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Survivors of self-inflicted stab wounds

Andrew Gerard, Gregory de Moore, Olav Nielssen and Matthew Large
Australas Psychiatry 2012 20: 44 originally published online 9 January 2012
DOI: 10.1177/1039856211432461

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APY20110.1177/1039856211432461Gerard et al.Australasian Psychiatry

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Clinical psychiatry

Australasian Psychiatry

Survivors of self-inflicted 20(1) 44­–48

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DOI: 10.1177/1039856211432461
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Andrew Gerard  Psychiatrist, St George Hospital, Kogarah, NSW, Australia†

Gregory de Moore  Psychiatrist, Westmead Clinical School University of Sydney, Westmead, NSW, Australia
Olav Nielssen  Psychiatrist, Clinical Research Unit for Anxiety and Depression, St Vincent’s Hospital and the Discipline of
Psychological Medicine, University of Sydney, Sydney, NSW, Australia
Matthew Large  Psychiatrist, School of Psychiatry, University of New South Wales, Kensington, NSW, Australia

Abstract
Objective:  There are a number of studies describing the survivors of self-incised wounds, but few studies have
described the psychiatric condition of survivors of self-inflicted stab wounds. We aimed to describe the character-
istics of a complete series of patients treated for self-inflicted stab wounds in a major hospital, and to compare the
characteristics of patients with psychotic illness to those with other conditions.
Methods:  A review of the files of all patients who had a psychiatric evaluation after presenting for treatment fol-
lowing deliberate self-harm. Stab wounds were defined as wounds made by a sharp instrument in which the width
was less than the depth.
Results:  There were 41 survivors of self-inflicted stab wounds among 2119 patients assessed after deliberate self-
harm. Of these, 15 were diagnosed with a psychotic illness and the remainder had other conditions, including
depression, personality disorder and substance use disorder. There was little difference in the demographic features,
clinical variables and in the proportion who were intoxicated between patients diagnosed with psychotic illness and
those with other disorders. The patients with psychosis were more likely to have inflicted multiple stab wounds, to
have stabbed their chest or abdomen and to have reported the intention of committing suicide.
Conclusions:  The results suggest that a significant proportion of patients who present for treatment after stabbing
themselves suffer from a psychotic illness. However, there were few differences in the characteristics of the patients
who had a diagnosis of psychosis and those with other disorders.

Keywords:  deliberate self-harm, hara-kiri, self-stabbing, suicide attempt

S
elf-stabbing is a well recognised method of suicide
and attempted suicide. The term to ‘to fall on one’s
sword’ has come to mean to accept responsibility
for failure, and the expression ‘hara-kiri’, understood to
mean suicide by a stab wound to the abdomen, is one of
a small number of Japanese words to have entered mod-
ern English.1 There are numerous references to suicide
by self-stabbing in mythology2 and among literary3 and
historical4 figures. A recent example can be found in the
film Black Swan, in which a troubled ballet dancer stabs
herself in the abdomen with a shard of mirror during
a drug-induced psychosis.5 Self-stabbing and self-incised
wounds are often seen in emergency departments,6 and
can be lethal. In Australia7 and in Japan8,9 about 2% of
completed suicides are by sharp object.
Despite the many historical and metaphorical references
to self-stabbing, surprisingly little is known about the
psychiatric condition of people who stab themselves,
and what is known comes from a small number of pub-
lished studies of the survivors of self-stabbing. One of
the first studies by Patel and de Moore described a series
of 10 survivors of deliberate self-stabbing, of whom five had
a combination of alcohol abuse and personality disorder
and five were psychotic.10 A second study examining the
surgical complications of a series of survivors of abdomi-
nal self-stabbing noted that five of 23 patients had a
diagnosis of psychosis, nine had depression and a further
nine patients were affected by substances at the time of
the stabbing.11 A recent study of the survivors of self-
inflicted injury using sharp implements that included
Correspondence:
Dr Andrew Gerard, Department of Consultation Liaison
Psychiatry, The St George Hospital, Gray Street, Kogarah,
Sydney, NSW, 2217, Australia
Email: andrew.gerard@sesiahs.health.nsw.gov.au

