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DOI: 10.1177/1534650113504821 2014 13: 181 originally published online 1 October 2013Clinical Case Studies

Paul R. KingCognitive-Behavioral Intervention in a Case of Self-Mutilation

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Article

Cognitive-Behavioral Interventionin a Case of Self-Mutilation

Paul R. King1

Abstract

Self-injurious behaviors are common among clinical populations, and have been associated withmood disturbance, personality pathology, and trauma histories. Such behaviors often serve

to displace emotional pain, produce physical or emotional sensations, or call for attentionfrom others. Genital self-mutilation in particular is a statistically rare phenomenon that is

typically associated with psychosis, extreme religious practices, or unsophisticated attemptsat sexual reassignment. The present report describes a unique case of genital self-mutilationin a nonpsychotic individual with history of chronic depression, hypersexuality, and sexualmasochism. Treatment consisted of a series of 10 individual therapy sessions that used

cognitive-behavioral and dialectical-behavioral techniques to reduce the frequency and severityof self-injurious behaviors, to increase distress tolerance skills, and to implement and maintaina healthy pleasurable activity schedule.

Keywords

cognitive-behavioral therapy, dialectical-behavioral therapy, genital self-mutilation, impulsive-

compulsive behavior, nonsuicidal self-injury

1 Theoretical and Research Basis for Treatment

As many as 4% of adults (Klonsky, Oltmanns, & Turkheimer, 2003) endorse nonsuicidal self-

injurious or self-mutilating behaviors. Self-injurious behaviors can pose a particular challenge

for clinicians given the complexity in managing the multidimensional nature of the problem. For

example, clinical management can transcend wound care, treating associated affective distur-

bances, and managing other short- and long-term biopsychosocial consequences of self-injury.

Such behaviors can exist within and outside the context of sexual activity. Common correlates of

nonsexual self-injurious behaviors include younger age, depression, low social support, ClusterB personality features, sensation-seeking, and childhood sexual abuse (Heath, Schaub, Holly, &

Nixon, 2009; Joyce et al., 2006; Knorr, Jenkins, & Conner, 2013; Muehlenkamp, Brausch,

Quigley, & Whitlock, 2013). In contrast to paraphilic sexual masochism, literature suggests that

nonsexual self-injury typically happens impulsively and with minimal pain (Nock & Prinstein,

2005), serving purposes such as displacing emotional pain, producing physical sensation, induc-

ing an emotional “high,” managing stress, and attention-seeking action (Hicks & Hinck, 2009;

Nock & Prinstein, 2004; Starr, 2004). Some studies (e.g., Sacks, Flood, Dennis, Hertzberg, &

1VA Western New York Healthcare System, Buffalo, NY, USA

Corresponding Author:Paul R. King, Center for Integrated Healthcare (116N), VA Western New York Healthcare System, 3495 Bailey Ave.,

Buffalo, NY 14215, USA.

Email: [email protected]

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182 Clinical Case Studies 13(2)

Beckham, 2008) have found that a primary motivator for self-injurious behaviors is the percep-

tion that it leads to increased positive affect, even if only temporarily, and a review by Bresin and

Gordon (2013) suggested that self-injury may regulate affect by prompting the release of endog-

enous opioids. Yet others (e.g., Brown & Kimball, 2013; Buser & Buser, 2013) posit that nonsui-

cidal self-injury may constitute a process addiction. The recent edition of the Diagnostic and

Statistical Manual of Mental Disorders ( DSM-5; American Psychiatric Association, 2013) hasidentified nonsuicidal self-injury as a condition for further study.

