Chapter 7 - Lesson 1 Physical Examinations: Fill & Download for Free

No!Were US POWs Starved to Death in German Camps?Reports of the Allied advance in Europe in spring 1945 raised concerns about the treatment of prisoners of war.July 23, 2018Background: During World War II, an estimated 90,0000 Americans were held as prisoners of war (POWs) in Germany. Once captured, the POWs were first processed through a Dulag (transit camp) where, according to the Geneva Convention signed in 1929, they were required to give their name, rank, and serial number. They were then sent to the actual POW camps, which were sometimes divided among different types of camps such as Marlag (Marinelager), a prison camp for naval servicemen; Oflag (Offizierslager), a camp for officers; Stalag (Stammlager), a camp for officers and enlisted men.Map of the major POWs camps in Germany. Image: Cindy Farrar Bryan and TheArrowheadClub.com.Under the Geneva Convention, officers were not required to work but enlisted men were often made to work, often in difficult conditions. While Allied POWs were subjected to harassment, beating, starving and sometimes death in German camps, their situation was altogether more tolerable than in the Pacific. Over 40% of the American POWs in the Pacific perished, compared to between 1 and 2% in Germany.The main concerns were shortages of food; the meager rations POWs received from the Germans were supplemented by the more than 27 million parcels sent by the Red Cross during the war.Standard content of a Red Cross parcel.In the USA, the parcels were assembled by more than 13,000 volunteers in distribution centers such as New York, Philadelphia, Chicago, and St. Louis, and sent to the International Red Cross Committee in Geneva, Switzerland, for distribution in roughly 60 POW camps in Germany.The packages contained nonperishable foods like prunes, raisins, liver pâté, coffee, corned beef, sugar, dried milk, oleomargarine, biscuits, orange concentrate, cheese, canned salmon or tuna fish and chocolate bars, along with amenities like cigarettes and soap.In an enormous logistical feat, POWs at first received one Red Cross parcel per week, greatly alleviating the plights of the POWs.Results:Source: Gallup Poll, May 1945, Roper Center for Public Opinion Research at Cornell University.What Happened: As the war progressed, the logistics of delivering the parcels became insurmountable. The German planes that flew daily from Lisbon, Portugal (a neutral country), to Germany carrying air mail to POWS were cut off after the liberation of France in the summer of 1944. In addition, surface mail and next-of-kin parcels, which were formerly shipped to Marseille, France, were stalled from June to October 1944. Fighting along the Marseille-Switzerland line made it almost impossible to move mail into or out of Switzerland (a neutral country). As a result, POWs experienced long periods in later 1944-early 1945 where they received no Red Cross parcels and no news from home. The few rations they received were woefully inadequate as the fierce fighting on the continent led to a tripling of the numbers of American POWs.When the Allied liberated their first POW camps in April 1945, they found prisoners in different states of poor conditions: recently imprisoned men who survived on a few slices of bread a week, those who had been in prison for a long time and suffered from the harsh conditions and the poor diet, while others, who had been on forced marches, sometimes 600 miles long, from the east as the Germans moved them inland, were in even worse shape.The Allies themselves, and future historians, however, found no documented effort by the Germans to purposefully starve or kill American POWS. The situation was different for eastern, especially Russian prisoners of war. It is estimated that about 3.5 million, or 57% of all Soviet POWs died in German custody.The results of this May 1945 poll can be explained by the fact that in April and early May 1945, there were numerous reports of Allied forces liberating concentration camps. The deliberate killing and starving of camp inmates was widely reported and may have been conflated with news of Prisoners of War camps by the American public. Articles such as the ones below use words such as “semi-starvation,” “slave labor,” mistreatment and appalling sanitary condition, when reporting on both POWs camps and concentration camps.Gene Currivan, "Out of Hitler Slavery Into the Light," in the New York Times, April 1, 1945.Were US POWs Starved to Death in German Camps? | The National WWII Museum | New OrleansJapan revisits its darkest moments where American POWs became human experimentsOne Japanese doctor has dedicated himself to ensuring the vivisection of eight US airmen by his fellow countrymen is not forgottenJustin McCurry in FukuokaThu 13 Aug 2015 12.40 EDTLast modified on Wed 29 Nov 2017 08.00 ESTShares3803Comments909B-29 crew that were used for live vivisection experiments. Photograph: World War II Database: Your WW2 History Reference DestinationFor a while after the end of the second world