44
Gerard et al.
stabbing and self- incised wounds to the torso, abdo-
men and neck found that 46 of 95 patients (48%) had a
psychotic disorder, mainly schizophrenia-related psy-
chosis, and more of than half of these patients had
never received treatment with anti-psychotic medica-
tion and could be considered to be in the first episode of
psychosis.12 A recent review of published case reports of
people who had committed the rare and bizarre act of
stabbing themselves in the brain found that most were
believed to be psychotic, although establishing the
underlying psychiatric diagnosis was not possible in
some cases because of the extent of the resulting brain
injury.13
The mental state of people who have completed suicide
is often uncertain, and the true incidence of psychosis
among people who commit suicide using violent meth-
ods is likely to be higher than the estimates made using
retrospective methods.14 Two studies have reported on
the psychiatric diagnoses of people who completed sui-
cide using a sharp object, both of which reported a sig-
nificant proportion of patients with an established
diagnosis of psychosis.15,16 However, most studies of
completed suicide by sharp object did not attempt to
make a post-mortem psychiatric diagnoses.17–19
Moreover, few studies have distinguished between self-
incised wounds caused by drawing a blade across a sur-
face of the body20 and stabbing. Previous studies have
used a variety of definitions of a stab wound, including
a pathological definition based on the depth and width
of the wound,10 self-inflicted sharp object penetrating
the abdomen and torso, or causing damage to vital struc-
tures of the neck12 and penetrating injury caused by
manual force.13 However, the Oxford English Dictionary
defines stabbing as: ‘to pierce or wound with a pointed
tool or weapon’1 and in forensic pathology, a stab wound
has been defined as a penetrating wound made by a
sharp object in which the wound’s width is shorter than
its depth.21
Based on the findings of the preliminary study of 10
patients,10 we aimed to examine the differences between
patients who survived self-inflicted stab wounds who were
found to have psychosis, and those with other conditions.
Methods
The sample was taken from patients referred to the
Consultation-Liaison department of Westmead Hospital
in Western Sydney from the beginning of 1998 to the
end of 2005. Westmead Hospital is a large teaching hos-
pital and trauma centre with 975 beds. A role of the con-
sultation-liaison psychiatry service is to assess each
patient admitted to the hospital after making a suicide
attempt. Cases of self-stabbing were identified using an
electronic search of a computerised database that
included details of every referral to the service.22
A stab wound was defined as a penetrating wound made
by a sharp object, in which the width of the wound was
less than its depth. Central wounds were defined as
those inflicted to the abdomen or thorax, and wounds to
the limbs or neck were defined as peripheral wounds.
Patients with self-inflicted incised wounds, where the
length was greater than their depth, and lacerations to
the skin caused by blunt trauma, were excluded.
Psychiatric diagnoses were made using the DSM-IV clas-
sification system.23 Psychotic disorders were defined as
schizophrenia and related psychoses (including schizo-
affective disorder and delusional disorder), affective psy-
choses including mania and major depression with
psychotic features, substance-induced psychotic disor-
der and psychoses arising from physical illness and the
complications of treatment. The non-psychotic group
included patients with depressive disorders or bipolar
disorder without psychotic features, substance use disor-
ders (including intoxication), patients with intellectual
disability and dementia, and those in which the diagno-
sis was personality disorder.
De-identified data was collected from the medical
records. The first 20 files were examined by two of the
authors (AG and GD). Although inter-rater reliability
was not formally assessed, there were few disagreements
about the characteristics of the patients or the nature of
their injuries.
Data collected included demographic information, med-
ical, psychiatric and social history, any information
about the patient’s mental state at the time of the self-
injury, and the patient’s mental state at the time of the
interview. Information about the nature of the injury
and its management was also recorded.
Permission to conduct the study was provided by the
Western Sydney Area Health Service Human Research
Ethics Committee.
Results
Case identification
During the 8 years from the beginning of 1998 to the
end of 2005, there were 2119 referrals to the Westmead
Consultation Liaison service following episodes of self-
harm or suicide attempts. These included 62 cases of
self-injury with a sharp object that were initially coded
as stab wounds.
The methods of self-harm among the remaining cases
were: 1657 cases of self-poisoning (78.2% of the total),
254 cases of self-inflicted incised wounds (12.0%) and 54
patients who had survived hanging attempts (2.5%).
Among the less common methods were jumping from a
height (12 cases), non-lethal self-shooting (seven cases),
electrocution (six cases) and self-immolation (two cases).
No method was identified in 65 cases.
Both GD and AG examined the files of the 80 patients
with significant self-inflicted wounds using a sharp
implement, including all 62 cases coded as stab wounds
and 18 cases that might have been miscoded as self-
45

