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The symptom of self-cutting without conscious suicidal intent is found most often in women who display severe disturbance in reality testing. Alcoholism, drug ingestion, and eating disturbances frequently accompany the symptom. In investigating self-mutilation from the five points of view of metapsychology, Novotny places most emphasis on the dynamic, structural, and adaptive aspects. The act not only expresses an attempt to handle castration anxiety, but represents the wished for and feared phallic penetration. Passive homosexual wishes, masochistic phenomena, and oral conflicts are common. An aim of the symptom would be the gratification of sexual impulses and rage.
The particular ego impairment in the patients described is characterized by an inability to separate fantasy from reality when stress reaches a certain intensity; otherwise ego functions are intact. Oral aggressive and incorporative modes are emphasized throughout the paper in spite of the scarcity of genetic data. That the skin is the target organ suggests disturbances in the body ego boundary: difficulty in differentiating what is inside from what is outside. An adaptational secondary gain from the symptomatic act would be an alleviation of the confusion between self and environment. Based on these formulations, some implications for treatment are discussed.