in connection with practices of bondagediscipline, dominancesubmission (BDSM) from natural death, suicide or homicide.

One symptom of Borderline personality disorder is self inflicting behavior, especially cuts and thermal injuries in the upper extremity. Due to the complex underlying psychiatric disease, surgical treatment of these injuries can be tedious and frustrating; therefore it is sometimes necessary to differ from classical plastic surgery principals and to favorite a more conservative approach. In every case, close cooperation with psychiatrist is inalienable.

Self-inflicted impalement is a rarity in forensic autopsies. The case of a 32-year-old man, who was found dead lying on a suburban street, is reported and compared with the relevant literature. A 5-cm-thick wooden stick with blood traces protruded from the oral cavity. At autopsy, it was found that the wooden post, which had a total length of 28 cm, filled the entire oral cavity with the pointed end being located at the entrance of the larynx with lacerations of the posterior wall of the pharynx. There were no signs of asphyxia or involvement of another party. As secondary findings, fresh hesitation cuts could be demonstrated on the right forearm. Death was assumed to have been caused by reflectory cardiac or respiratory arrest similar to bolus death. The police investigations showed that the man had suffered from paranoid hallucinatory schizophrenia for 12 years with 3 previous attempts to commit suicide and had been discharged from inpatient treatment in a psychiatric institution only 4 days before his death. The pattern of injuries is described and an attempt is made to reconstruct the course of events on the basis of the results of the police investigations and the psychiatric documentation. The rare case of self-inflicted fatal impalement is compared with other reports in the literature.

Self-mutilation in the context of factitious disorder can lead to prolonged and complicated treatment in every medical field. Because of a prevalence of 1-5% in hospitalised patients, it is important to be aware of this disorder to protect patients from self- and foreign-induced harm. Often the patient history gives important hints. The different manifestations of this disorder, the specific doctor-patient relationship, several techniques of confrontation and current treatment are presented. Clinical cases from the fields of hand and plastic surgery are presented.

Self-mutilation is well-known in various psychiatric diseases and represents a challenge for forensic pathologists as regards the differentiation of accidental versus self-inflicted injuries, especially when a criminal charge is likely to emerge.A case of extraordinarily severe self-inflicted injuries is presented as well as the related implications concerning clinical and ambulatory care for patients, whose underlying motivation remains unknown.A 60 year-old worker exhibited an open scull fracture and 14 abdominal wounds with protrusion of small intestine, from which a part of 160 cm length was completely removed beforehand. The patient claimed the wounds having been caused accidentally. When examined by a psychiatrist, disturbances in orientation, unrest and ill concentration were found, but no symptoms related to psychosis, depression or suicidal behaviour.Although the need for more detailed examination seemed to be clearly evident, the medical authorities did not take action. Consequently, no further psychiatric treatment was initiated. The implications of this case on the background of the literature are discussed.

Autoerotic manipulations of external male genitals resulting in mutilation with different degrees of severity are rare. We report the clinical case of a 12-year-old boy who injured his glans, left corpus cavernosum and corpus spongiosum with opened urethra as a consequence of autoerotic genital self-mutilation. According to our knowledge of the current literature this is the first description of autoerotic genital self-mutilation with a Moulinette. A Moulinette is a kitchen tool with an electric engine and an extremely fast rotary double knife, which is used to reduce food into small pieces, especially vegetables and fruits.

Automutilistic behaviour is frequently correlated with personality disorders and should be differentiated from suicidal behaviour during acute episodes of affective disorders. The aim of the study was to investigate psychotherapeutically and psychodynamically significant personality traits and affect regulation. The dimensions "relationship", "conflict" and "structure" were examined by means of Operationalized Psychodynamic Diagnostics.20 female patients with depression and automutilistic behaviour and 20 age-matched female subjects with a similar educational background, suffering from depression without automutilistic behaviour. RESULTS The female patients with depression and automutilistic behaviour could be differentiated from the control group in all categories in the OPD dimension "structure". They showed an "isolated" and "disclosed" self-image. This negative self-perception corresponded with a negative countertransference. There were no differences between the patients with automutilistic behaviour and the control group regarding the OPD dimension "conflict". Low and moderate levels of integration were prominently correlated with the autonomy-dependence conflict. CONCLUSION The results underline the significance of aspects of personality structure in automutilistic behaviour seen in female patients with depression. Operationalized Psychodynamic Diagnostics can reveal therapeutically relevant personality dimensions for empirical research.