incised wounds. Of these, 41 cases met the inclusion cri-
teria of at least one stab wound (1.9% of the total). Most
of the 39 excluded cases were found to have incised
wounds rather than stab wounds, and there were several
cases of patients who had accidentally stabbed them-
selves.
Among the group of self-stabbers, the most common
sites of injury were abdomen, chest, limb, neck and then
multiple sites. Stab wounds to the chest were more likely
to be on the left side (over the heart) and stab wounds to
the abdomen were more often in the right upper quad-
rant (over the liver).
Comparison of patients with psychosis and
those with other disorders
The 41 self-stabbing cases included 26 people who were
found to have a non-psychotic illness at the time of psy-
chiatric evaluation and 15 who were diagnosed with a
psychotic illness (Table 1). The non-psychotic group
included 12 patients with affective disorders (five cases
of major depressive disorder and seven cases of dysthy-
mia or adjustment disorder) and 14 with other diagno-
ses. The 15 cases in the psychotic group included nine
with a schizophrenia-spectrum disorder, four with psy-
chotic depression and two with a diagnosis of substance-
induced psychosis.
The mean age of all patients was in the mid-thirties,
with no difference in the age distribution between the
psychotic and non-psychotic groups. There was a trend
towards a greater proportion of males in the psychotic
group.
There was no significant difference in the historical fac-
tors of prior deliberate self-harm, childhood trauma, a
history of criminal convictions or a history of substance
abuse between the two groups, although there was a
trend towards more prior deliberate self-harm in the
non-psychotic group compared with the psychotic
group.
There were also no significant differences between the
groups in the overall history of intoxication, intoxica-
tion with specific substances (alcohol, cannabis, stimu-
lants), a history of being able to recall inflicting the
injury or the presence of specific psychosocial triggers.
The patients with psychosis were significantly more
likely to have made a central stab wound, have multiple
stab wounds and were more likely to have reported sui-
cidal intent. Patients with psychosis were more likely to
be prescribed psychotropic medication and were more
likely to be admitted to the psychiatric ward of the hos-
pital after medical treatment.
Discussion
In this large series from a major trauma centre, almost
15% of episodes of deliberate self-injury involved the
46
Australasian Psychiatry 20(1)
use of a sharp object and 2% had self-inflicted stab
wounds using the definition of a stab wound taken from
forensic pathology. This finding was consistent with ear-
lier studies of self-harm in hospital settings24,25 and is
also close to the proportion of completed suicide in
Australia using a sharp object.7
This series is notable because earlier studies reported to
be about self-stabbing did not use a formal definition of
stabbing or distinguish between stab wounds and self-
incised wounds. For example, the large study of suicide
and suicide attempts by sharp objects in Tokyo between
1959 and 1970 by Watanabe et al. found that 2% of sui-
cides were by sharp objects, but only as few as 0.2% were
related to penetrating abdominal injuries that might be
consistent with hara-kiri, or ‘seppuku’ as it is known in
Japan. Among the large incised wounds of the abdomen
in the series, less than half were fatal.9
We found that a significant proportion of survivors of
self-inflicted stab wounds had a psychotic illness, which
is consistent with the results of other studies10,12,13 and
suggests the presence of an association between this
form of violent self-injury and psychosis.26 However, the
similar proportion of patients identified as having psy-
chosocial triggers, substance use and intoxication in
both groups suggests that these are important factors in
the aetiology of self-stabbing, irrespective of the effect of
symptoms of psychosis. Furthermore, there were patients
where psychotic symptoms such as command hallucina-
tions and delusions of passivity were important in the
act of self-harm.
We did find that patients with psychosis were more
likely to stab themselves multiple times, were more
likely to stab themselves in a central location and were
more likely to report intending to commit suicide.
Central stabbing and inflicting multiple stab wounds
would appear to be associated with increased suicidal
intent when compared with single and peripheral
wounds.
The main limitation of this study stems from the small
number of cases, which might have resulted in a lack of
statistical power to detect differences between those
with psychosis and those with other diagnoses. The
number of cases meant that it was not possible to exam-
ine the characteristics of self-stabbing patients according
to each psychiatric diagnosis. For example, a larger sam-
ple might have enabled us to detect differences in the
characteristics of self-stabbing by those with depression
and those with other diagnoses. Furthermore, because
the included cases were survivors of self-stabbing, the
findings may not apply to groups of people who have
completed suicide.
Our clinical experience of these cases and the examina-
tion of the medical records raise some particular issues
that should be considered in the general hospital care
for this group of patients. Patients with self-inflicted stab
wounds can evoke negative responses from health pro-
fessionals, particularly if the patient is perceived to be
Gerard et al.

