Self cutting behavior precipiated by Abilify and the psychology of self cutting

A woman in her mid forties, who suffers from extensive psychiatric problems, the core of which is her extremely high level of anxiety, reported that on being put on Abilify 10 mg., instead of getting better, began cutting herself.

She at once added that it is not a suicidal behavior, though everyone is viewing it that way, and repeatedly hospitalizing her when she goes to the ER to get the cuts stitched.  She had had four admissions in two months. After a little reflection she said that it could be suicidal behavior too, because at one point, in between the cuttings, she tried to hang herself.

On stopping the Abilify, the thoughts to cut herself went away.

When I stated to her that Abilify by itself could not have caused the behavior, and some other experiences in the past must have set the stage for Abilify to enable the self-destructiveness, she said that she was constantly hearing the warning that they blare at the end of drug commercials as to what the drug can do to you and Ability commercial tells you that it will make you suicidal.

"Maybe it was the commercial playing at the back of my mind impelling me to cut myself."

This conjecture was, of course, rejected by both of us. The commercial alone could not have had such a powerful effect, and the psychogenic roots of self-cutting had to be searched for elsewhere.

Patient then recalled that the self-cutting had began 10 years ago, and after a few years had gone away, only to reemerge on being placed on Abilify.

She could recall the very first time she cut herself.

"I was fighting with my husband and could not defend myself. So I broke a bottle and cut myself with it, and it felt so good. Cutting relieved myself of anger."

"Why did you not cut your husband instead?"

"I wanted to hurt him. But he was huge. In one move he would have strangled me. So I had no choice but to take the anger out on myself. I cannot describe the relief it gave me. After that anytime something would upset me very much I just knew how to end it. You know I have psoriasis. Whenever I get bad nerves I break out terrible. But cutting myself helped with the nerves. If I did not cut myself the psoriasis flared up even worse."

"Why would cutting yourself help with nerves?"

"If you cannot win them, join them. If I get really pissed off with someone, that person sits in my chest like a knot. The only way to get relief from that knot is to create a split in myself and see my body as somebody else's body and to cut it up. Once it becomes an alien then I can cut it and I feel no pain. Just tremendous relief. Though the next day its hurts."

"What do you mean you see your body as somebody else's?"

"I have to treat my body as a non-self before I can cut it. But before I turn it into non-self, I have to see myself as evil and full of hatred towards others that must be destroyed. In fact sometimes I do destroy my whole house. From one end to the other. The house symbolizes me. I am destroying myself for being evil. I even hit myself. I don't feel any pain while doing it. Just relief from anger. And when it is over calm. Though tired and sleepy. Only the next day I feel as if a truck has ran over me."

My construction that this beating herself up and getting a great release from it could be a form of sexual discharge, and the immense relief and calmness and falling asleep afterwards a form of orgasm, was rejected by the patient.

Another girl confirmed that what you are cutting in yourself is the person you hate but to whom you cannot do anything by stating the following: "When I get real mad I cut my wrist and that takes away the pain. It started with my parents. I was so angry at my father that I went to stab him with the pencil I was holding but at the last minute I stabbed it on my own self. It was a tremendous relief. After that whenever my parents made me mad, I would see myself stabbing them, but it would be my wrist that I would be cutting."

Obsessive visualization of violence as a protection against self cutting

A woman in her mid-twenties complained bitterly about her "madness" of seeing, in embarrassing details, her daughter being subjected to all kinds of violence.
When asked to give an example, she said like her running across the street and getting run over by a truck that smashes her skull into so many pieces. That she could imagine the violence in such minute details caused her intense shame and horror.
An interpretation was made that obsessive ruminations of violence happening to one's loved ones is a displacement of violence happening to one's own self. The original fear is of violence happening to oneself. However, the mind, in order to lessen the fear, reasons, unconsciously, as follows: there is someone there who you love so much that if this happens to him or her, you will suffer even more. So instead of now worrying about harm coming to yourself you start worrying about harm coming to someone very close to you. And as a rule, this fear of harm coming to oneself - and in displacement harm happening to the loved one - is a fear of retaliation for wishing harm to somebody else.
The patient protested that she wishes evil to nobody.
When it was explained that such irrationalthoughts of violence towards oneself could not arise de novo for nobody wishes harm to oneself for no reason. They make sense once one makes the presumption that they are punishment fantasy for having violent impulses towards others.
She wanted to know why would one want to punish oneself for wishing evil to others.
It is not you but your conscience/superego that wants to do that. It remains in the background, completely unconscious. Even the thought of harming others remains under repression and unconscious. What comes to the conscious mind is the affect of guilt, and images of retaliatory violence happening to oneself and those who are close to oneself.
She was not convinced but added that she has to concede that her constant sense of guilt makes no sense. She always feels guilty, which she should not, because she is a very conscientious person and strives to hurt nobody.
When it was explained that there is no such thing as irrational guilt and if there is guilt which one cannot account for that means in the unconscious mind there are evil intentions/thoughts, she added that she does see visual images of harm coming to herself.
"Like what?" I asked her.
"Like a I am combing my hair with an iron brush and the bloody layers of my scalp are peeling off. It is horrifying image."
"Any other images?"
"I see my head getting cut off or I am getting cut into two or I am hanging myself."
When interpretation was made that beheading is a symbol of castration and perhaps she sees it as a punishment for castrating someone else, she said she had never thought of cutting her husband's penis so I am wrong on that one.
But such a spontaneous association without any suggestion on my part that the impulse was directed against her husband, left me no choice but to assume that the person she wants to castrate is her husband.
When I said that perhaps the impulse is directed towards her husband, she said, "I cannot see that but I do admit that I am a cutter. When in great anxiety I cut myself. In my teenage years I was a great self-cutter."
Is cutting a self-punishment for the impulse to castrate others, I wondered silently.
But loudly I asked her if the imagery of her being cut in to two has to do with her parents getting divorced when she was four. The guilt of separating the parents in to two being avenged by her getting cut in to two.
She drew a blank on that construction. But added that number 6, or any multiple of number 3 is bad for her.
When asked to explain that she said that after her parents' divorce she had to live either with her father and her step-mother or her mother and grandmother. There was always three people, and she was always the odd one out, and she blames it upon her parents divorce.
At this point the patient started dreading that if she talks more about such thoughts, she will start cutting herself again which she has not done in years. She also admitted that she always fears that one of these days she will give into the thoughts of beheading or hanging herself.
It was explained that bringing such thoughts to consciousness protects one from acting upon them rather than other way round. Such impulses are more likely to get hold of the motor system without any hint to the conscious mind, if they are allowed to fester for too long in the unconscious, without any outlet.
Patient agreed and said," Yes you are right on that one. In my teenage years I just would have these irresistible urges to cut myself to get relief from guilt and anxiety and impending sense of doom. But since these obsessive images of harm coming to my children and myself have started coming to my mind I have stopped cutting myself. These images make me very uncomfortable and I feel horrible about thinking of such things happening to my children, but still it is better to deal with unpleasant thoughts than to deal with a cut arm, and having to explain it to the ER doctors."