The frequency of the diagnosis of self-induced injuries is rising, especially in patients with borderline personality disorder. The number of unreported cases is estimated to be high. Self-mutilation typically affects the patient's skin and therefore often presents to dermatologists or general practitioners. Such injuries are often clinically typical; a knowledge of these features is essential for the correct diagnosis and treatment. Multidisciplinary care is essential because of the tendency for overlap with other psychiatric diseases and the risk of suicide. Self-induced injuries are also used to simulate criminal offences and to fraudulently obtain insurance payments. In these cases appropriate diagnosis is important from both a legal and psychiatric point of view. Typical morphological aspects and combination of clinical signs in cases of self-mutilation are presented from forensic point of view to facilitate confirming the diagnosis.

Male genital injury, although rarely life-threatening, demands prompt, appropriate management to prevent long-term sexual and psychological damage. However, because of the rarity and disparity of severe genital injuries, there is still no universal therapeutic strategy. Urethral injury, although rare, may be associated with substantial long-term morbidity such as fistulas and strictures. Injuries to the scrotum and its contents may cause impaired fertility, chronic pain, hypogonadism, and altered self-image. Penile injury may lead to pain, curvature, and erectile dysfunction. This article concentrates on reviewing the major etiologies and mechanisms of urethral and genital injuries in men and summarizes principles and strategies of treatment based on the guidelines of the European Association of Urology.

Factitial cutaneous lesions result from self-inflicted injury leading to objectifiable clinically relevant damage to the skin. Triggering factors are frequently psychiatric disorders or specific stress situations. Clinical manifestations range from superficial erosions to deep wounds.The establishment of the diagnosis is often a time-consuming and complicated process that precedes acceptance of the underlying pathology by both the therapist and patient. If lasting therapeutic success is to be achieved, the possibility of such cutaneous lesions must be included in differential diagnostic considerations, and early interdisciplinary cooperation is necessary.

A 50-year-old surgeon was working with his electrical circle saw as a do-it-yourselfer. He was alone, nobody witnessed his mishap when he amputated his left index finger. He claimed high financial compensation from two accident insurance companies because of his disability. A long series of medical expertises followed. The juridical procedures took 12 years in total. All higher authorities had to deal with the forensic medical implications. Finally, the high court (Bundesgerichtshof) decided that the complainant would receive no compensation because he gave two very different descriptions. Concerning the reconstruction of the accident, the first version was unlikely from a biomechanical point of view. The decision of the court was solely based on the violation of the obligation to give a clear presentation of the course of events (Obliegenheitsverletzung).

Pathomorphological findings for the male genital are an exception among forensic cases. In earlier publications they were usually published as individual cases. A significant percentage are the so-called fertility- and potency medical certificates, which are usually commissioned for doubtful paternity cases. Old forensic writings about genital injuries distinguish--apart from the necessity of a complete dissection--between "deadly as such" and "accidentally deadly" injuries. Another group consists of reports about self-inflicted genital mutilation, e.g. among prison inmates or soldiers of the last world wars to become an invalid. When it was necessary to identify a corpse, e.g. in cases of progressive decomposition, Merkel recommended in 1945 the representation of the so-called "Schnepfenkopf" (snipe head; colliculus seminalis) in the lesser pelvis. In this article a medical and forensic review of forensically relevant findings of the male genital is presented and illustrated with historical cases.

