It is noticed that in several cultures—primitive, modern, and contemporary—the body represents a communication object. Besides the artifacts used on the body with the intention of transmitting information such as identity, status, faith, among others. We also observe throughout history the body marks from self-inflicted injuries [1].

Macedo and Paravidini (2015) [2], in a study called, “O ato de tatuar-se: Goso e identificação o to de tatuarse” question why men started to tattoo, scarify or even mutilate themselves.

Whenever we talk about self-mutilation, we refer to individuals who cause injuries to their own bodies in various ways, such as cutting, burning, or beating themselves, among others. According to the definition of the Descriptors in Health Science (DeCS), self-mutilation is the “act of damaging one’s own body until permanent destruction of a limb or other essential body region is achieved.” It is also possible to associate it with the term “self-injurious behavior,” which, according to DeCS, means “the act of hurting or harming oneself without the intention of suicide or sexual perversion” [3].

One way of reading this question is that self-injury is characterized as a symptom of various mental disorders. In the medical and psychiatric reading, the symptom is something that often needs to be eliminated—or treated—in order for the subject to return to his or her baseline state. Another reading, also instituted by the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), indicates that self-harm, in itself, is a disorder [4],[5].

Beginning in the middle of the 19th century, the United States began to publish numerous articles about the various forms and severity of self-mutilation. These were especially about psychotics who had isolated incidents of extreme self-mutilation, usually instigated by hallucinations or religious delusions, such as enucleation of the eyes or castration [6].

Although it presumably represents an attenuated or partial form of suicide, self-mutilation is a kind of agreement to avoid the total annihilation of the person, that is, suicide. In this perspective, it represents a victory, sometimes a pyrrhic victory, of the pulse of life over the pulse of death, where a dichotomous relation is assumed [7].

Therefore, the objective of the present study is to present a case report about self-mutilation habits in an 18-year-old patient and to discuss the different psychic elements that are involved in the understanding of the scarification act in adolescence.

An 18-year-old, female, student, smoker, drinker, refers that she does not use illicit drugs. She reports that months before her mother’s death she started self-mutilating behaviors on her arm, forearm, and thigh (Figure 1). Such bruises and sometimes cuts were seen as inevitable consequences of stumbles and bumps occurred in everyday life. In her hometown, she underwent medical follow-up, however, without success in the established therapy. When asked about the reasons that drove her to practice physical injuries on her own body, the patient verbalized: “I feel relief when I provoke another pain different from the one I feel internally.” She adds: “I don’t feel panic when I see blood running down my arm”; “today I am no longer able to cry, so I feel the need to inflict self-injury.” She states that at the moment before the mutilation acts, she is balanced, and there are no triggering factors for the injuries. Next, the grandmother of the patient says that about two months ago the patient began to commit acts of violence, stealing money from her. She was medicated with Lamotrigine, Sertraline, and Sodium valproate. The patient was asked to return in about two months after the beginning of therapy.

When we analyze the categories of expression of psychic pain in the contemporary field, we understand as one of its notable peculiarities, the attempt to refuse this experience both to the self and to others. If, on the one hand, there is no other to welcome the message of pain, on the other hand there is a difficulty for the subject himself to admit to others that he is unhappy. However, the lack of the other reaffirms the inability to find words for the pain, since the resonance of the other is a necessary state for psychic suffering to be constituted as such [8].

Schneider (2002) [9] in “La souffrance psychique,” points out that the ability to feel and characterize one’s own pain has as a state not only a contact of the subject with himself, but, necessarily, the relationship with his neighbor. Psychic suffering must be addressed to the other, who will provide a space of resonance through which the subject can legitimize his pain. If the pain does not resonate with anyone, it is packaged within the subject and redirected to the body itself. A privileged form of redirecting pain to one’s own body among adolescents is self-mutilation.

A research conducted by Fortes and Macedo (2017) [10] in “Automutilaçâo na adolescência - rasuras na experiência de alteridade” sought to analyze the status of the body in contemporary symptomatology through some narratives of adolescents. The discussion about self-mutilation is inserted, from the point of view of this study, in the field of problematizations. The bodily pain was seen, by the adolescents, as a substitute for the moral pain, that is, as a presentable way through cuts in the body that declares the inability to feel the pain of the soul. Thus, paradoxically, they sought to appease unbearable psychic pain through the act of inflicting physical pain. It is believed that the appearance of a physical pain can replace and even make disappear a psychic pain.

The attempt to substitute one pain for another demonstrates the undeniable difficulty of psychic production of a painful event. According to Ana et al. (2003) [11], in their article, “scarification elucidates a kind of symbolic game in the domain of pain, imputing pain to suffering, the physical wound to the laceration of the soul.”

According to Whitlock et al. (2006) [7], in any case, even if appearing to be an attenuated form of suicide, such as self-aggression behaviors would be a formation of commitment, a substitute that would ratify the non-success of the subject’s total self-annihilation. Self-mutilation would be a search for cure or self-preservation.

Also according to da Fonseca et al. (2018) [12], suicide is an exit toward death, an action of escape, while self-mutilation is a possibility of re-entry into a state of normality, as in a morbid act of regeneration. The subject who attempts suicide seeks to cease all feelings, but a person who possesses self-mutilating behavior seeks to feel better. The patient who mutilates himself does so because of an inability to deal with extreme emotions, external pressures, and relationship problems. Such actions would be a way to manage feelings by acting out, instead of verbalizing them, because the other to be destroyed, by the aggressive act, would be internalized. In this way, injuring oneself would be a way to alleviate anguish, causing concomitant pain and pleasure.

The one who is affiliated to pain does not need the other to make him suffer and enjoy such pain, as in the case of the one who mutilates himself. It is, therefore, something different from the sadistic-masochistic bond, because in these partnerships there are parties occupying, either fixedly or alternately, active and passive qualities, where there is the expectation of punishment—or of idealizing oneself in someone being punished—suffering at the “hands” of a loved one [7],[12],[13].

The undeniable psychic precariousness makes this “private” self-mutilation show, in the recourse to the pain-act, the conceivable damage truly experienced by the subject. In this dimension of absence or emptiness and facing the act of self-mutilation, the physician is called to exercise not to capture the look of the mutilated body, but to resort to the artifices of a clinic whose ethics is based on listening to a subject, trapped in the repetition of the same.