Upper-extremity self-amputation and replantation: 2 case reports and a review of the literature.

BACKGROUND: Patients who deliberately amputate 1 or more of their own extremities present a unique set of challenges for the entire treatment team. Decisions regarding replantation of the amputated extremity must be made quickly, and the psychiatrist is involved early in the care of these difficult patients. Surgical staff may feel that replantation surgery is inappropriate for such patients, although there is limited literature addressing this issue. Therefore, the psychiatrist must also address the strong feelings that such patients generate in nonpsychiatric caregivers.
METHOD: Two cases of deliberate upper-extremity self-amputation are discussed, and the world literature on self-amputation and replantation from 1966 to the present, identified via a MEDLINE search, using the key words self-amputation, self-inflicted, upper extremity, and amputation, is reviewed.
RESULTS: There have been 11 reported cases (plus 2 in the current report) of deliberate upper-extremity amputation in the last 30 years. All patients have been psychotic, and many of the case reports note that patients with this presentation are rarely suicidal. Instead, the amputation usually stems from psychotically driven feelings of guilt and concrete religious preoccupations. Patients who undergo replantation often are pleased with the reattachment, and both psychiatric and surgical outcomes appear to benefit from prompt and aggressive psychiatric treatment.
CONCLUSION: Patients who deliberately amputate one or more of their extremities can be unsettling as well as challenging. The psychiatrist must coordinate diagnosis and treatment among multiple services to ensure the best possible outcome. As replantation surgery becomes more common, the psychiatric implications of surgical reattachment are of increasing importance. More cases need to be described to better understand the best treatment options for this particular patient population.