Like nonsuicidal self-injury, there has not been a clear consensus as to whether problematic

sexual behaviors fall along an impulsive-compulsive spectrum (Mick & Hollander, 2006),

within a behavioral or process addictions model (Garcia & Thibaut, 2010; Schneider & Irons,

2001), or among a separate sexual disorder taxonomy (Bradford, 2001; Cantor et al., 2013;

Finlayson, Sealy, & Martin, 2001; Kafka, 2001; Kingston & Firestone, 2008; Marshall &

Briken, 2010). Although the pathological taxonomy and nomenclature of aberrant sexual behav-

ior are controversial (Karim & Chaudri, 2012; Samenow, 2010), it is clear that problematic

sexual behaviors do exist. For example, nonparaphilic hypersexuality can be associated with

medical and psychosocial risks such as infectious disease, mood disturbance, and relationshipconflict, particularly in cases where unprotected and multiple-partnered sex are routinely

involved. Some paraphilic behaviors, for example sexual masochism (which entails nonsimu-

lated injury by self or other), can be associated with increased risk of medical complications,

serious physical injury, and even death (consider hypoxyphilia, for example) depending on the

severity of the injury sustained. Some paraphilia-related behaviors (e.g., repetitive and exces-

sive use of pornography; Kafka, 2001; Kafka & Hennen, 1999) can also be associated with

isolation and psychosocial disruption.

Despite the prevalence of other self-injuring behaviors, genital self-mutilation is an especially

rare phenomenon (Catalano, Morejon, Alberts, & Catalono, 1996), and one that is typically asso-

ciated with psychosis (Chand, Kumar, & Murthy, 2010; Feldman, 1988; Nakaya, 1996). Some

literature suggests that nonpsychotic individuals engage in genital self-mutilating acts for reli-

gious or cultural purposes (e.g., self-circumcision), to deal with sexual guilt, or as independent

attempts at sexual reassignment surgery (Cole, O’Boyle, Emory, & Meyer, 1997; Feldman,

1988). Presumably due to the low base rate of the phenomenon, there is a corresponding paucity

of research specific to clinical interventions for nonpsychotic genital self-mutilation. However,

cognitive-behavioral interventions such as replacement skill training, behavior modification,

stimulus control, relapse prevention, cognitive restructuring, and dialectical behavior therapy

have shown promise in reducing the frequency of impulsive-compulsive behaviors, paraphilic

and hypersexual acts, and other forms of self-injurious behavior (see Andover, Pepper, & Gibb,

2007; Bradford, 2001; Dracobly & Smith, 2012; Feldman, 1988; Franklin, Zagrabbe, &

Benavides, 2011; Healey, Ahearn, Graff, & Libby, 2001; Kreuger & Kaplan, 2002; Linehan et al.,1999). Recent literature (e.g., Muehlenkamp et al., 2013) suggests that interventions that target

improving social support, coupled with emotion regulation skills, also may be of therapeutic

benefit.

2 Case Introduction

The present report describes a case of genital self-mutilation in M, an individual with a history of

hypersexuality, excessive pornography use, and sexual masochism. M was a 56-year-old,

Caucasian, male Vietnam-era veteran referred to a Department of Veterans Affairs (VA) outpa-

tient mental health clinic by his psychiatrist for treatment for dysthymia and nonsuicidal self-injurious behavior. He lived alone and was unemployed at the time of intake. The therapist was

a predoctoral psychology intern who was supervised by a licensed clinical psychologist.


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King 183

3 Presenting Complaints

M described his chief complaints as depression and self-injury in the form of genital mutilation.

He reported a long history of depression and anxiety, with boredom, lack of concentration, and

rapid loss of interest in things as notable features of his mood disturbance. He also endorsed what

he referred to as a 30-or-more year history of autoerotic genital “manipulation,” which ultimatelyescalated to cutting behavior and other forms of self-mutilation.

4 History

M was born in a large metropolitan area to an intact family. He described a childhood wrought

with familial conflict and physical and emotional abuse. Multiple family members abused alco-

hol, and his paternal grandfather and great grandfather died by suicide. His mother died when he

was a teenager, and he eventually was estranged from all biological family members with the

exception of one sister. He enlisted in the military within 2 years of completing high school, and

married shortly thereafter. By his report, he was honorably discharged from the military after

approximately 1 year of service after revealing that he was bisexual. Though he divorced after 2years of marriage, he stated that he remained on amicable terms with his former wife. He admit-

ted to drinking and experimenting with illicit drugs during his 20s and 30s.

