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MEDICINE This text is a translation from the original German which should be used for referencing. The German version is authoritative. REVIEW ARTICLE Self-Inflicted Injuries: A Forensic Medical Perspective Steffen Heide, Manfred Kleiber SUMMARY Introduction: Deliberate self harm (DSH) is the term for self inflicted physical injury without suicidal intent. Among plethora of motivations, it is possible to distinguish between psychological, legal and material causes. Methods: Selective literature review and dicsussion. Results: Reliable incidence data on deliberate self harm, which ranges from cutting to limb amputation, are lacking in Germany. However, data emerging from academic departments of forensic medicine suggest that periodic clusters of so-called "copycat" DSH episodes arise, in response to episodes of self harm publicized in the media. Discussion: Self-inflicted injuries show characteristic features which can be used to distinguish them from injuries inflicted by third parties. The sooner self harm is recognized as such, the sooner medical help can be offered and possible judicial consequences avoided. Dtsch Arztebl 2006; 103(40): A 2627–33. Key words: self-inflicted injuries, self-mutilation, forensic medical reports, simulation of a criminal offence, insurance fraud S elf-injury as an act of deliberate deception to avoid service in the Roman army was described as early as the second century AD (1). In recent decades, the phenomenon has received greater attention from the public at large, particularly because of a large number of purported "racist" attacks with skin injuries in the shape of the Nazi swastika (2). In the contemporary view, self-injury may express a psychopathological disorder that can be considered a disease in its own right; if not, it may still require medical treatment because of its physical manifestations. This group of patients must be treated with empathy, but also with the professional diagnostic objectivity of the physician who is aware of the existence and motivation of self-inflicted injuries committed with the intent to deceive. The topic "self-injury" has had an expanding presence on the Internet over the last few years (a Google search now reveals ca. 1,260,000 entries containing this term). Not surprisingly, this complex entity and the reasons for it are usually dealt with quite superficially. The marked degree of suffering of the affected persons is revealed in anonymous chat rooms. Deliberate self-harm is defined as an injury inflicted on oneself without suicidal intent. Reliable statistics on its incidence in Germany are lacking (3). The English-language literature reports a prevalence of 0.6% to 0.8% of the population, with overrepresentation of individuals between 15 and 35 years old. Women are affected two to five times more often than men (4). Reliable statistics are even more difficult to find concerning the relative proportions of deliberate, goal-directed self-injury (e.g., with the intent to deceive persons in authority, parents, or intimate partners) on the one hand, and overt or hidden self-destructive behavior based on psychopathology on the other. The two categories overlap with a large "gray area," rather than a clear boundary, in between. It may thus be difficult or impossible to render a clear diagnosis in certain cases. There is no question that expertise in forensic medicine is required (3, 4). It is clear from the publications of academic departments of forensic medicine (2, 4, 5, 6, 7) that the extent to which forensic medical expertise is requested in such cases, and the manner in which the above-mentioned "gray area" is dealt with, vary widely from one region to another. It is also clear that temporal clusters periodically arise, often because of imitative self-injuries after widely publicized cases. It seems impossible a priori to assess the extent of the "dark zone" of self-injuries that are never detected as such. These certainly exist and are handled by the criminal justice system. Institut für Rechtsmedizin, Martin-Luther-Universität Halle-Wittenberg (Dr. med. Heide, Prof. Dr. med. habil. Kleiber) Dtsch Arztebl 2006; 103(40): A 2627–33 ⏐ www.aerzteblatt.de 1 MEDICINE DIAGRAM The motives and causes of self-inflicted injuries The motivations for self-injury are exceedingly diverse (Diagram) and often multifactorial. The types of injury are diverse as well, ranging from superficial scratches to limb amputation. According to Sachsse (8), self-injurious behavior as a clinical phenomenon represents the far end of a spectrum of normal human behavior. Fingernail chewing, hair extraction, and the like are part of everyday behavior for nearly everyone. Debate will probably remain on whether the placing of extreme and excessive demands on oneself, in sports or at work, should already be considered a type of "self-injurious behavior" (4, 8). Overt self-injury without any intent to conceal one's own responsibility for the deed is distinguishable from covert self-destructive behavior. Certain types of injury are characteristic of particular causes or motivations for deliberate