war, Toshio Tono could not bear to be in the company of doctors. And the thought of putting on a white coat filled him with dread.As a young man with an interest in gynaecology, it was an aversion that could have quickly ended his dream of a career in medicine.But there were powerful reasons behind his phobia.In 1945, as a first-year student at Kyushu Imperial University’s medical school in southern Japan, Tono became an unwilling witness to atrocities.Those atrocities – namely the dreadful medical experimentation on live American prisoners of war – decades later, continue to provoke revulsion and disbelief in his country and abroad.The man who survived Hiroshima: 'I had entered a living hell on earth'Read moreAs Japan prepares to mark the 70th anniversary of its wartime defeat on Saturday, speculation is building over how, or if, Shinzo Abe, the conservative prime minister, will apologise for his country’s wartime atrocities.Amid widespread criticism, including in the US, that under Abe Japan is attempting to expunge the worst excesses of its past brutality from the collective memory, Tono believes his “final job” is to shed light on one of the darkest chapters in his country’s modern history.In early May 1945, just weeks after he began his studies, a US B-29 Superfortress crashed in northern Kyushu island after being rammed by a Japanese fighter plane. The US plane, part of the 29th Bomb Group, 6th Bomb Squadron, had been returning to its base in Guam from a bombing mission against a Japanese airfield.One of the estimated 12 crew died when the cords of his parachute were sliced by another Japanese plane. On landing, another opened fire on villagers before turning his pistol on himself. Local people, incensed by the destruction the B-29s were visiting on Japanese cities, reportedly killed another two airmen on the ground.“The B-29s crews were hated in those days,” Tono, now the 89-year-old director of a maternity clinic in Fukuoka, told the Guardian in a recent interview.FacebookTwitterPinterestToshio Tono, who now heads a maternity clinic. Photograph: Justin McCurry/GuardianThe remaining airmen were rounded up by police and placed in military custody in the nearby city of Fukuoka. The squadron’s commander, Marvin Watkins, was sent to Tokyo for questioning. There, Watkins endured beatings at the hands of his interrogators, and is thought to have died in his native Virgnia in the late 1980s.The prisoners were led to believe they were going to receive treatment for their injuries. But over the following three weeks, they were to be subjected to a depraved form of pathology at the medical school – procedures to which Tono is the only surviving witness.“One day two blindfolded prisoners were brought to the school in a truck and taken to the pathology lab,” Tono said. “Two soldiers stood guard outside the room. I did wonder if something unpleasant was going to happen to them, but I had no idea it was going to be that awful.”Inside, university doctors, at the urging of local military authorities, began the first of a series of experiments that none of the eight victims would survive.According to testimony that was later used against the doctors and military personnel at the Allied War Crimes Tribunals, they injected one anaesthetised prisoner with seawater to see if it worked as a substitute for sterile saline solution.Other airmen had parts of their organs removed, with one deprived of an entire lung to gauge the effects of surgery on the respiratory system. In another experiment, doctors drilled through the skull of a live prisoner, apparently to determine if epilepsy could be treated by the removal of part of the brain.The tribunals also heard claims from US lawyers that the liver of one victim had been removed, cooked and served to officers, although all charges of cannibalism were later dropped owing to a lack of evidence.As an inexperienced medical student, Tono’s job was to wash the blood from the operating theatre floor and prepare seawater drips.“The experiments had absolutely no medical merit,” he said. “They were being used to inflict as cruel a death as possible on the prisoners.“I was in a state of panic, but I couldn’t say anything to the other doctors. We kept being reminded of the misery US bombing raids had caused in Japan. But looking back it was a terrible thing to have happened.”Medical staff preserved the POWs’ corpses in formaldehyde for future use by students, but at the end of the war the remains were quickly cremated, as doctors attempted to hide evidence of their crimes.When later questioned by US authorities, they claimed the airmen had been transferred to camps in Hiroshima and had died in the atomic bombing on 6 August.On the afternoon of 15 August, hours after the emperor had announced Japan’s surrender, more than a dozen other American POWs held in Fukuoka camps were taken to a mountainside execution site and beheaded.The macabre experiments at Kyushu University were not without precedent. In occupied China, members of the imperial army’s Unit 731 experimented on thousands of live