Intracranial Self-Stabbing Matthew Large, BSc(Med), MBBS, FRANZCP,*Þ Nicholas Babidge, MBBS, FRANZCP,þ and Olav Nielssen, MBBS, MCrim, FRANZCPÞ§ Background: Little is known about the psychiatric state of patients who stab themselves in the brain (intracranial self-stabbing), including whether the behavior is usually an attempt to commit suicide and whether it is performed in association with symptoms of psychotic illness. Method: A search for cases of intracranial self-stabbing in New South Wales, Australia (NSW), and a systematic search for published case reports of intracranial self-stabbing. Results: We located 5 cases in NSW in the last 10 years and 47 published case reports of intracranial self-stabbing since 1960. Intracranial self- stabbing was associated with a diagnosis of a psychotic illness in 27 of 49 (55%) cases in which a diagnosis was available. Intracranial self- stabbing was not always performed with the intention of committing sui- cide and does not usually have a fatal outcome. Conclusions: Intracranial self-stabbing appears to be an under- recognized form of self-harm that is associated with, but not limited to, psychotic illness. Key Words: suicide attempt, self-stabbing, penetrating injury, psychosis (Am J Forensic Med Pathol 2012;33: 13Y18) C ase reports of patients who stab themselves in the brain have appeared from time to time in surgical and pathology journals, but there has been only 1 case report in an English language psychiatry journal in the last 50 years. 1 By contrast, there have been regular case reports and small series describing the mental state of patients who self-enucleate 2,3 or shoot themselves in the brain. 4 Stabbing oneself in the brain is an unusual form of self-harm. The brain is almost completely protected by bone and can only be reached directly through soft tissue via the optic canal or orbital fissures. Protecting the brain from this method of entry is the natural aversion to self-harm involving the eye, which is the only external part of the body that has not been ritually mutilated in at least one culture, 5 and almost all the published cases of self-enucleation describe patients with a severe form of psychosis. 2 In contrast to self-stabbing of the brain, self-inflicted gunshot injury to the brain is a recognized method of committing suicide and only a small proportion of people who do so are believed to be psychotic. 4 In his book Bodies Under Siege; Self Mutilation in Culture and Psychiatry, Favazza described the 19th century case of a 25-year-old man with a severe psychotic illness who performed multiple self-mutilations, including self-emasculation, and who died after hammering a nail into his frontal lobe (p. 70). 5 In the only case report published in English in a psychiatric journal since 1960, Puri et al described a man in his 30s who survived a similar self-inflicted nail injury to the frontal lobe and who was also found to have a psychotic illness, probably schizophrenia. 1 The finding of 3 unpublished cases of intracranial self- stabbing in an earlier survey of major self-mutilation in the state of New South Wales (NSW), Australia prompted this study. 3 We aimed to perform a systematic search for published case reports of intracranial self-stabbing and to locate any additional cases of intracranial self-stabbing in NSW during the last 10 years. METHODS We found 3 cases of intracranial self-stabbing by surveying NSW psychiatrists. 3 Another case was located in the course of a multicenter study of survivors of violent suicide attempts 6 and a fifth case was found by asking senior neurosurgeons in each of the neurosurgical units in the state whether they had seen or heard of any patients admitted after intracranial self-stabbing in the last 10 years. Published case reports were located by searches of the electronic databases PubMed/Medline, PsycINFO, Embase, and Cinahl. We examined case reports of self-inflicted intracranial injury published in English between 1960 and 2008 using the following search terms: intracranial or orbitocranial or transor- bital or cranial or brain or cerebral or intracerebral and self-harm or suicide or self-injury or mutilation or injury. In addition, all fields of PubMed (including the abstract and the major subject heading) were searched using the terms: brain and pen or pencil or scissors or chopstick or knife or nail. The reference lists of any published cases were then hand-searched for further relevant publications. For the purpose of this article, intracranial self-stabbing was defined as self inflicted penetrating injury to the intracranial contents caused by the application of direct force rather than force inflicted through a trigger mechanism. Hence, nails ham- mered into the brain were included as self-stabbing, 7 whereas injuries caused by nail guns, 8 crossbows, 9 and improvised guns or explosives 10 were excluded. Cases in which an electric drill was used to penetrate the skull were included because the force directed toward the brain was applied manually. 11 Most of the published cases reported the patient_s age, sex, the type of injury, the instrument used, the medical outcome, the psychiatric diagnosis, and the stated motivation for the self- stabbing. However, few of the reports contained information about the patient_s mental state at the time of the injury, or their psychiatric history or social circumstances. Where possible, the authors of case reports that did not include a psychiatric diag- nosis were contacted by e-mail to ask whether a psychiatric diagnosis had been established. M.L. and N.B. independently examined the case histories and extracted the data, with no disagreement about the mode of injury, diagnosis, age, or sex. Approval for the multicenter study of survivors of serious suicide attempts was obtained from the Human Research and ORIGINAL ARTICLE Am J Forensic Med Pathol & Volume 33, Number 1, March 2012 www.amjforensicmedicine.com 13 Manuscript received October 8, 2009; accepted November 16, 2009. From the *Mental Health Service, Prince of Wales Hospital, Randwick, NSW, Australia; †School of Psychiatry, University of New South Wales, Randwick, NSW, Australia; ‡Mental Health Service, Sutherland Hos- pital, Caringbah, Australia; and §Mental Health Service, St Vincent_s Hospital, Darlinghurst, Australia. The authors report no conflicts of interest. Reprints: Matthew Large, BSc(Med), MBBS, FRANZCP, The Euroa Centre, Mental Health Services, The Prince of Wales Hospital, Randwick, Sydney, NSW 2031, Australia. E-mail: mmbl)bigpond.com.au. Copyright * 2012 by Lippincott Williams & Wilkins ISSN: 0195-7910/12/3301Y0013 DOI: 10.1097/PAF.0b013e3181dd5b47 Copyright © 2012 Lippincott Williams & Wilkins. 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