Self-inflicted injurious behavior Auto-aggressive behavior such as the simulation of crimes, attempted insurance fraud or suicidal intent are observed in psychiatric diseases and, in particular, in borderline personality disorder. The self-inflicted injuries often show typical characteristics, the knowledge of which is helpful for making a diagnosis and can critically influence further therapy. Borderliner injuries are often noticeably uniform, arranged in parallel, superficial and on body locations that are easily reached. For affected persons who are at high risk for suicide, it is of great importance that they receive psychiatric therapy as soon as possible.

The author describes the course of an adolescent psychotherapy with guided affective imagery (Leuner 1985) using the therapeutic material of a 15 year old female adolescent with a severe depression und automutilative behaviour. She considers this therapeutic method as very useful especially for severely disturbed adolescents, because the method enhances the creativity of the patient and enables him to express traumatizing experiences in a symbolical form thus facilitating their integration.

The term "complex suicide" stands for suicides committed by using more than one method. A distinction can be made between planned and unplanned complex suicides (primary/secondary combinations). In planned complex suicides 2 or more methods are applied simultaneously in order to make sure that death will occur even if one method fails. In unplanned complex suicides the mode of performance is changed after the first method chosen failed or was working too slow or proved to be too painful. In planned complex suicides typically two of the generally common methods of suicide (e.g. ingestion of medicines, hanging, use of firearms, drowning, fall from a height) are combined. But also unusual combinations have been described such as the simultaneous firing of two guns, self-immolation in combination with other suicide methods or shooting oneself while driving a car. In unplanned complex suicides self-inflicted injuries by sharp force, especially cuts of the wrists, are often found as the primary act of suicide. In some cases the suicide switches from cuts to stabs (mostly to the heart region). Other methods often used after the first phase of suicide are hanging and jump from a height. In the literature the use of up to 5 suicidal methods applied one after the other have been described.

The present study analysed the self-injurious, destructive behaviour of a mentally retarded boy, ten years of age which was generally noticed through his resistance to demands and because of his self-destructive behaviour and aggressions against others. This behaviour appeared in critical situations (following instructions; not getting something). It is maintained by positive (getting attention) and negative reinforcement (let off demands). The interventions followed the mediating concept, including both female teachers and the mother of the boy. They were instructed to set effective demands, to give positive reinforcement for following rules and to sanction deviant behaviour by over correction. The effects of the intervention were measured through four problem behaviours (oppositional defiant behaviour, self-injurious behaviour, aggressive behaviour against others, evading) with 80 measurements in a multiple baseline analysis (replication over behaviours). The interventions reduced the destructive behaviours of the boy. A follow-up after 10 months proved that no problem behaviours were noticeable anymore.

Self-mutilation of the genitals in man is a rare phenomenon mainly occurring in young males. The importance of conflicts about the male role, difficulties with the male identification in childhood and feeling of guilt for sexual offences are discussed in the literature. The influence of developmental crisis on this symbolic form of automutilation will be discussed in our case report.We present a case of a young schizophrenic man whose illness started in adolescence. He committed genital automutilation already in early adolescence, as a young male he autocastrated himself.We demonstrate the connection of specific problems of development in adolescence and psychopathology. Autocastration will be discussed as a "psychotic" solution of the adolescent conflict of dependence.Developmental conflicts may be important pathoplastic factors who may lead to severe psychopathology and misbehavior. Additionally to a psychopharmacological treatment a specific adolescent- and conflictoriented psychotherapy for solving the developmental conflicts in young schizophrenic patients should be established.

The paper describes a fatal autoerotic accident of a 23-year-old man who derived sexual pleasure from painful irritation of the peritoneum by sharp force. For this purpose he clamped two knife blades into a vice suspended from a rope-pulley construction so that he could lower it to pierce the abdominal skin with the tips of the knives. When one of the ropes broke, the vice with the knives fell onto the man's belly piercing the inferior vena cava and leading to death by exsanguination. This, to the authors' knowledge, has been the first ever report of a fatal autoerotic accident in which sexual pleasure was to be obtained from painful irritation of the peritoneum.