Chinese and Russian POWs and civilians as part of Japan’s chemical and biological weapons programme.Of the 30 Kyushu University doctors and military staff who stood trial in 1948, 23 were convicted of vivisection and the wrongful removal of body parts. Five were sentenced to death and another four to life imprisonment. But they were never punished.They were the beneficiaries of the slow pace of justice as US-led occupation authorities attempted to deal with large numbers of military leaders and civilian collaborators suspected of war crimes. One of the most senior doctors, Fukujiro Ishiyama, killed himself before his trial.By the early 1950s the Korean peninsula was in the midst of a bloody civil war, while Japan had been officially recognised as a US ally under the terms of the San Francisco peace treaty.With a politically stable Japan regarded as key to preventing the spread of communism in the region, President Truman issued an executive order that led to freedom for imprisoned war criminals, including those awaiting execution.By the end of 1958, all Japanese war criminals had been released and began reinventing themselves, some as mainstream politicians, under their new, US-authored constitution.“The way Japan was during the war, it was impossible to refuse orders from the military,” Tono said. “Dr Ishiyama and the other doctors committed crimes, but in a way they were also victims of the war. But I hated doctors for a while. I couldn’t get to sleep without pills.”After the war, Tono spent years examining documents and revisiting relevant locations in an attempt to establish what had happened.Ignoring pleas from his former superiors not to disclose the truth about the POWs’ treatment, Tono revealed all in Disgrace, his meticulously researched account of the crimes.Like the leaders of Unit 731, the doctors who conducted live vivisection re-entered postwar society as respectable members of the medical community. Most never spoke of their wartime experiences.Earlier this year, the university, which has long since dropped its imperial title, made the surprising decision to acknowledge the darkest chapter in its history with the inclusion of vivisection exhibits at its new museum.Tono, too, is currently displaying photographs and documents at his clinic.Seven decades on, a simple stone monument erected by a local farmer marks the spot where the B-29 came down, and where the airmen’s terrifying ordeal began.“The job of a doctor is to help people, but here were doctors doing exactly the opposite,” Tono said. “It’s difficult to accept, but this really happened. I decided to tell the truth because I don’t want anything like this to ever happen again.”What War Captives FacedIn Japanese Prison Camps,And How U.S. RespondedBy JESS BRAVINStaff Reporter of THE WALL STREET JOURNALApril 7, 2005After his B-24 Liberator crashed into the Pacific Ocean in May 1943, U.S. Army Capt. Louis Zamperini spent 47 days on a life raft before being rescued by a Japanese patrol boat. Then his ordeal really began.Shipped through a succession of prison camps, he finally arrived at Japan's secret Ofuna interrogation center. There, prisoners thought to hold critical intelligence were placed under a strict regimen designed to make them break. Solitary confinement, blindfolding and compulsory calisthenics were routine. Prisoners were shaved and stripped, forbidden from speaking to each other and made to stand at attention or assume uncomfortable positions for interrogations. Cooperate, and treatment might improve. Violate the rules and you might be slapped or beaten -- or worse."There was no such thing as international law, just Japanese law," says Mr. Zamperini, now 88 years old. Japan had never ratified the Geneva Conventions, and Ofuna inmates were told they had no treaty protections -- such as the right to reveal nothing but name, rank and serial number.Upon Tokyo's surrender, however, the U.S. declared that international law did apply -- and held accountable much of the Japanese hierarchy, from prison guards to cabinet ministers. U.S. military prosecutors brought hundreds of cases for mistreatment of captured Americans, failure to classify them as prisoners of war and hiding them from delegations of the International Committee of the Red Cross. Offenses as minor as failing to post camp rules or holding up a prisoner's meal were considered war crimes. A single count could bring a year at hard labor."The defendants in these cases, as you would expect in most contexts of war, believed that the circumstances justified what they were doing," says Prof. David Cohen of the University of California, Berkeley, who has been collecting trial records from around the world for a War Crimes Studies Center he founded in 2000.Summary ExecutionsAlthough Nuremberg and other postwar tribunals largely are remembered for prosecuting the Nazi leadership for crimes against humanity, the trials originated in the mistreatment of prisoners of war. It was the German practice of summarily executing downed Allied flyers that in 1944 led Washington to begin