BOOK REVIEW: Cutting: Understanding and Overcoming Self-Mutilation
Reprinted from Eating Disorders Review
January/February 1999 Volume 10, Number 1
©1999 Gürze Books
(by Steven Levenkron. New York: W. W. Norton, 1998; 269 pp; $25.00)
Over the past several decades clinicians have become more aware of the syndromes of self-mutilatory cutting and burning, which are distinct from actual suicidal intent and behavior. Cutting and burning are often associated with severe personality disorders, dissociative phenomena, and various disorders marked by impulsive and compulsive features.
In this easy-to-read book written for both the lay public and professionals, Steven Levenkron, perhaps best known for his previous book on anorexia nervosa, The Best Little Girl in the World, lightly touches on some of the research that's been done on cutting and self-mutilation. Dr. Levenkron enlivens the text with case histories and illustrations of caregiver-client interactions as they discuss and deal with these issues in therapy sessions. As Levenkron points out, self-mutilation is not listed as a separate diagnostic entity in the Diagnostic and Statistical Manual, but it is described as a behavioral pattern in association with other disorders, notably borderline personality disorder. He distinguishes clinically significant self-mutilation from the body piercing and tattooing that have become increasingly trendy over the past few years. Only time will tell whether further research will show that self-mutilation merits a separate diagnostic category.
Levenkron considers self-mutilation from the perspectives of phenomenology; its effect on others, including family, intimates, and friends; and its relation to attachment theory and developmental traumas such as childhood abuse, shame, and pain. He discusses how for self-mutilators these behaviors constitute attempts to cope and to emotionally self-regulate. Finally, through anecdotes and stories of self-mutilators and their therapeutic encounters, he describes paths to recovery. A resource list of self-help organizations is included.
The book is weakest in neglecting systematic observations that have been made on these phenomena, particularly in relation to co-morbidities, biology and temperament, and alternative treatments. Levenkron says little about self-mutilation in psychosis, developmental disorders such as Lesch-Nyhan syndrome, or the many other disorders in which it is seen. He also says little about trichotillomania (abnormal hair-pulling). Nothing is included about cognitive and behavioral approaches that have been used for these conditions (see Psychiatr Serv 48:1131, 1997), about medications that may been helpful (J Nerv Ment Dis 185:348, 1997; J Clin Psychiatry 58:32,1997), and about the fact that several animal models of self-injurious behavior exist.
Those seeking authoritative and critical reviews of the research and treatment literature in this area will have to look elsewhere. For example, see J Nerv Ment Dis 186:259,1998, for a general review; check Clin Psychol Rev 18:531, 1998, and J Clin Psychol 53:177, 1997, on the functions of self-mutilation; and see Am J Orthopsychiatry 67:650, 1997 on self-mutilation in substances abusers. Good articles on biological and personality research can be found in Psychiatry Res 69:17,1997 and J Psychiatr Res.31:451,1997.
Despite its shortcomings, this book may be helpful for those who wish to offer their self-mutilating patients reading material to show that they are not alone, to offer some possible explanations, and to suggest that people do get better.