Asked how she felt during the interview, Kisha answered with an easy smile, "I feel fine." It seemed to me the happy face owed more to practice than to spontaneity. I doubted her affect reflected her mood, then or earlier that day. When I asked Kisha why she burned herself so seriously, she looked at me blankly and said she did not know. She denied anything had changed in her life recently. She acknowledged no disappointment or setback, no problems at home or at school. According to Kisha, everything was fine.
The burn that brought Kisha to the ER on the evening I interviewed her was not her first act of self-mutilation. Seven months earlier, she had jumped out of a second-story window. Inexplicably, she did not go to a hospital, either for medical treatment or for psychiatric evaluation. I was the first mental health clinician Kisha had spoken to.
During the previous year, Kisha also had made modest cuts with a razor on the underside of one forearm and on her cheek. "I was just bored," was her explanation. Asked why she jumped out of the window, her only response was, "I have no idea." She denied this potentially lethal act had anything to do with what was going on in her life at the time. Despite my persistent efforts to elicit more information about the reason for Kisha's self-destructive behavior, she did not offer a scintilla of explanation. That she was acknowledging no reasons for what she had done did not strike her as the least bit odd.
Kisha's mother told me with understatement that her daughter "keeps it all inside." Clearly, Kisha was not the only minimizer in this family. The mother also volunteered that Kisha had trouble getting over disappointments. The day before she burned herself with the curling iron, a woman who had promised to take Kisha to a museum in another city abruptly canceled the trip. At the time she jumped from the window, Kisha was having problems with a boyfriend, and the relationship soon ended. Kisha vigorously denied she had difficulty getting over disappointments in general or that a particular disappointment had anything to do with any of her self-destructive acts. Her mother thought differently.
Kisha had no words for the feelings that led her to do these things. But her silence spoke volumes. Clearly, she had emotions she did not acknowledge or understand. This young woman put a smile on her despair. She gave no hint of what was going on under the mask.
Most patients who come to the ER after harming themselves seem eager to discuss the meaning of their behavior. Rather complex issues are clarified, often with startling insight. These patients are willing to have their initial, often self-deceiving explanations challenged and to allow the subtext of their destructive act to be interpreted to them. But after Kisha burned her arm, no words came to name the emotions that drove her to do this. She clarified nothing, for herself or for me. Kisha was alexithymic.
Particularly memorable among the many self-mutilating patients I have evaluated in the ER was a 19-year-old college student who had cut marks of various lengths and depths all over her arms, legs and torso. The incision that brought her to the ER was made with a razor blade on the underside of her right wrist. After making the initial incision, several repetitive cuts went deeper than she intended, and she severed a tendon. The hand surgeon who was called in the middle of the night to do the repair had trouble locating the proximal end of the tendon, which had retracted into the forearm after snapping. While he called his supervisor for assistance, I completed my interview.
This young woman, lying on a gurney under bright fluorescent lights, facing a long period of rehabilitation with an uncertain outcome, unabashedly told me about the problems she had, her feelings of anxiety and depression, and how for many years she had tried to counter this emotional pain by cutting her body and watching the blood come.