planning for war-crimes prosecutions.Ofuna prison camp, where American prisoners were interrogated during World War II. Image courtesy "Devil at My Heels," the memoir of POW Louis Zamperini.Other than the flyers, Prof. Cohen says, American and British soldiers captured by the Germans usually received adequate treatment. (Russian POWs fared far worse, under Nazi racial policies that considered Slavs subhuman.)Prisoners of the Japanese, however, faced grueling treatment across the board. Forced labor, meager rations and poor medical care were the rule, along with occasional beheadings by samurai sword and even incidents of cannibalism.But as the U.S. saw it, mistreatment didn't have to rise to the level of torture to merit punishment. For conditions that fell short of torture, prosecutors brought charges under the sweeping Geneva provision that barred "any unpleasant or disadvantageous treatment of any kind." Along with routine beatings, Japanese interrogators had used solitary confinement, sleep deprivation, blindfolding, head shaving, restricting meals, uncomfortable positions and other techniques to make prisoners talk. Japan failed to register some prisoners or facilities with the Red Cross, delayed delivering their mail or Red Cross packages and denied some Americans POW privileges without full-blown judicial proceedings.Japanese regulations required that prisoners of war "be humanely treated and in no case shall any insult or maltreatment be inflicted." In a February 1942 diplomatic note, Tokyo told Washington that while Japan held "no obligations" under the Geneva Conventions, it nevertheless intended to apply "corresponding similar stipulations of the treaty" to captured Americans. When complaints arrived from the foreign governments or the Red Cross, which then as now was the only independent group allowed to visit prisoners, officials forwarded them to military authorities.Soda Pop and a BiscuitMr. Zamperini, who still lives in his hometown of Los Angeles, says his first encounters with Japanese interrogators were hardly pleasant, but to his surprise, "they didn't beat you to get information out of you" -- at least not always.Louis Zamperini, held by the Japanese during World War II, in a 2003 photo.After subsisting on a diet of plain rice, Mr. Zamperini was led before "naval officers in white suits with gold braid" who sat feasting at "a table full of goodies." Refuse to answer and they sent "you back to your cell more miserable than when you started." To get some of the food, Mr. Zamperini says he used a ruse, pretending to crack under pressure and then offering misleading information about the location of U.S. airstrips. "I got a soda pop and I got a biscuit, so I won," he says.U.S. military commissions classified practices like these as war crimes. "Any corporal punishment, any imprisonment in quarters without daylight and, in general, any form of cruelty is forbidden," an Army judge advocate explained.Government-appointed defense attorneys protested the vagueness of some charges. Threatening prisoners with "unpleasant or disadvantageous treatment … does not constitute any war crime," one argued. "It does not allege any specific act." The attorney recalled his own World War I experience as a U.S. interrogator. "We tried by all manner of words and all manner of inducements -- I will not go beyond that -- to attempt to glean information which would be helpful in our operations against the enemy," he said, and no one considered it a war crime."We looked this up very carefully," the prosecutor replied. "When you start to threaten a man, of course you violate the provisions of the Rules of Land Warfare." The commission ruled for the prosecution.The World War II defendants insisted that they hadn't received proper training, or that prisoners exaggerated their mistreatment, or that any problems resulted from cultural misunderstandings or were appropriate punishment for breaking camp rules. Low-ranking guards claimed they were following superior orders, while top officers and cabinet ministers blamed rogue subordinates. Defense lawyers argued that Japan wasn't legally bound by the Geneva Conventions and, even if it were, many prisoners, such as Allied flyers, had no right to treaty protections because they committed such war crimes as sabotage or "indiscriminate bombing" of cities.Hundreds of TrialsWhile the international tribunals at Tokyo and Nuremberg focused on a handful of high-ranking Axis defendants, hundreds of lower-profile national military commissions tried the small fry. For instance, in November 1945, a British military court at Wuppertal, Germany, sentenced three German officers to terms of up to five years for crimes at a Luftwaffe interrogation center. The central offense: "excessive heating of the prisoners' cells … for the deliberate purpose of obtaining from the prisoners of war information of a kind which under the Geneva Convention they were not bound to give," according to the summary published in 1948 by the United Nations War Crimes Commission."POW asleep, Ofuna" (1945) by John