To the Editor: Non-suicidal self-injury (NSSI) is defined as intentional, direct damage to one’s body tissue without suicidal intent. Although it is often associated with several types of syndromes and mental disorders, such as major depressive disorder, schizophrenia, substance abuse, anxiety disorders, eating disorders, personality disorders, and posttraumatic stress disorder, is not usually related to mania.1
We describe a case of a patient with bipolar disorder in which the onset of NSSI has been associated with manic episodes, during a period of ultradian cycle.
When “Mr. John” was 31 years old, he had his first mood episode, a depression crisis, followed by a switch into mania. Afterward, he remained euthymic for 10 years, when he had his second episode of depression with another switch into mania.
In the 4 following years, the mood episodes became more frequent and more severe. Then, at the age of 45, the patient started to show ultradian cycling—switching between episodes of mania and depression during a 24-hour day. In this period, he also presented psychotic symptoms: olfactory hallucinations during depression; and delusions of grandeur, thinking that he had a superior intelligence and could move objects with the power of his mind, during mania.
During these short manic episodes, which lasted around half an hour, Mr. John commonly shouted and destroyed objects. So, in one of these daily episodes of mania, he hurt himself for the first time, piercing his abdomen with a hot fork. This brought him relief from his irritability and calmed him down. Then, the next day, he scratched his arms and chest with a wire until he bled, feeling even more pleasure. Thus, the practice of scratching himself has become frequent during these crises. Sometimes, he knocked his head against the wall and whipped himself with a steel cable, too, when the wire was out of reach.
Mr. John, in outpatient treatment, was taking lithium (1,200 mg/day) and valproic acid (1,000 mg/day), without significant improvement. However, when quetiapine (800 mg/day) was added to both prescription drugs, the ultradian cycling and the NSSI stopped completely, without recurrence for the last 2 years. The symptoms became milder, with absence of psychotic symptoms; but switches of mood remain, on average, every fortnight, where he remains euthymic for a short period.
In the case of Mr. John, the introduction of quetiapine was associated with remission of NSSI and ultradian cycling. Indeed, this atypical antipsychotic has shown to be efficient in cases of rapid-cycling bipolar disorder2 and in NSSI, with reports of improvement in impulsivity and hostility in patients with borderline personality disorder.3
Furthermore, the main function of the practice of NSSI, in literature, would be the regulation (prevent or suppress) of negative affects of high arousal, such as dysphoria,1 as it was seen in this case.
Despite these relations, and the fact that impulsivity and dysphoria are prominent symptoms both in manic states4 and in NSSI,5 this is the first time, as far as we know, that this association between irritability in a manic episode and NSSI is described. More research in this area is needed to clarify this relationship.