Isr J Psychiatry Relat Sci Vol 45 No. 1 (2008) 39–48 Self-Mutilating Behavior in Patients with Dissociative Disorders: The Role of Innate Hypnotic Capacity Servet Ebrinc, MD,1 Umit B. Semiz, MD,1 Cengiz Basoglu, MD,1 Mesut Cetin, MD,1 Mehmet Y. Agargun, MD,2 Ayhan Algul, MD,1 and Alpay Ates, MD1 1 GATA Haydarpasa Training Hospital, Department of Psychiatry, Istanbul, Turkey ý 2 Yuzuncu Y l University, School of Medicine, Department of Psychiatry, Van, Turkey. Abstract: Background: Despite the fact that the assumption of a relationship between self-mutilation and dissociative disorders (DD) has a long history, there is little empirical evidence to support this premise. The present study exam- ined this relationship and investigated whether this commonality is associated with innate hypnotic capacity. Methods: Fifty patients diagnosed with DD and 50 control subjects with major depression were assessed by using a self-mutila- tion questionnaire, Dissociative Experiences Scale, Traumatic Experiences Checklist, and the Eye-Roll Sign for their self-mutilating behaviors, dissociative symptoms, early trauma, and innate hypnotic capacity, respectively. Results: We have found that 82% of the present sample of patients with DD injured themselves. They had higher scores on trauma, dissociation and eye-roll measurements than controls. In addition, DD patients with self-mutilation were more likely to have high scores of trauma, dissociation and eye-roll than those without self-mutilation. Innate hypnotic capacity was a strong predictor of self-mutilating behavior in DD patients. Conclusions: This study strongly supports the as- sumption that patients with DD are at high risk for self-mutilating behavior and points to the necessity of routine screening for self-mutilating behavior as well as the hypnotic capacity which may constitute a high risk for self-injury in this patient group. Introduction dissociative disorders (DD; 8). Particularly, studies Self-mutilating behavior, defined as deliberate self- conducted in patients with the most complex injury without conscious suicidal intent (1), is a dissociative disorder, dissociative identity disorder symptomreportedby4%ofthegeneraland21%of (DID), have found between 34% and 86% have histo- the clinical sample, and is equally prevalent among ries of self-mutilation (9, 10). Patients with DD have males and females (2). As a morbid form of self-help, been reported to have used more methods of self-in- self-mutilating behaviors often provide rapid but jury and started to injure themselves at an earlier age temporary relief from distressing symptoms such as than patients who have not dissociated (10). mounting anxiety, chaotic thoughts, rapidly fluctuat- Dissociation is the main characteristic for DD ing emotions, hallucinations and depersonalization and is defined as a conscious and/or unconscious (1). separation of mental processes (e.g., perceptions, co- Literature on self-mutilation has focused mostly nation, emotions, memories, and identity) that are on self-injurious behavior in personality disorders, ordinarily integrated in and accessible to conscious especially borderline personality disorder (BPD; 3). awareness. This may manifest as an adaptation to Because BPD is the only psychiatric diagnosis with stressinahealthyorpathologicalmanner.Itisbe- self-injuryasacriterion,itiscommontohearthe coming increasingly recognized that dissociative two equated in clinical settings. However, high rates processes can underpin self-injury (11). Some self- of self-destructive behaviors are found in patients mutilating patients have reported an altered state of with many different psychiatric disorders, such as consciousness while cutting or picking, resembling a major depression (4), antisocial personality disorder dissociative state, and declared that they have not ex- (5), post-traumatic stress disorder (6) and eating dis- perienced pain (1, 12). Childhood abuse, which is orders (7). This behavior is also prevalent in supposed by many to play an etiological role in the Address for Correspondence: Dr. Umit B. Semiz, GATA Haydarpasa Egitim Hastanesi, Psikiyatri Servisi, Uskudar, 34668 Istanbul, Turkey. E-mail: [email protected] 40 SELF-MUTILATING BEHAVIOR IN PATIENTS WITH DISSOCIATIVE DISORDERS development of dissociative symptoms, may be a ences. To avoid these psychosocial influences (type, variable that leads to both dissociation and the pro- severity and current level of the psychiatric illness, pensity to self-mutilation (3, 11). Alternatively, sev- comorbid psychiatric diagnoses, cognitive capacity, eral clinical observations (13) also suggest that medication used, etc.), determining particularly bio- dissociation and self-mutilation might be related in- logical hypnotic potential seems