self-harm (3, 4, 9). The medical aspects of self-inflicted injuries are relevant to physicians in a number of specialties, including general practitioners. Particular aspects are of special relevance to each discipline. Forensic physicians are concerned above all with the distinction between self-inflicted injuries and those inflicted by others. The present review of self-inflicted injuries from the forensic physician's point of view is based on the authors' practical experience and a survey of the current literature. We will point out characteristic types of injury that should Dtsch Arztebl 2006; 103(40): A 2627–33 ⏐ www.aerzteblatt.de 2 MEDICINE draw the clinician's attention to the possibility of self-inflicted injury and its consequences. Self-inflicted injury for psychological gain Self-injurious behavior is a relatively common manifestation of mental disorders and diseases. The psychological gain that is obtained can take many forms: sympathy, attention, sexual pleasure, recognition, admiration, or satisfaction of a desire for revenge. The pattern of self-inflicted injury is more homogeneous in persons with the emotionally unstable personality disorder of borderline type than in other psychiatric patients (10). The leading manifestation is overt self-injury of the skin with numerous, parallel, usually superficial cuts or scratches (Figure 1) in areas that are Figure 1: Numerous cuts and scratches of varying ages on the arm relatively insensitive to pain. of a deceased woman with borderline personality disorder (cause of Cigarette burns may be found death: suicide by carbamazepine overdose). as well. According to Sachsse (11), the psychodynamic functions of self-injurious behavior in borderline personality disorder are manifold. On the one hand, it serves intrapersonal functions, acting as a global pressure valve and tranquilizer in states of excess tension, or else as an antidepressant or a form of self-punishment. On the other hand, in serves interpersonal functions, providing an intense, non-verbal appeal to others, or a means of escape from excessive demands placed on the individual by society. Self-inflicted injuries are also seen in histrionic, dissocial, or paranoid personality disorder, though less commonly than in borderline patients (10). Neurotic patients most often injure their own skin by scratching, rubbing, or biting. Severe auto-aggression, on the other hand, tends to occur in schizophrenia, affective psychoses, oligophrenia, and organic brain disease. Paranoid hallucinatory schizophrenia, in particular, may manifest itself in bizarre injuries, mainly involving the violent use of sharp implements. The spectrum ranges all the way to autocastration and limb amputation (12). Artificial disorder is characterized by the simulation, exaggeration, or deliberate production of manifestations of illness. Well-known examples include cutting, scratching, or abrasive injuries, the self-injection of infectious or toxic material, or the reopening of surgical wounds (13). Such patients undergo repeated hospitalization and are often subjected to extensive diagnostic and therapeutic procedures. Over the course of the disease, permanent damage ensues, sometimes severe enough to merit the term "mutilation." A subgroup of patients with artificial disorder contains those with Münchhausen's syndrome, who present with a detailed history of invented events (pseudologia phantastica), a bizarre collection of symptoms, and multiple hospitalizations ("hospital hopping"). It is a matter of personal opinion whether certain procedures on the body, such as tattooing or piercing, that are fashionable in some places and times for sociocultural reasons, should be considered a type of normal human behavior or a type of deliberate self-harm. An intensified form of such practices is the infliction of a burning or cutting injury to produce a desired scar pattern ("branding," "cutting"). The term "body modification" also covers the visible implantation of pins or other, larger metallic objects on the body surface, Dtsch Arztebl 2006; 103(40): A 2627–33 ⏐ www.aerzteblatt.de 3 MEDICINE as well as splitting of the tongue (14). Self-injury for judicial advantage Self-injuries to simulate a crime are usually cutting and scratching injuries and often show typical features. Most of the affected persons are girls and young women; some are young men. The "attacks" are described in relatively uniform fashion, though the motives can be very diverse. The underlying motivation is often to attract public attention and sympathy. In other cases, it is to justify an illicit absence or a late return home (Figure 2). The particular Figure 2: 47 individual scratches on the abdomen of a 38-year-old difficulty created by this group man after a "racist attack" (self-injury to provide an alibi for an extra- of cases is that the deceptive marital affair). act, intended for a specific purpose, automatically activates the criminal justice system, whether this was the initial intent or not. The proceedings thus set in motion may have a snowball effect that overwhelms the "victim." Crimes with a political or xenophobic motive are