Goodchild, Australian war artist.At Yokohama, Japan, meanwhile, the U.S. Army conducted more than 300 war-crimes trials through 1948. More than 90% involved prisoner mistreatment, says Berkeley's Prof. Cohen. American prosecutors focused on Ofuna, a secret interrogation camp run by the Imperial Navy for pilots and other high value prisoners, including Col. Gregory "Pappy" Boyington, the Marine Corps flying ace. Using affidavits and testimony from former prisoners, prosecutors depicted a grim world where men were broken through physical and psychological cruelty.When Japan failed to cooperate with the Red Cross, the U.S. considered it a war crime. Lt. Gen. Hiroshi Tamura, head of prisoner management, was sentenced to eight years hard labor for, in part, "refusing and failing to grant permission" to the Red Cross to visit prison camps, denying Red Cross delegates "access to all premises" where prisoners were held and refusing to let prisoners speak to the Red Cross without Japanese observers present.Japanese authorities told Ofuna prisoners that they weren't POWs but unarmed "belligerents" who weren't entitled to Geneva's protections. Navy aviator James Balch testified that an interrogator "explained to me that I wasn't a registered prisoner of war, that I was a special prisoner of the Greater East Asia Co-Prosperity Sphere and was, as far as the Japanese were concerned, still a combatant."Lawyers for the Japanese defendants argued that since some captured Americans "lost the status of POWs in that they were saboteurs," it was no war crime to withhold POW privileges from them, Army records say. A military commission rejected that argument as "untenable" because "there is no evidence of any judicial proceedings against the … victims for the alleged acts of sabotage by which they would be deprived of their status" as POWs.The 'Ofuna Crouch'Japanese interrogators put captured Americans in painful contortions for periods of 30 minutes to several hours. One hated position, the so-called Ofuna crouch, involved "standing on the ball of your foot, knees half bent and arms extended over the head," Navy Lt. Cmdr. John Fitzgerald said in a http://deposition.In an affidavit, Navy Capt. Arthur Maher recounted his treatment after his ship, the USS Houston, was sunk in February 1942 off Indonesia. Captured after swimming to Java, Capt. Maher said Japanese officers "promised that we would be treated in accordance with international law."Upon reaching Ofuna, things were different. "As we entered the camp gates, the utter stillness was noticeable." The Americans were told not to speak, locked in nine-by-six-foot cells and put to a stultifying routine of closely timed meals, exhausting calisthenics and limited chances to wash up. Prisoners were given just one cigarette a day and had to smoke it immediately, Capt. Maher said. Many of the guards, he said, "were sadists, some obviously cowards who did not wish to see battle," he said. "A few were definitely decent and tried to alleviate our condition."During interrogations, "prisoners were required to sit at rigid attention and were never allowed to relax," Capt. Maher said. "At times, a cigarette would be offered in an attempt to throw you off guard. Interrogators used different tactics to obtain results. Some tried flattery, cajolery and sympathy; others used threats of violence. But the prisoner was never allowed to forget that he was in a subservient position and there was nothing that he could do about it," he said.Mail between prisoners and their families was restricted to a trickle of censored letters, Capt. Maher said. "This flagrant violation of international law caused great anxiety on the parts of the relatives of all prisoners in Ofuna. The Japanese frequently referred to the fact that we could write as soon as we left Ofuna, using that as an added incentive to talk and be rewarded by being sent to a regular prisoner-of-war camp."At trial, Japanese officials insisted they had done nothing wrong. The chief of naval intelligence, Rear Adm. Kaoru Takeuchi testified that he had ordered that prisoners be treated well."I had a pamphlet named 'How to Interrogate Prisoners of War' compiled," he said. "The main points in the book" were "to respect international law. Not to mistreat prisoners of war. And to conduct the interrogation in a free, conversational manner." To make sure staff got the message, he had these passages "printed in gothic letters and underlined it with a black line," he said. Moreover, abusing the prisoners was ineffective. "Since Anglo-Saxons would not betray their countries, it would be no use to force them to talk," the admiral testified.Officers were held liable for their subordinates' mistreatment of prisoners -- even if they tried to stop the abuse. Camp commander Suichi Takata "took immediate action and investigated all complaints made by the POW officers as to abuses committed upon POWs, reprimanding the guilty," and also "tried to correct the food situation and living conditions in the camp," concluded Army reviewer George Taylor. Two former prisoners -- the senior American and British officers held there -- wrote letters recommending clemency. In view of such "mitigating circumstances," Mr. Taylor recommended that Mr. Takata's punishment be reduced -- to 15 years at hard labor, from the original sentence of 40 years.Half the time, Army reviewers found the commissions too lenient and recommended that harsher sentences be imposed. On occasion, though, they accepted defense arguments. Prison guard Masatomo Kikuchi was convicted of compelling prisoners "to practice saluting and other forms of arduous military exercises on their rest days and at other times when they were tired." The reviewer concluded that "drilling a detail of men for 15 or 30 minutes … is so universally utilized in the armies of the world to teach discipline and for exercise that it would be unjust and unreasonable to consider it a war crime."'No Serious Injury'Moreover, the reviewer found that the commission had overreached in convicting Mr. Kikuchi of two "beatings." In fact, testimony showed "that the mistreatment consisted of a series of slappings." Since "no serious injury was sustained by any of the POWs as a result of his mistreatment," Mr. Kikuchi's sentence was cut to eight years hard labor, from 12.Cmdr. Sashizo Yokura, an Ofuna interrogator, testified that he opposed beating American prisoners, even though beatings commonly were used to discipline Japanese soldiers. He said he had learned from an interpreter who studied in the U.S. that, while "the Japanese think that beating is the simplest punishment when someone violates a regulation, … the Americans consider beatings as the greatest humiliation." Moreover, he said, beatings were counterproductive, as prisoners wasted interrogators' time bemoaning their treatment.CASE FILE• See documents describing cases involving the beatings of American soldiers.Prosecutors, however, contended that Cmdr. Yokura had subtly signaled guards to soften up prisoners for interrogation. Specifically, they introduced evidence that in December 1944, Cmdr. Yokura delayed the meal of a captured B-29 flyer, Maj. H.A. Walker, and forced him to perform kampan soji, an awkward floor-cleaning exercise using a no-handle mop that typically was used to discipline Japanese sailors. These acts, prosecutors argued, contributed to Maj. Walker's "death by inches" nine months later, after he had been severely beaten by guards and denied medical attention.Cmdr. Yokura's defense attorney, Michael Braun, challenged this theory in his closing argument. "We all regret the death of Maj. Walker, just as we regret the deaths of 250,000 to 300,000 other Americans who died in the past war," he said. "But the fact that a man died in a Japanese prisoner-of-war camp does not automatically mean that any Japanese brought to trial theoretically for his death is guilty of it." Cmdr. Yokura denied holding up Maj. Walker's meal, but even if he had, Mr. Braun argued, he would have been justified because Maj. Walker refused to give his name, rank and serial number, as required by the Geneva Conventions. The U.S. Army's own Rules of Land Warfare authorized "food restrictions as punishment," he http://observed.Mr. Braun urged the military commission not to apply a double standard. "The eyes of the world are focused on what America does here," and "whatever we do is going to be carefully read, carefully scanned, carefully measured against the principles we enunciate."The commission sentenced Cmdr. Yokura to 25 years at hard labor.Post-War LessonsIn 1949, the lessons of World War II trials were incorporated into international law. But following Sept. 11, 2001, Bush administration lawyers reexamined the degree of force and cruelty that could be used to interrogate prisoners captured in the war against terrorism. An April 2003 interrogation policy approved by Defense Secretary Donald Rumsfeld listed permissible methods including 20-hour interrogations, "dietary manipulation," "isolation," "sleep deprivation," "face slap/stomach slap," and "prolonged standing."Mr. Zamperini, the former Japanese prisoner, says that in today's war on terrorism, severe treatment of the enemy might be called for."You've got a bunch of religious cutthroats that don't follow rules and regulations," he says, and "if it's a question of saving a lot of lives, then torture would be in keeping" with the country's best interest. "This is a whole new ballgame," he says.Write to Jess Bravin at [email protected]

