self - amputation , the extreme form of self - mutilation , is uncommon . the vast majority of cases are associated with psychosis , with a small number being assigned the controversial diagnosis of body identity integrity disorder ( biid ) . favazza and rosenthal ( 1 ) define self - mutilation as the deliberate alteration or destruction of body tissue without conscious suicidal intent , proposing three categories of self - mutilating behavior : ( a ) superficial - moderate self - mutilation e.g. superficial cuts , burns and scratches , associated with various mental disorders such as personality disorders ; ( b ) stereotypic - fixed self - mutilation , associated with mental retardation but not psychosis ; and ( c ) major - infrequent self - mutilation e.g. , self - amputation of limbs and genitals , associated mainly with psychoses and acute intoxication ( 2 ) . in this article , we report two cases of non - psychotic self - amputation examining the similarities , with a view to highlighting the risk factors and develop appropriate management plan . he had repeatedly felt compelled to expose himself in public places , in front of women , and continued to do so even though he considered his behavior offensive and harmful to others . he subsequently experienced extensive physical , emotional , and sexual abuse at a children s home . seven years later he started exposing himself for the first time , at a train station . he suffered from alcohol - dependency until his third incarceration , when he received . in prison , he received treatment in the form of counseling and antidepressants , which he discontinued afterwards . in 2005 , he was admitted to the hospital following an overdose , but had no further contact with the psychiatric services since discharge . the patient had no delusions or hallucinations and was reported to be feeling desperate as he was unable to stop his exposing behavior . three months after being released from prison , he amputated his hand with an electric saw in an attempt to prevent himself from re - offending . following amputation , he was assessed and found to have the capacity ; this allowed him to refuse re - plantation of his finger . despite this drastic action , his mood did not improve , and 15 days later he committed suicide by hanging himself . this was a 46-year - old man with a history of severe depression in the context of a mixed personality disorder . he had a history of repeatedly attempting suicide by overdose and was once hospitalized after stabbing himself in the abdomen . he left school without any qualifications and began misusing alcohol at the age of 13 . the patient had been admitted to a psychiatric unit twice following his suicide attempts ; the first admission was a compulsory detention . his personality was of impulsive nature , but there was no evidence of formal thought disorder and he was not having hallucinations . the patient had regretted his violent behavior and was keen to accept help in any form as he felt that he could not cope any longer . in february 2010 , the patient accidentally injured his left little finger with a kitchen knife while preparing his dinner . he was distressed by the deformed finger , and it was causing him severe pain that radiated up to his arm . he had asked the doctors to remove the remainder of his finger , but they refused . in june 2011 , and after much deliberation according to him , he amputated the finger himself in a safe manner . he subsequently admitted that it was an  extreme  action to take for getting rid of discomfort . following the amputation , his mood seemed to have improved as he stated he was feeling he had repeatedly felt compelled to expose himself in public places , in front of women , and continued to do so even though he considered his behavior offensive and harmful to others . he subsequently experienced extensive physical , emotional , and sexual abuse at a children s home . seven years later he started exposing himself for the first time , at a train station . he suffered from alcohol - dependency until his third incarceration , when he received . in prison , he received treatment in the form of counseling and antidepressants , which he discontinued afterwards . in 2005 , he was admitted to the hospital following an overdose , but had no further contact with the psychiatric services since discharge . the patient had no delusions or hallucinations and was reported to be feeling desperate as he was unable to stop his exposing behavior . three months after being released from prison , he amputated his hand with an electric saw in an attempt to prevent himself from re - offending . following amputation , he was assessed and found to have the capacity ; this allowed him to refuse re - plantation of his finger . despite this drastic action , his mood did not improve , and 15 days later he committed suicide by hanging himself . this was a 46-year - old man with a history of severe depression in the context of a mixed personality disorder . he had a history of repeatedly attempting suicide by overdose and was once hospitalized after stabbing