simulated in order to obtain the maximum advantage (appellative function) for the "victim." A common variant, breaking an especially strong taboo, is the scratching of a swastika or the SS double thunderbolt into the skin. Persons also sometimes injure themselves to incriminate police officers, overseers, and teachers, to conceal a suicide attempt, or to hide their own misdeeds (e.g., burglary or embezzlement) (15). The relevant passages in the German criminal code are those dealing with the simulation of a crime (§145) and, when a specific person is blamed, false incrimination (§164) or defamation (§187). Precise data on the frequency of self-injury for judicial advantage are not available. In 2004, according to the statistics of the German Federal Department of Criminal Justice (Bundeskriminalamt), 13,696 cases of "simulation of a crime" were registered. Some of these incidents, however, did not involve self-injury (simulated theft, etc.). Patients with factitious injuries may account for as many as 2% of persons treated in dermatological clinics (16), yet cases of the type discussed here, such as the simulation of a crime motivated by xenophobia, are relatively rare, though they sometimes attract nationwide attention. Self-injury for material gain Persons in investigative custody are particularly prone to self-injurious behavior. Common mechanisms include the refusal of food, cutting injuries, self-poisoning, and even the swallowing of foreign bodies, such as table utensils. These acts may have an appellative character, as a demonstration of alleged innocence; other possible motivations include providing a means of escape, alleviating prison conditions, or effecting a transfer to another facility. Self-injury to avoid military service was more common in the past. Reported types of self-injury for this purpose include shooting oneself through a piece of ration bread (in order not to produce the telltale signs of a short-range bullet wound), finger injuries, the consumption of spoiled rations, and deliberate smear infections (17). Self-injury for insurance fraud usually consists of the self-amputation of one or two fingers (usually the thumb and/or index finger of the non-dominant hand) with a sharp implement; less commonly, an entire hand is amputated (18), and presses, hammers, or other blunt tools are occasionally used (19). Most affected persons are men. The "accident" usually occurs in the private sphere and without witnesses. 90% of cases are claimed within the first 6 months of coverage. About 75% of these persons have more than one insurance Dtsch Arztebl 2006; 103(40): A 2627–33 ⏐ www.aerzteblatt.de 4 MEDICINE policy, and the limbs are often insured for unusually large sums of money (20). Precise information on the frequency of this type of insurance fraud is lacking; Gerlach (21) conservatively estimates that there are at least 200 traumatic limb amputations in northern Germany over a 10-year interval. Selfinflicted injuries are not separately listed among the 11,743 cases of insurance fraud reported in police statistics for 2004. Extensive descriptions of selfinflicted injuries for insurance fraud are provided by Dotzauer (22), Bonte (18), Püschel (23), and Möllhof (17), among others. The medicolegal investigation of potentially self-inflicted injuries requires the use of all available sources of information, such as photographs, x-rays, operative reports, and medical examination reports (19). The findings should be thoroughly Figure 3: Reconstruction of a self-injury for insurance fraud: note the documented with photographs marked discrepancy between the alleged position of the ax and the taken from a number of diffecourse of the amputation line through the first metacarpal bone. rent angles (17). The site of injury, as well as the amputated body part, should be inspected for the nature of the cut edges, the course of the amputation line, and any accompanying injuries (22). Traces of injections, if present, may indicate the prior administration of a local anesthetic; a chemical toxicological study may be indicated. The injured person should be asked to describe the course of the alleged accident precisely. Descriptions of deliberate injuries are often at considerable variance from the objective findings. A visit to the site and an inspection of tools and materials (for bloodstains, precautionary measures, etc.) may be necessary for a reconstruction of the event (body posture, position of the hands). Figure 3 shows a major discrepancy between the alleged position of the ax and the course of the amputation line through the 1st metacarpal bone in the reconstruction of an "accident" involving amputation of the left thumb. Most genuinely accidental ax-blow injuries are accompanied by injuries to the neighboring fingers; thus, an isolated, complete, proximal amputation of the index finger should prompt suspicion of self-injury (23). In accidental injuries, the edge of the wound is usually irregular and its course oblique, while, in self-injuries, it tends to be relatively sharp, and the angle of the cut perpendicular. So-called tentative injuries adjacent to the actual amputation wound