Autoenucleation is the worst form of self-mutilation of the eye. Patients affected are mostly those with psychosis and delusions, but such acts can also happen under the influence of drugs, alcohol, solvents and seldom with organic illnesses. Often, these patients are known to be autoaggressive and suicidal.We present two psychiatric patients who autoenucleated one eye and injured the other. A 41-year-old patient with known organic epilepsy based on a temporal-lobe-hemangioma and psychosis with delusions autoenucleated his right eye and lacerated the conjunctiva of the other, following imperative voices. A 50-year-old female suffered from a long-standing paranoid schizophrenia and religious delusions, and autoaggressive acts with resulting amaurosis of the right eye and several suicidal attempts had preceded the autoenucleation of the left eye.After the completion of the autoaggressive act the patients experience relief, but often the autoaggresive or suicidal impulses persist or recur. A close cooperation between ophthalmologists and psychiatrist in these patients is imperative.

After surgical treatment of an inguinal hernia, a 26-year-old male was discharged from hospital with a well healing surgical wound. Four weeks later he was admitted again with a major localized painful swelling of the soft tissues, whereas the clinical examination revealed no further local or systemic signs of inflammation. The immediate operation disclosed no abscess formation, but a large colliquation necrosis of the subcutaneous tissue with an outstanding petroleum-like odour. On toxicological examination of the necrotic tissue, a respective petroleum distillate was found. The patient was confronted with the suspicion of having injected the petroleum preparation himself to prolong the wound healing and finally admitted the self-mutilating behaviour. The pathophysiology, clinical history and morphological findings are discussed in comparison with case reports of chemically induced self-mutilation.

Autoaggressive syndromes as causes of diseases underlying chronic blepharitis and keratoconjunctivitis that are refractory to treatment are often difficult to recognize.Three female patients (age 21, 25, 41 years) and one male patient (age 42 years) had suffered from a right-(4x) or left-(1x) handed treatment-refractory blepharokeratoconjunctivitis for 1, 2, 11 and 30 months prior to admission. In each case more than 5 ophthalmologists and 2-6 eye hospitals had been consulted, and extraocular surgery had been performed 1-4 times.Patients presented with a visual acuity of 0.3 p (1x), 0.1 (1x), FC (1x), HM (1x). In three patients contact eczema of the facial skin and lids and a corneal pannus were observed; in two patients we saw purulent pseudomembranous and in two patients chronic cicatrizing keratoconjunctivitis. Conjunctival smears grew P. aeruginosa, and S. aureus; impression cytology showed infiltration with neutrophils and epithelial keratinization; histopathology indicated chronic inflammatory, partly purulent subepithelial and stromal conjunctival infiltrate with hyper- and parakeratosis fibrous strands and epithelial cell loss; the lower lids showed parakeratosis, focal necrosis, intercellular edema and a lymphohistiocytic round-cell infiltrate. Furthermore, multiple allergies to antibiotics and preservatives (4x), lacerations of the arms and legs (2x) and an irritative-toxic dermatitis (1x) were substantiated. In the patients who agreed to a psychiatric consultation, somatized-agitated longing for care combined with a dependent and infantile personality (1x) and reactive depression (2x) were verified.In patients suffering from treatment-refractory unilateral chronic blepharokeratoconjunctivitis correlated with the hand, one must take into consideration the fact that other factors may be involved: possible exacerbation prior to examinations; multiple inpatient diagnostic and surgical procedures in different locations; histopathological mixed inflammatory patterns; and psychiatric syndromes.

An unusual case of self-injury involving several, partly deep penetrating stab wounds is described. A young emotionally disturbed consulting-room assistant accused her husband of having inflicted the injuries upon her in the course of an argument over custody of the children. An analysis of the injury pattern showed clear indications of self-injury and willfully transferred blood from punctures in the woman's fingertips to the clothes of the accused. The case demonstrates that in cases involving members of a medical profession and individuals with psychiatric disorders, the possibility of highly unusual types of self-injury should not be excluded. It further emphasizes the importance of a physical examination performed by a medico-legal specialist.