Table 1:  Factors associated with self-stabbing with and without psychotic illness

Diagnosis of a Diagnosis of Test df p

non-psychotic psychotic
illness, n=26 illness, n=15
Demographic factors
  Mean age (SD) 36.3 (SD=18.0) 34.3 (SD=10.8) t = -0.39 39 0.69
 Male 13 (50%) 11 (73%) Fisher’s exact test 1 0.20
  Overseas Born 10 (39%) 7 (47%) Fisher’s exact test 1 0.74
Historical factors
  Prior deliberate self-harm 12 (46%) 4 (27%) Fisher’s exact test 1 0.32
  Disrupted childhood 12 (46%) 5 (33%) Fisher’s exact test 1 0.52
  Forensic history (self-reported) 10 (39%) 5 (33%) Fisher’s exact test 1 1
  Substance abuse diagnosis 16 (62%) 9 (60%) Fisher’s exact test 1 1.0
  Personality disorder 15 (58%) 7 (47%) Fisher’s exact test 1 0.53
Factors at time of self-stabbing
  Any intoxication 10 (39%) 4 (27%) Fisher’s exact test 1 0.51
  Intoxication with alcohol 10 (39%) 2 (13%) Fisher’s exact test 1 0.15
  Intoxication with cannabis 2 (8%) 0 (0%) Fisher’s exact test 1 0.52
  Intoxication with stimulants 0 (0.0%) 2 (13%) Fisher’s exact test 1 0.13
  Identified psychosocial trigger 20 (77%) 7 (47%) Fisher’s exact test 1 0.09
Characteristics stab wound
  Tentative incisions 4 (8%) 2 (13%) Fisher’s exact test 1 1
  Mean number of wounds (SD) 1.34 (SD=0.75) 3.0 (SD=3.8) t=2.17 39 0.04
  Stabbing confined to central regions 17 (68%) 15 (100%) Chi-square=6.65 2 0.036
  Stabbing confined to peripheral regions 7 (28%) 0 (0%)  
  Stabbing involving both peripheral and 2 (8%) 0 (0%)  
central regions
Mental state associated with self-stabbing
  Depressive cognitions 14 (54%) 9 (60%) Fisher’s exact test 1 0.75
  Melancholic features 8 (31%) 7 (47%) Fisher’s exact test 1 0.33
  Ability to recall stabbing 21 (81%) 13 (87%) Fisher’s exact test 1 1
  Reports suicidal intent 8 (31%) 10 (67%) Fisher’s exact test 1 0.049
Treatment variables
  Psychotropic medication prescribed 10 (39%) 12 (80%) Fisher’s exact test 1 0.02
  Psychiatric admission 4 (15%) 10 (67%) Fisher’s exact test 1 0.002
  To operating Theatre 17 (68%) 9 (60%) Fisher’s exact test 1 0.75
  Mean days in surgical care (SD) 4.5 (SD=3.3) 6.1 (SD=4.8) t=1.31 39 0.19

responsible for their actions. Common misconceptions Disclosure

include the perception that the patient will go on to
repeat the injury, might be dangerous to others or that
other patients are more deserving of intensive medical
care. Research that highlights the kinds of predica-
ments and mental disorder that result in this rare but
confronting form of self-injury has the potential to
assist liaison psychiatrists in their efforts to reduce
the prejudice experienced by patients with this type of
self-injury.
The authors report no conflict of interest. The authors alone are responsible for the content
and writing of the paper.
Acknowledgements
The authors would like to thank Elizabeth Jurd and Marissa Lassere for assistance with the
initial statistics, and Peter Ellis for help with forensic pathological definition of wounds.
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