are an important sign of the deliberate amputation of a finger (22). Other suspicious features pointing toward self-injury include unusual provisions in the insurance policy, a lack of witnesses or the influencing of witnesses after the fact, inexplicable disappearance of the amputated body part, hasty cleaning of the "scene of the accident," and false statements about right- or lefthandedness (18, 22). It is indisputable that physicians acutely treating persons with self-destructive behavior must not let their care be negatively influenced by their own ethical or moral attitudes to such behavior. The unsparing exposure of self-injury with fraudulent intent, with its far-reaching consequences, is certainly not the physician's primary duty, yet the physician should not shirk this responsibility in his or her capacity as the relevant professional expert. Not all cases of possible self-injury can be submitted to a judicial inquiry for a final determination Dtsch Arztebl 2006; 103(40): A 2627–33 ⏐ www.aerzteblatt.de 5 MEDICINE (§34 of the German Criminal Code). Ultimately, this decision, like many others that physicians must make, is a personal matter that is up to one's own conscience. Differential diagnosis The medical examination of victims of violence should take place as soon as possible after the event, particularly for the securing of biological evidence. A forensic physician may be consulted by the police or by medical colleagues, victim-protection organizations, or legal advisers. One of the responsibilities of the physician examining victims of violent crime is to consider, in every case, the possibility of a self-inflicted injury. The necessary medical objectivity must be preserved despite the physician's empathy for the presumed victim. If a self-inflicted injury is not recognized as such, the result may be a continuation or reinforcement of the self-injurious behavior and a roadblock along the path to appropriate help for the underlying mental disturbance (16). The forensic medical examination must take the entire body in view, as even trivial injuries may be of great importance to the overall assessment. The type, size, location, and color of all wounds should be exactly described and photographically documented both in survey images and in close-ups, with a ruler to indicate the scale. Blood or urine specimens may need to be analyzed if it is thought that alcohol, medications, or illicit drugs may have been involved in the causation of the violent event. Important distinguishing criteria for self-inflicted injuries, as opposed to those inflicted by others, are the intensity, location, surface area, structure, and overall severity of the injury (Table). Sometimes the forensic medical examination reveals the presence of nearly all of the pathognomonic criteria for a self-inflicted injury (24). Figure 4, for example, shows an injury allegedly inflicted by skinheads on a wheelchair-bound young woman. Each of the about 30 individual scratches runs evenly in a straight line. The scratches are parallel, meet at right angles, and rarely extend beyond the points where two orthogonal lines meet; together, they form a precisely drawn, immediately recognizable swastika. Our experience in forensic medicine indicates that the characteristic features listed in the Table hardly ever suffice to establish the diagnosis conclusively in individual cases, yet the more criteria fulfilled, the greater the suspicion of a self-inflicted injury. Discrepancies between the "victim's" description of the event and the objective findings may further strengthen this suspicion. Police detective work may also turn up the implements used, such as a knife or razor blade, in the individual's possession, sometimes with traces of blood, as well as the presence or absence of bloodstains at the alleged scene of the crime. At times, even self-inflicted injuries may be quite deep (e.g., a stab injury entering the peritoneal cavity) or in atypical locations (stab wounds on the back; see Reference (4)). Though the list of typical features and accompanying circumstances is long, no schematic flowchart or checklist for self-inflicted injuries can be given that would guarantee a correct diagnosis in every case. The indispensable initial step for clinicians confronted with this situation is simply to consider the possibility that the injury might be self-inflicted. The physician suspecting a self-inflicted injury must Figure 4: Swastika scratched into the left cheek of a 17-year-old proceed with extreme sensitivity female high school student, with the typical features of a self-inflicted injury. and awareness of the attendant Dtsch Arztebl 2006; 103(40): A 2627–33 ⏐ www.aerzteblatt.de 6 MEDICINE TABLE Characteristic features of self-inflicted injuries versus injuries inflicted by others Feature Injuries inflicted by others Self-inflicted injuries Type of injury Usually stab wounds, occasionally cuts Nearly always cutting or scratching injuries or blunt trauma Number of individual injuries A large number is rare Often present in large numbers Location Anywhere on the body Preference for easily accessible parts of the body