27 cases of questionable self-mutilation among physicians (concerning finger and hand injuries) were analyzed retrospectively. The evaluation based on files of the insurance companies, reconstructive examinations and experimental investigations. Three typical cases are described in detail, the "victims" were suspected to have committed a special kind of fraud in order to claim financial compensation from their accident-insurance companies; the contract included special invalidity payments for finger injures (so-called "Gliedertaxe"). Many of these physicians had worked in the surgical field: apart from one 38-year-old female all of them were males, aged between 41 and 66 years. The mutilating instruments were often circular saws, sometimes chain saws and a great variety of other tools, for example hatchet, big scissors and other sharp instruments. By means of forensic-medical expertise and criminalistic investigations the insurance companies were able to demonstrate clearly that the amputation was voluntarily self-inflicted. The forensic-medical argumentation concerning intentional self-mutilation included the so-called execution position of the finger, the injury pattern, the investigations of blood stains and ergonometric aspects.

The presence of a borderline personality disorder must also be considered in forensic medicine appraisements, beside the various motivations for a self injurious behaviour and apart from other psychiatric illnesses. This personality disorder is frequently characterized by cuts and scratches made by the patients using sharp objects to inflict themselves when in situations causing great psychological distress. A case of a young female student is presented who exhibited a clear auto-destructive behaviour. Due to a tragic psychodynamic development, she committed suicide by means of carbamazepine intoxikation. In addition to the impressive morphological and traumatological injury pattern, the psychiatric case history of the female patient also showed that she had suffered from a typical borderline personality disorder.

During a 18-year-period 93 patients (f = 76, m = 17) with a factitious disorder were identified in the psychiatric consultation service of a university hospital (incidence: 0.62%). 50% of women were working in medical professions whereas only 6% of men. Chronic courses of illness were prevailing, but at least one quarter of female patients showed an intermittent type. There was a classical Munchhausen syndrome in 11% of patients. Depressive and anxiety disorders (10%, 4%) were to be respected as psychiatric comorbidity. Ca 25% of the patients suffered from a somatic illness in addition to the factitious disorder, and one third of the women had symptoms of psychosomatic, especially of eating disorders. Previous somatoform disorders, deliberate self harm and attempts of suicide were to be noted in the psychiatric history of many patients. There were frequent traumatizing events (foster home, disturbing family disharmony, physical and sexual abuse, early losses, serious illnesses) in the early biography. Various psychosocial stressors could be identified in the actual eliciting situation. The results are discussed in respect of epidemiology, development and clinical phenomenology of factitious disorders, psychodynamics and psychopathology of deception and self harm, and therapeutic options in the psychiatric consultation service.

According to DSM-IV affective instability in borderline personality disorder is due to marked reactions to environmental events. The aim of this study was to investigate affective responsiveness of abnormal personalities with self-harming impulsive behaviors by means of an affect-stimulation design. The first experiment was based on the presentation of a short story that allowed affective responses to various stimuli to be assessed in regard to quality, intensity, and alterations over time. The second one presented a typical frustration design, which provoked specific feelings of anger and disappointment. Impulsive personalities showed an affective hyperreactivity that was characterized by a decreased threshold for affective responses, as well as by intensive, rapidly changing affects. Furthermore, affect experiences turned out to be qualitatively diffuse and undifferentiated. Results support that affective instability of patients with borderline personality disorder should be differentiated from the autonomous deviations of mood typical of affective disorders. Their affective hyperreactivity is a crucial part of impulsive personality functioning.

