Heidi Combs

Self-immolation: Socioeconomic, cultural and psychiatric patterns

INTRODUCTION Self-immolation remains a significant contemporary problem. Its epidemiology and causes, and the intervention strategies these suggest vary significantly between higher- and lower-income countries. We summarize what is known about suicide by self-immolation in terms of its demographic and psychiatric risk factors, causes, local patterns and means employed, and points of possible intervention. METHODS We reviewed the literature for all published papers on self-immolation between 1973 and 2010. Epidemiologic and psychiatric risk factors and aspects of method, locale and timing of self-immolation were compared between higher- and lower-income countries. RESULTS In higher-income countries self-immolation tends to be rare and the majority of self-immolation patients are male. In lower-income countries, the incidence of self-immolation is much higher, and the majority of patients are female. Self-immolation was more frequently associated with a history of mental illness or substance abuse history in higher-income countries than in lower-income countries. CONCLUSION Reports in the literature of self-immolation divide most informatively into two groups according to the higher- or lower-income of the societies affected. This classification is not arbitrary, as it correlates with other measures of development, and the epidemiologic patterns revealed show distinct differences, suggesting differing causes and intervention strategies. Analytical studies are needed to distinguish associations from underlying causes and identify efficient points of intervention.

Self-Immolation: Cause and Culture

Accounts of self-inflicted death by fire are numerous and are found from antiquity to present times. We review selected examples of self-immolation from historical record, in mythology and as part of religious and cultural tradition. We discuss the use of self-immolation as a literary device in the arts including fiction, opera, movies, and song. We offer motives for this horrifying act and discuss how it has been used as a form of protest for political reasons or for individual maltreatment or as a means to end intense personal suffering. Finally, we explore what setting oneself alight may represent from a psychodynamic perspective.

Morgellons Disease and Delusions of Parasitosis

Morgellons disease is a controversial and poorly defined symptom cluster of skin lesions and somatic symptoms, most notably ‘fibers’ in the skin. Because of widespread coverage in the media and on the Internet, there are an increasing number of patients presenting to dermatologists. We present three patients who believed that they had fibers in their skin. We offer a discussion of delusions of parasitosis to demonstrate similarities between these conditions. It has been suggested by a limited number of healthcare providers that an unknown infectious agent underlies this symptom complex yet no available evidence supports this assertion. Laboratory values that would be reflective of an infectious process (e.g. elevated white blood cells, sedimentation rate, C reactive protein) are routinely normal and biopsies often reflect only nonspecific findings such as acute and chronic inflammation with erosion or ulceration.Patients with Morgellons disease generally lack insight into their disease and reject the need for psychiatric help. The goal is to build trust and refrain from minimizing what the patient experiences. Attentive examination of the patient’s skin and fragments they present is necessary to rule out a true underlying pathologic process and to establish a trusting relationship. A supportive, non-confrontational approach is ideal. The patient is best treated by a team of practitioners of several specialties, including dermatologists, psychiatrists, and counselors.

How to Remediate Learners on a Short Clinical Rotation: Getting the Learner Back on Track

Regular feedback is essential for students and residents to achieve expected competencies. But what should be done when learners do not show improvement despite being given appropriate feedback? There are many barriers to helping these learners progress: attending physicians are busy, clinical rotations are short, and it can be emotionally taxing to embark on remediation. Yet remediation is necessary to help our learners succeed. This chapter presents strategies to recognize when there is a need for remediation, diagnose the type of learner deficit, and build an appropriate action plan.