M described a history of hypersexuality from the time of his divorce through his mid 40s. By

his report, he engaged in solo and/or partnered sexual activity up to six times a day, at times

anonymously or with multiple partners. He stated that frequent sexual activity helped him man-

age stress, and that perception of his own sexual prowess improved his chronically low self-

esteem. He also became increasingly preoccupied with his genitalia during this time frame, and

began to frequently engage in what he termed genital “manipulation” as a habitual autoerotic,

masochistic act.

M was diagnosed with HIV/AIDS in his early 30s. Shortly thereafter, a long-term partner ofhis died from AIDS-related complications. M previously trialed antiretroviral therapy, but dis-

continued due to financial limitations, the perception that it would not help him, and belief that it

worsened a preexisting irritable bowel condition. His last partnered sexual activity was at approx-

imately age 45. Previous medical and mental health records suggested that he had injured his

penis in the past, though it is unknown whether this was intentional as with his current behaviors,

or unintentional side effects of the masochistic “manipulation” he described. One episode of

genital manipulation circa age 46 led to excessive penile bleeding, though he avoided emergency

medical treatment due to embarrassment. He hypothesized that this episode may have ultimately

contributed to the onset of erectile dysfunction, though there was no current medical evidence

that this was the case. He estimated that his last erection was at age 47, and he admitted to sub-stantial rumination over his impotence since that time. Even considering his inability to attain an

erection, he began to view pornography in excess, which he described as “out of character.” He

also reported that the types of pornography he sought access to had become increasingly “bizarre”

in hopes that it would stimulate him, though he did not provide explicit details on the content.

M reported that depressive symptoms had been present for most of his life, and that he also

suffered from a historically low frustration tolerance. He cited a single inpatient psychiatric hos-

pitalization for suicidal ideation, but framed it in the context of a consequence of sleep depriva-

tion over several days. This hospitalization coincided temporally with the onset of erectile

dysfunction. He endorsed a long history of suicidal ideation and fantasies of public suicide, but

denied history of attempts, intentions, and plans to end his life. Though he had credentials as a

home inspector, he was prevented from working due to disability, and his only current income

was derived from disability benefits. He accrued over $20,000 worth of debt due to longstanding

financial limitations, and his home was in foreclosure. He occasionally attended religious


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services, sang in a choir, and had lunch with two acquaintances. Prior to initiating this episode of

treatment, he had been linked intermittently with multiple other therapists and psychiatrists for

management of depression over two decades, with his last use of psychotherapeutic services 4

months prior. He reported that he had discarded many of the tools with which he injured himself

at the urging of his medical and psychiatric providers, but admitted to retaining a wire brush,

paint scraper, and box cutter.

5 Assessment

M completed two neuropsychological assessments prior to commencing therapy for his current

concerns. The first evaluation found mild deficits in verbal learning and recall associated with

severe depression. The second evaluation (2.5 years later) found similarly severe depressive

symptoms. Personality assessment indicated that he was prone to obsessive and negative rumina-

tions, and suggested that therapeutic interventions avoid introspective self-analysis in favor of

concrete problem-solving interventions. Though previous medical records documented history

of stroke with mild memory loss, neither neuropsychological evaluation suggested substantialcognitive impairments typically associated with history of stroke or immunodeficiency. During

the course of the current treatment episode, M was assessed with the Beck Depression Inventory-II

(Beck, Steer, & Brown, 1996), which suggested severe symptoms of depression; the Beck

Anxiety Inventory (Beck & Steer, 1993), which suggested mild to moderate anxiety; and the

Alcohol Use Disorders Identification Test–Consumption questions screening tool (AUDIT-C;

Babor, Higgins-Biddle, Saunders, & Monteiro, 2001), which did not suggest current alcohol

abuse. Self-report ratings of mood pathology were consistent with history documented over

many years. As such, the primary assessments during the current treatment episode pertained to

tracking the frequency and severity of self-injurious behavior as well as the frequency and nature

of pleasurable activities.

