Van Gogh syndrome

Van Gogh syndrome is a mental condition in which an adult performs self-mutilations. It usually happens on the ground of a specific psychiatric condition.[1][2] The term is derived from the action of Vincent van Gogh in 1888, cutting off his own ear, or a part of it, after a quarrel with fellow artist Paul Gauguin[3][4] during one of his psychotic episodes.[5] Sufferers may burn themselves, attempt to severely damage their genital organs (especially amputate their penis), castrate themselves, extract their own eyes, amputate their own hands, or commit suicide.[5] Self-injury in children may be labeled with different diagnostic terms such as Lesch-Nyhan and Munchausen syndromes.[6]

Vincent van Gogh, Self-Portrait with Bandaged Ear (1889), Courtauld Institute of Art, London

Another medical condition for which the term is used, but only rarely, is when the vision turns yellow for a period of time as, for example, in digoxin toxicity.[7] Van Gogh syndrome is, now, a synonym for Nonsuicidal Self-Injury (NSSI), where participants intentionally and repetitively inflict injuries on their bodies without suicidal intention and not social sanctioned. These injuries are not meant to cause lethal harm and range from biting, scratching, cutting to serious acts like mutilating reproductive parts.[8] Self-injuring occurs quite commonly in children from 9–18 months, and is considered pathological in children beyond 3 years of age.[9] NSSI is most prevalent in adolescents and patients with diagnosed psychological illnesses, however frequent incidents are also recorded among young adults. In the past, NSSI was thought of as symptoms that associated with many psychological conditions, not an entity by itself. With increasing reports of prevalence and causative origins, recently, NSSI has been classified as an independent syndrome that can co-occur with a variety of other mental conditions. The fifth edition of Diagnostic and Statistical Manual of Mental Disorder (DSM-5), published in 2013, has officially recognized NSSI as its own entity and updated diagnostic methods for patients with clinical symptoms for NSSI.[10] NSSI patients usually use self-mutilation as a mean to relieve stress and negative feelings, often harbor thoughts of self-injure, repeat injuries, and experience satisfaction post-action. Although NSSI is often associated with suicidal attempts, there is a clear distinction between the two conditions.[11] People who practice NSSI do not set death as their final goal. Severity of wounds may vary and some may end up needing medical attention, however, the purpose is never to cause lethal harm.[8] Indeed, NSSI serves as several functioning outlets for participants, including negative and positive reinforcements.

Diagnostic

Because NSSI is associated with a wide range of psychological syndromes, like eating disorders, dissociative disorder, borderline personality, depressive disorders, and suicidal, it used to be regarded as manifesting symptoms of these conditions.[11] Nevertheless, many cases have been reported where patients with NSSI were diagnosed without comorbidity of any other psychological dysfunctions. Thus, it is irrefutable that NSSI is a stand-alone syndrome with distinct symptoms and causes. The DSM-5 outlines 6 criteria that patients must qualify for diagnostic.[12]

  1. Criteria A: the person must be involved in at least 5 days of self-mutilation without suicidal intention in the past year. However, this number has been reported to be relatively low when compared to realistic rate for adolescents, which was 11 days in one year.[10]
  2. Criteria B: persons must commit self-injure behaviors due to interpersonal problems, whether it is to alleviate unpleasant feelings and stress from such problems, or to seek positive feelings and relief. Studies have shown that females tend to expect relief from negative feelings and stress more than males.
  3. Criteria C: persons must be struggling from negative feelings and thoughts prior to NSSI, thoughts of NSSI are premeditated and constantly occupied in their minds.
  4. Criteria D: self-injure behaviors must be not socially sanctioned or minor wounds. This means that tattoos, piercings, or scab-picking are not considered as NSSI.
  5. Criteria E: NSSI-related emotional issues must be interfering with daily tasks like school/work relationships, or performances.
  6. Criteria F: NSSI must not overlap other dysfunctional episodes from other mental conditions, like withdrawal symptoms from drug abuse or eating disorders, psychosis, delirium, or substance intoxication. This criteria serves to rule out any consequential characteristics of self-injury behaviors as result of these episodes.

Risk factors

Adolescents are the most prevalent age group for NSSI, the average age of onset is around 13–14 years old. Studies showed that adolescents are vulnerable to NSSI due to the sensitive transitional period in life that happens during adolescent years.[8] NSSI is usually induced by stress and feelings of uncontrollable stress and anxiety, while adolescents and young adults face a wide range of challenging life events, different changes, along with limited mental control to protect them from self-harm decisions. Thus, a high percentage of NSSI participants admits to carrying out self-injure behaviors as a mean of coping mechanism. Adolescents also harbor external and internal factors that put them in the at-risk age group.[11] External factors include childhood events, parenting condition, or peers. Children that went through childhood adversities are more prone to cognitive distortion that tend to permit NSSI behaviors. Severity of such adversities also play a major role in increasing risk for adolescents. Those who grew up with child maltreatment like physical/sexual or emotional abuse, household with drug-use problems, negligence, poverty, exposure to parental violence,... are more likely to develop psychopathology in later years.[11] Women with NSSI tendency are shown to have experienced emotion negligence from both parents and insecure paternal bonding, while men with NSSI tendency are predicted to have gone through parental abandonment, mostly from father.[13] Non physically abusive parenting can also place high susceptibility on adolescents. Parental control refers to when parents want to influence their child either by physical or emotional manipulation, while parental support implies behaviors that are encouraging, accepting, and supportive. Households with heavy use of parental control, and lack thereof of parental support, usually lead to high tendency of NSSI. Internal issues stem from emotional dysregulation and psychological distress also push individuals towards NSSI tendency.[11]

Inability to digest and process emotional situations can lead to improper or insufficient awareness and understanding of emotional responses. Misjudgment of emotional surroundings also result in outbursts that are beyond acceptable range of emotional response. Individuals that are under psychological distress also fall into the at-risk group due to constant heightened state of anxiety from demanding stressors and unregulated external stimuli. People with other existing psychological conditions like BPD, EDs, or other dissociative disorders may also develop NSSI. NSSI is often seen as a coping mechanism for patients that are suffering with stress and psychopathology.