The case of a self-amputation of the left-sided forefinger is presented. It was an isolated smooth amputation near the basic ankle of the finger without any accompanying injury of other fingers. The victim (a physician) claimed financial compensation from his accident-insurance; his contract included special disability taxes for finger injuries. However, the insurance company did not pay but was able to demonstrate--by means of a medico-legal reconstructive expertise--that the amputation was voluntary and self-inflicted. The argumentation concerning self-mutilation is presented (including the so-called execution-position of the finger and ergonometric aspects). Concerning the surgical care, intervention and diagnostic procedures a detailed documentation of the case history and the morphology of the injury pattern are recommended (especially in isolated finger-amputations of the non-working hand.

The therapy of factitious disorders is a challenge for the treating surgeon. Only a clear understanding of the underlying causes and a good doctor-patient relationship make a successful outcome possible. Discussion about a confrontation of the patient with the diagnosis and the best made of treatment is still in progress. Early diagnosis and the cooperation between surgeons and psychiatrists are the most important parts of dealing with factitious disorders. This article gives an overview of symptoms and therapies. Six case reports demonstrate possibilities of the disorder's appearance.

Sexual and/or physical abuse can be found in large numbers in the history of severely disturbed borderline patients. The treatment of experiences of incest can induce new symptoms as well as reinforce still existing symptoms. Thus the free-floating anxiety, which is connected with the anxiety of impending doom in early childhood, can be reduced. During in-patient treatment the extent of free-floating anxiety of borderline patients can be reduced by the holding function of the therapeutic team. Reduction of the other symptoms can take place only subsequent to this. A therapy geared to the reduction of singular symptoms might be less successful.

Disturbances of body experience in schizophrenia patients occur frequently. They vary phenomenologically and lack exact and distinct definitions. Their theoretical and clinical relevance remains widely unclear. This review summarises the literature on clinically relevant symptoms such as coenaesthesis and body hallucinations, disturbances of pain perception, out-of-body-experiences, dysmorphophobia and self-injuries or self-mutilation. Empirical studies on the concepts of body schema, body concept and body cathexis are reported. Many of these studies have serious methodological shortcomings. The correlation of disturbances of body experience with other psychopathology is considered. Standardised methods for assessing these disturbances are listed. Effects of body-oriented psychotherapy have been suggested, but not empirically tested. Finally, the possible relevance of further research in this field is discussed.

The main principal in the treatment of behavioural disorders in psittacines consists of optimizing the keeping conditions which have to be ruled out by precise anamnesis. Wounds caused by automutilation require a collar to be put around the patient's neck. This, however, is not a method for longterm preventing of feather plucking. A balanced diet that takes into account the bird's natural behaviour in food intake, larger cages and suitable toys as well as close relationship between bird and bird keeper are changes that should be achieved. Manifest behavioural disorders can only be treated successfully by keeping the bird together with a partner. Exceptionally this may be a bird of a different species. The problems of abnormal fixation to human beings are discussed.

So far, psychiatric-psychoanalytic theories have been able to explain the phenomenon "self-injury" only unsatisfactorily. Moreover, the patients do not turn to a psychiatrist in the first place, but to surgeons, dermatologists, gynecologists or general practitioners. This is therefore an interdisciplinary problem. Since general medical knowledge is relatively unhelpful in diagnosing self-inflicted disease and its treatment, these patients often do not receive adequate psychiatric co-management or further care or indeed often get the chance to delegate the act of self-injury to the physician. In view of the sustained tendency for the disorder to chronify, this frequently results in severe, partly irreversible and sometimes iatrogenically co-induced physical impairments. In the final analysis, it also leads to enormous financial burdens for the agencies which bear the costs.

The present investigation combines a review of the literature on self-mutilation and our own findings. The literature on this topic is extensive, but there are very few reports on self-mutilation in children and adolescents with a psychiatric diagnosis. In our study we explored the symptoms and psychopathological features of 64 children and adolescents with self-mutilative behavior who had been seen at an inpatient psychiatric facility. The topic is presented from a phenomenological and nosological point of view. We identified a subgroup of adolescents with both self-mutilative and suicidal behavior. The implications for the use of longitudinal studies are discussed.