Integration of medical and psychiatric management in self-mutilation.

The traditional management of factitious patients with self-inflicted injuries consists of medical/surgical treatment of the physical lesions, followed by psychiatric referral. The former is assigned to the dermatologist, the surgeon, or the primary care physician. More often than not, the subsequent psychiatric referral for treatment of the psychiatric disorder underlying and actually causing the self-mutilation fails because of self-mutilators' notorious resistance to psychiatric help. The integration of a psychiatric strategy into the medical management is more effective than a sequential division of medical/surgical and psychiatric treatment. This integrated treatment strategy is based on three key issues: education of the medical team in understanding the self-mutilation as a morbid form of help-seeking behavior, the judicious use of confrontation as a therapeutic tool, and the combination of psychotropic drug treatment with psychotherapeutic techniques.