Functions

An overwhelming amount of NSSI cases were reported in accordance to stress release intention. Most NSSI patients are associated with sadness, anxiety, depression, feeling of abandoned, and isolated, they often find themselves trapped in high amount of uncontrollable stress and emotional burden that are hard to endure; living quality is also negatively impacted. Inflicting physical wounds is an outlet to relieve unbearable distress, the act of cutting through skin is a mean to physically lesson the pain, and many have reported that feeling of satisfaction and goodness were perceived post-injury.[8] Among other individuals, NSSI behaviors are also considered as a way to self-punish and self-directed anger. Other uses of NSSI include wanting to fit in, gaining attention, and alleviating emotional numbness.[11] NSSI functions are classified into four sub-functions: automatic negative reinforcement, automatic positive reinforcement, social negative reinforcement, and social positive reinforcement. Automatic negative reinforcement aims to eliminate feeling of emotional numbness or negative feelings of emotional disturbances, automatic positive reinforcement seeks to gain any type of feelings, even pain, social negative reinforcement helps individuals get away from feeling peer pressure and being forced to do things against their wills, lastly, social positive reinforcement is done to attain attention, negative or positive.[13]

Overall, automatic negative reinforcement and automatic positive reinforcement prevail the other two methods, while automatic negative reinforcement is more common than automatic positive reinforcement. These findings correspond to popular utilization of NSSI as tool to alleviate negative stress. Individuals that participate in automatic positive reinforcement have higher risk for suicidal attempts. The desire to obtain certain feelings from self-mutilation tends to push those individuals towards higher frequency of self-harm repetition, along with desensitization to pain and elimination of fear towards suicidal thoughts.[11]

References
  1. Abram, Harry S. (1966). "The van Gogh Syndrome: An Unusual Case of Polysurgical Addiction | American Journal of Psychiatry". American Journal of Psychiatry. 123 (4): 478–481. doi:10.1176/ajp.123.4.478. PMID 5957391.
  2. Aryal, S.; Puri, P. R.; Thapa, R.; Roka, Y. B. (2011-11-24). "Van Gogh Syndrome| Journal of Nepal Health Research Council". Journal of Nepal Health Research Council. Retrieved 2018-09-19.
  3. Segen, J. (2010). Concise Dictionary of Modern Medicine. BookBaby. ISBN 9781609840730. Retrieved 2018-09-19.
  4. Taylor, R.B. (2016). White Coat Tales: Medicine's Heroes, Heritage, and Misadventures. Springer International Publishing. p. 128. ISBN 9783319290553. Retrieved 2018-09-19.
  5. "Postgraduate Medical Journal". Blackwell Scientific Publications. 1 July 1998 – via Google Books.
  6. "The American Journal of Psychiatry". American Psychiatric Association. 19 September 1967 – via Google Books.
  7. "Toronto Notes 2011 - Cardiology_and_Cardiovascular_Surgery - [PDF Document]". vdocuments.site.
  8. Klonsky, E David; Victor, Sarah E; Saffer, Boaz Y (November 2014). "Nonsuicidal Self-Injury: What We Know, and What We Need to Know". Canadian Journal of Psychiatry. 59 (11): 565–568. doi:10.1177/070674371405901101. ISSN 0706-7437. PMC 4244874. PMID 25565471.
  9. "Van Gogh syndrome". ResearchGate. Retrieved 2020-04-29.
  10. Zetterqvist, Maria (2015-12-01). "The DSM-5 diagnosis of nonsuicidal self-injury disorder: A review of the empirical literature". Child and Adolescent Psychiatry and Mental Health. 9: 31. doi:10.1186/s13034-015-0062-7. PMC 4584484. PMID 26417387.
  11. "Nonsuicidal Self-Injury". ResearchGate. Retrieved 2020-04-29.
  12. Gratz, Kim L.; Dixon-Gordon, Katherine L.; Chapman, Alexander L.; Tull, Matthew T. (October 2015). "Diagnosis and Characterization of DSM-5 Nonsuicidal Self-Injury Disorder Using the Clinician-Administered Nonsuicidal Self-Injury Disorder Index". Assessment. 22 (5): 527–539. doi:10.1177/1073191114565878. ISSN 1073-1911. PMC 5505727. PMID 25604630.
  13. Cipriano, Annarosa; Cella, Stefania; Cotrufo, Paolo (2017). "Nonsuicidal Self-injury: A Systematic Review". Frontiers in Psychology. 8: 1946. doi:10.3389/fpsyg.2017.01946. ISSN 1664-1078. PMC 5682335. PMID 29167651.
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