himself in the abdomen . he left school without any qualifications and began misusing alcohol at the age of 13 . the patient had been admitted to a psychiatric unit twice following his suicide attempts ; the first admission was a compulsory detention . his personality was of impulsive nature , but there was no evidence of formal thought disorder and he was not having hallucinations . the patient had regretted his violent behavior and was keen to accept help in any form as he felt that he could not cope any longer . in february 2010 , the patient accidentally injured his left little finger with a kitchen knife while preparing his dinner . he was distressed by the deformed finger , and it was causing him severe pain that radiated up to his arm . he had asked the doctors to remove the remainder of his finger , but they refused . in june 2011 , and after much deliberation according to him , he amputated the finger himself in a safe manner . he subsequently admitted that it was an  extreme  action to take for getting rid of discomfort . following the amputation in the above , two non - psychotic and non - biid cases have been reported . the first patient removed his hand out of guilt and desperation to stop his exhibitionism and completed suicide . the second patient reacted to the pain and deformity , which seems to have improved his psychological well - being . both patients are in their mid - forties , share a history of childhood abuse , alcohol dependency and self - harming behavior , and both were careful and well - prepared when executing their planned self - mutilation . there was no formal thought disorder , no hallucinations and no delusions of sin or distorted body image . minor or superficial self - mutilation is common , and not necessarily associated with psychosis . in contrast , major self - mutilating behavior is rare and almost exclusively occurs in the presence of serious mental illness , e.g. , schizophrenia - spectrum psychosis . major self - mutilation can be classified into ocular , genital or limb mutilation ( 2 ) . patients , who have removed an eye or have amputated a limb , are almost always psychotic , and so are 75% of patients with genital mutilation ( 3 ) . our knowledge of major self - mutilation is drawn almost entirely from case reports ( 3 , 4 ) . due to a lack of epidemiological studies on the subject , the risk factors for major self - mutilating behavior are not yet clear but it is generally agreed that it is the direct effect of psychosis . ( 5 ) reviewed the cases that had removed an eye or amputated their genitals or portion of a limb . the researchers concluded that the etiology behind major self - mutilation was acute psychosis , especially first - episode schizophrenia . they proposed that an earlier treatment of psychosis could help reduce the frequency of these incidents . a small number of self - amputees have been controversially diagnosed as biid , a condition that characterizes individuals , who are convinced that they were meant to have a physical defect , for example , an amputated leg , and who feel trapped in their able bodies . biid s principles are similar to gender identity disorder in that the patient , instead of having gender dysphoria , has a body integrity dysphoria , which disappears once the  corrective  amputation has been performed ( 6 ) . as established earlier , the infrequent reporting of non - psychotic self - amputation cases has meant that no universal risk factors have been identified to predict this behavior , with the exception of genital self - mutilation ( gsm ) . several risk factors that greilsheimer and groves ( 4 ) listed for gsm , seem to apply to one or both cases we reported , including paraphilia - stemming guilt , childhood deprivation , depression , deliberate self - harm and suicide attempts ( 5 ) . we propose that a positive answer to routine psychiatric screening questions about self - harming ideation should serve as a springboard for the mental health professional to explore self - amputation ideation . special attention should be given to the patients who report feelings of guilt , those who are distressed by their behavior , and those who deliberately self - harm . due to the  case report  nature of this phenomenon , there is no set management protocol in non - psychotic / non - biid patients that have self - amputated or are considered to be at risk . careful monitoring is required , and these patients may benefit from individual cognitive behavioral therapy to modify their negative thinking and thoughts of guilt , or psychotherapy to understand the source of and attempt to learn to control their guilt and self - destructive behavior .
self - amputation , the extreme form of self - mutilation , is uncommon . the vast majority of cases are associated with psychosis , with a small number being assigned the controversial diagnosis of body identity integrity disorder . in this article , we report two cases of non - psychotic self - amputation and their similarities with a view to highlighting the risk factors and formulating an appropriate management plan .