6 Case Conceptualization

M reported a long history of hypersexuality and masochistic activity. He recently began to utilize

an excessive amount of pornography despite that he felt it was “out of character” for him. He

admitted to using sexual activity as a coping skill, and indeed linked his sexual performance to

his self-worth. Impotence was a notable point of rumination for him, and he went to great lengths

to seek stimulation via use of masochism and viewing pornography, which intensified in terms of

frequency, duration, and content over the years. The frequency and manner in which he viewed

pornography resembled the concept of behavioral addiction. Genital manipulation escalated to

mutilation in an attempt to experience penile sensation; evidence of a sensation-seeking motiva-tion was found in his description of what motivated his self-injurious behavior: “When I see

blood, it’s like a climax; I feel that there’s life down there.”

Cognitive-behavioral and dialectical behavioral techniques, to include behavior chain analy-

sis, have been implemented in cases of nonsuicidal self-injury (e.g., Andover, 2012). The primary

behavioral antecedent to M’s self-injury appeared to be his use of internet pornography, though

isolation and close proximity to tools with which he typically would injure himself were also

important contextual factors. Specific target behaviors included cutting, squeezing, and piercing

his penis and scrotum, and inserting foreign objects into his urethra. Consequences of his self-

injurious behavior included the primary reward of sensation (perhaps as a substitute for sexual

release), but also necessitated wound care and may have contributed to ongoing issues withincontinence.

Beyond the hypothesis that M’s self-injurious behaviors were attributable to a sensation-

seeking hypothesis, other explanations for M’s behaviors may be viable as well. For example, it




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King 185

is possible that his actions were an extension of his masochistic tendencies and sexual fantasies.

It is plausible that he became desensitized to severe masochistic activities over time. Self-injury

also could have served to manage stress in the absence of his ability to attain an erection. As

sexual activity had certainly been a significant component of his identity, he may have at times

acted to punish himself out of depression or self-loathing, and a body of literature does exist to

support that some individuals self-injure to alleviate feelings of guilt (Inbar, Pizzaro, Gilovich, &Ariely, 2013). Aside from his difficulties with impulse control, a number of other Cluster B per-

sonality features and risk factors were evident as well. For example, persistent mood disturbance,

chronic suicidal ideation, and disruption of identity were important historical trends. Other clini-

cal factors, such as personal abuse history, inadequate social support, and suboptimal engage-

ment in medical treatment for wound care and HIV/AIDS management were also noteworthy.

7 Course of Treatment and Assessment of Progress

M presented for 10 sessions of individual therapy, scheduled weekly for 50 min each. The first

session was dedicated to a comprehensive intake, consisting of mental status examination, per-sonal medical and social history, lethality assessment, and behavior chain analysis, which detailed

self-injurious behaviors as recent as approximately 2 weeks prior to intake. Session 2 centered

around joint treatment planning and introducing basic cognitive-behavioral principles and tech-

niques such as identifying core beliefs, belief testing, and behavior modification. At this meeting,

M commented that psychotherapy had recently been his only positive interpersonal exchange,

and he was hopeful that it would facilitate his ability to lead a healthier life. Consistent with ini-

tial aims of dialectical behavioral therapy, a general goal was to reduce behavioral dyscontrol.

Specific treatment goals included reducing the frequency and severity of self-injurious behav-

iors; implementing and maintaining a healthy pleasurable activity schedule; and enhancing M’s

overall quality of life.