not covered by clothing (e.g., limbs, cheeks, forehead, anterior trunk); sparing of sensitive areas (e.g., lips, nipples); the back and other inaccessible areas are hardly ever injured; usually on the side opposite the dominant hand Arrangement Random Often in groups; there may be large numbers of parallel injuries, arranged in rows; symmetrical Form and nature or individual injuries Usually short, sometimes of variable or markedly curved shape, forming no particular overall figure Often long, constant in shape, only mildly curved; may form geometric shapes, symbols, letters, or words Intensity of individual injuries Highly variable, often deep Always superficial; notably even depth of injury (also on body surfaces that are not flat) Fine structure of individual injuries Hardly any Branching patterns, accurate start of new lines Overall severity of injury Usually severe or very severe Nearly always mild or very mild Self-defense injuries Common, usually deep; most frequently Absent or atypical, superficial cuts on the fingers, on the palms, flexor surfaces of the hands, and forearms fingers, and ulnar surface of the forearms Clothing Included in the injury in a manner Usually not harmed, or harmed in a manner corresponding to the presumed posture that is not congruent to the injury during the attack; many signs of struggle Accompanying injuries of other types Common Very rare Evidence of repeated injury (old scars) Rare Often, linear scars of varying ages modified from 7, 15, 25 difficulties. The diagnosis should be communicated to the patient in a kind and empathic manner, yet without leaving any possibility of doubt. The patient need not be immediately and forcefully confronted with the need for treatment (16). There may still be a chance to point out to the patient that unnecessary difficulties will be avoided if he or she refrains from making a complaint to the police (4). Sometimes psychiatric or psychotherapeutic help will only be accepted after a latency period in which the physician offers multiple times to act as an intermediary. If a complaint to the police has already been made or cannot be avoided for other reasons, the police should be informed in timely fashion of the suspected diagnosis of self-injury, so that they will not embark on an extensive and fruitless search for the supposed perpetrators. Even when it has become clear that the simulated crime was actually a case of self-injury, the district attorney has the discretion not to prosecute, despite the fact that the simulation of a crime itself constitutes a punishable offense. The criminal proceedings can be suspended, or punitive measures can be dispensed with (§153b of the German criminal procedure regulations), on the basis of a low degree of guilt or lack of public interest (§153) or upon the fulfillment of requirements imposed by the authorities (§153a). If the individual has already been charged with an offense, the court can still terminate the proceedings by agreement with the prosecution. Conflict of Interest Statement The authors declare that no conflict of interest exists according to the Guidelines of the International Committee of Medical Journal Editors. Manuscript received on 10 October 2005, final version accepted on 30 March 2006. Dtsch Arztebl 2006; 103(40): A 2627–33 ⏐ www.aerzteblatt.de 7 MEDICINE Translated from the original German by Ethan Taub, M. D. REFERENCES This text is a translation from the original German which should be used for referencing. The German version is authoritative. 1. Möllhof G, Schmidt G: „Selbstbeschädigungen“ – psychiatrische, rechts- und versicherungsmedizinische Aspekte (I). Versicherungsmed 1998; 50: 226–31. 2. Püschel K, Kleiber M, König HG, Strauch H: Zum Verletzungsmuster bei Selbstbeschädigung. In: Festschrift für Gunther Geserick. Heppenheim: Helm 1999; 71–81. 3. Banaschack S, Madea B: Selbstbeschädigung. In: Madea B: Praxis der Rechtsmedizin. Berlin, Heidelberg, New York: Springer 2003; 268–73. 4. Kernbach-Wighton G: Selbst zugefügte Verletzungen. Rechtsmed 2004; 4: 277–93. 5. Behrmann K, Wienberg H, Püschel K: Zur Vortäuschung von Sexualdelikten. Eine Untersuchung unter Berücksichtigung selbst beigebrachter Verletzungen. Kriminalistik 1990; 44: 207–10. 6. 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Püschel K, Hildebrand E, Hitzer K, Al-Hashimy S: Selbstverstümmelung als Versicherungsbetrug. Unfallchirurgie 1998; 24: 75–80. 24. Kleiber M: Morphologie der Selbstbeschädigung. In: Saternus KS, Kernbach-Wighton G: Selbstbeschädigung. Forensische Bewertung und Therapiemöglichkeiten. Rechtsmedizinische Forschungsergebnisse Band 14. Lübeck: Schmidt-Römhild 1996; 11–7. 25. König HG: Spurentechnischer Vergleich realer und fingierter Überfälle. In: Saternus KS, Kernbach-Wighton G: Selbstbeschädigung. Forensische Bewertung und Therapiemöglichkeiten. Rechtsmedizinische Forschungsergebnisse Band 14. Lübeck: Schmidt-Römhild 1996; 23–49. Corresponding author Dr. med. Steffen Heide Institut für Rechtsmedizin Martin-Luther-Universität Halle-Wittenberg Franzosenweg 1 06112 Halle/S., Germany [email protected] Dtsch Arztebl 2006; 103(40): A 2627–33 ⏐ www.aerzteblatt.de 8