reasonable. Evi- dependent of abuse history. It has been hypothesized dence has also been found of a positive relationship that self-mutilation terminated the discomfort of between childhood punishment and child abuse and dissociative experiences, in particular, deadness and hypnotizability (23). Butler et al. (24) recently pro- depersonalization (14). Indeed, many self-injurers posed a diathesis-stress model to describe how report feeling emotionally numb, detached from pathological dissociation might arise from an inter- themselves or dead inside prior to the act, feeling lit- action between innate hypnotizability and traumatic tle or no physical pain during the act, and feeling experience. They suggested that high hypnotizability more alive, more real and more grounded following might be a diathesis for pathological dissociative the act (12). states, particularly under conditions of acute trau- A connection between dissociation and hypnosis matic stress. However, because of the lack of longitu- has been evident since the introduction of the term dinal studies, it can be difficult to tell whether the “dissociation” by Janet in 1889. Janet conceived of the high abilities of autohypnosis and capacity for disso- process of dissociation as an explanation for the phe- ciation are inherent and somehow genetically prede- nomena he observed during hypnosis and in hysteria termined, or if long practice has developed this skill. patients (15). Spiegel et al. (16) described Although high rates of self-injury have been re- hypnotizability as “the fundamental capacity to ex- ported in patients with DD, no study has investigated perience dissociation in a structured setting.” Simi- the relationship between self-mutilating behaviors larly, dissociative states have been defined as and innate hypnotizability among patients with DD. uncontrolled autohypnosis and patients with We hypothesize that DD represents one of the psy- dissociative disorders have most frequently been chiatric diagnostic categories which most commonly found to be highly hypnotizable (17). The capacity engage in self-injurious behavior and this common- for dissociation seems to be biologically determined ality may be associated with innate hypnotizability. and is reflected in the mobility of the external ocular On the premise that hypnotic potential is a construct eye muscles. Braid reported in 1843 that a patient that is related to dissociative processes, we expected could most rapidly and intensely be hypnotized as that DD subjects with higher levels of innate hyp- indicated by an upward eye gaze (18). notic capacity would show higher rates of self-de- Experimental studies investigating the relation- structive behavior. The present study assesses the ship between dissociative experiences and rate and clinical features of self-destructive behav- hypnotizability have revealed conflicting results (19, iors and investigates whether innate hypnotic capac- 20). Actually, current data associate the hypnotic ity may have predictive value of a high rate of self- state with a trait (21, 22) that manifests as an innate destructive behavior in a group of patients who have capacity to shift states of consciousness and varies on DD. a spectrum from low to high hypnotizability. In other words, innate hypnotic capacity is an ability whichallowsthehypnotizedpersontomakemaxi- Methods mal use of innate abilities to control perception, memory and somatic function. It represents both a Subjects potential vulnerability to certain kinds of psychiatric The participants of the present study were com- illness, such as posttraumatic stress, conversion and prised of 50 subjects (41 men, 9 women) consecu- dissociativedisorders,andanasset,inwhichitcan tively admitted to the in- and outpatient psychiatric facilitate various psychotherapeutic strategies. The unitsatGATAHaydarpasaTrainingHospital,anac- resulting experience for the subject is a reflection of ademic, tertiary care military hospital in Istanbul, genetically endowed talent and psychosocial influ- from June 2004 through May 2006. Dominancy of SERVET EBRINC ET AL. 41 male gender was due to the relatively higher admis- how one got there. Total scores are calculated by sion rate of male military personnel. Only those pa- averaging the scores of the 28 items. The DES is not tients who met the diagnostic criteria for any designed to diagnose dissociative disorders per se dissociative disorder according to the DSM-IV were andisgenerallyusedasascreeninginstrument.Itis eligible. They had no history or current symptoms of widely accepted as a standard measure of spontane- an organic condition that could cause psychiatric ous dissociation in both clinical and non-clinical symptoms. Subjects less than 18 years and those who samples. Typically,