At Session 3, M reported that he had resumed self-injury by striking his penis with a wire

brush and “jamming” his finger into his urethra, which resulted in excessive penile bleeding. He

recounted that this and other episodes of self-injury began after using pornography, and described

regular feelings of self-loathing. Medical records suggested that he refused wound examination

at an earlier clinic visit. Additional coping strategies were introduced, including distress toler-

ance skills (e.g., distraction and self-soothing skills) and activity scheduling. We also discussed

the possibility of pharmacological therapy as a way to continue moving toward M’s goal of a

better quality of life. M agreed to follow up with his medical care provider for wound care and to

discuss the merits of starting a medication, and was ultimately started on alprazolam .25mg as

needed. By the time of our fourth session, M reported one additional instance of nonpenetrative

self-injury and increases in suicidal ideation. This meeting was dedicated to crisis managementand safety planning. Sessions 3 and 4 endured for 60 and 75 min, respectively.

M reported improvements in mood in Sessions 5 and 6. He limited his use of pornography and

did not engage in self-injurious behavior. He also had been implementing a behavior activation

plan which included watching comedy and going to see movies. Over the course of these meet-

ings, he discarded some other items that he used to injure himself and was able to successfully

use response-prevention skills to avoid pornography on some occasions, and to avoid what he

described as the “temptation” to self-injure. He agreed to trialing an antidepressant after Session

6, and also began to discuss the possibility of resuming antiretroviral medications with his medi-

cal provider at his regularly scheduled follow-ups.

M reported one episode of genital cutting at Session 7. He did not take alprazolam one day,relapsed with pornography use, and subsequently cut his penis. In contrast, he was notably bright

at Sessions 8 through 10, consistently indicating that he felt more hopeful and “in control” of his




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King 187

use of pornography, discontinue self-injurious behavior, increase social contact, and maintain a

pleasurable-activities schedule. A significant strength of this treatment setting was that it allowed

for regular, direct communication and consultation with medical providers, and facilitated multi-

disciplinary care management for this individual. Despite the relative success of this therapeutic

endeavor, M did relapse with self-injury three times over the course of therapy. However, with

ongoing medical, psychiatric, and therapeutic support, M appeared to maintain therapeutic gainsat approximately 2 months post-intervention.

12 Recommendations to Clinicians and Students

The nature of presenting concerns, client preferences, and limitations of clinical settings do not

always allow for the full implementation of manualized treatment protocols. However, M’s case

highlights that the use of cognitive-behavioral and dialectical-behavioral techniques is flexible

and indeed can afford the opportunity for clients to learn a set of skills that are highly transfer-

rable to their daily lives. Despite the effectiveness of these approaches, the importance of the

therapeutic alliance and clinical supervision and technical consultation cannot be understated.Given the delicacy and multimorbidity of M’s presenting concerns, a strong therapeutic alliance

served to promote the notion that the therapist and client would work together to develop treat-

ment and safety plans, and to establish short- and long-term goals. Treatment planning and goal-

setting were facilitated by open and ongoing communication among M’s therapist, psychiatrist,

and medical provider. Although neither supervisor nor supervisee had clinically managed genital

self-mutilating behaviors in the past, each had experience in the delivery of cognitive-behavioral

and dialectical behavioral interventions, and biweekly supervision was used to plan interventions

and to review progress.

Author’s Note

The views expressed in this article are those of the author and do not necessarily reflect the position or

policy of the Department of Veterans Affairs or the United States government.

Declaration of Conflicting Interests

The author declared no potential conflicts of interest with respect to the research, authorship, and/or publi-

cation of this article.

Funding

The author disclosed the receipt of the following financial support for the research, authorship, and/or pub-

lication of this article: Writing of this article was supported in part by the Department of Veterans AffairsOffice of Academic Affiliations, Advanced Fellowship Program in Mental Illness Research and Treatment;

the Department of Veterans Affairs Center for Integrated Healthcare; and the VA Western New York

Healthcare System at Buffalo.

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Author Biography

Paul R. King is a postdoctoral fellow in the VA Advanced Fellowship Program in Mental Illness Research

and Treatment. He earned his MA and PhD from the University at Buffalo, State University of New York.

Documents

Clinical Case Studies Cbt Autolezare