Eight Common Fears That Men Have of Making a CommitmentOver the years as a clinical psychologist and researcher, I’ve found that guys have eight common fears of commitment, all of which have their roots in childhood and adolescence. The process of picking, projecting and provoking these fears can lead men to recreate their negative relationship scenarios and sabotage themselves when it comes to romance and love. Unfortunately, if a man is not growing and working on his issues, he will often follow these same patterns over and over again with woman after woman—sinking his possibilities of committed love into the netherworld.I know you may be all too familiar with men’s fears in this department, but bear with me. I want you to have a much deeper understanding of the minds of men. Remember, there is a matter of degree of difficulty: some men are truly mired in their issues, while others are growing and working on themselves. You want to determine if your prospective partner is in the mired-in-quicksand category so that you can get out quickly and cut your losses. But if he is moving forward with developing himself, understanding these self-sabotaging patterns will help you know how to key into his psychology.1. Fear of RejectionThis is a man who is afraid a woman will suddenly lose interest and abandon him. Because of this, he has a hard time having honest straight talk and is very afraid of conflict. When the inevitable disagreements and differences come up in a relationship, he stuffs his feelings and drifts away. He prefers email or texts when dealing with uncomfortable issues. He doesn’t have the courage to stand up to his partner, so problems fester and blow up. When tension reaches the boiling point, he doesn’t have the cajones to break up. Instead he becomes passive-aggressive, gently slipping away as his texts and calls fade out—or he quickly dumps you before you can dump him. Above all, he fears rejection, a feeling so painful, that it is almost like annihilation, like being completely destroyed. So he slithers around any direct conflict.Many men suffer from some degree of this conflict-avoidant pattern. That’s because guys tend to have much more difficulty in dealing with stress. Research shows that after an argument, men’s heart rates and blood pressure readings get more elevated than women’s[i]. And they stay elevated. Why? Because men, unlike women, have a more difficult time soothing and quieting themselves down after any kind of upset. So they may pull away and distance themselves emotionally in order to calm down.Fear of Rejection: The Story of EmmettEmmett, one of my therapy clients, was a computer security expert who had a history of falling for gorgeous Asian women whom he believed were “out of his league.” Emmett met Riko, a much younger Japanese woman, online. He was awestruck by her delicate beauty. Riko looked up to Emmett and his great intelligence. Nonetheless, he told me in numerous sessions how he was sure she would get disenchanted and leave him. After several months, Emmett was very unhappy with Riko’s passivity during sex. He shared his unhappiness with me but even after my prodding, he refused to tell his lover. Eventually, Emmett agreed to a joint session with Riko. He was very nervous that when he was straight with Riko she would storm out (like his mother, who had a difficult personality). But with support, he was able to speak his truth. Riko was fine about it. She had her own issues about Emmett’s lack of support for her work as a graphic designer. Whenever she brought this up, Emmett tended to clam up and withdraw. But he was committed to therapy and over time the couple worked together and to Emmett’s great relief, became engaged.article continues after advertisementFear of Rejection Warning Signs: He avoids angry exchanges like the plague. If there is a disagreement, he tends to pull away and use text/email or simply does not respond to your messages.2. Fear of Being Controlled and SmotheredBecause of the strong mothering pressure that most men experience growing up, fear of being controlled is also a common pattern. In my experience, men value their independence and freedom even more greatly than women. Remember that in order to define their own separate identities, they really had to pull away from their mother early on in their lives. This battle for a separate identity is, according to some scholars on gender differences, harder for men than women.[ii] As a result, many men grow up with a view of women as weights that hold them down or as controlling objects that won’t let them go. You can hear these fears echoed in the phrases men use, like, “the ball and chain,” and “she had me by the balls.” It’s easy to see then how marriage becomes the definite marker of an imbalance of power—where the woman-as-wife simply takes over the man’s life.When the fear of smothering is very strong, it leads to classic commitment phobia. Talk of a future makes this guy quiet, nervous, upset or angry. He may be reluctant to act like he’s in a couple when you are with friends or out in public. He may only speak in the first person, saying “I” instead of “we” or “me” instead of “us.” He may keep you away from his friends and family. Guys who are afraid of smothering may be in an on-again-off-again relationship for years—where he always seems to want you when you break up because he then feels free and unencumbered—yet he just cannot pull the trigger and commit when you are together because it feels like he is losing his independence.If the relationship has progressed to having regular sex, he may need to make an escape by asking you to leave or going home instead of spending the night. He may feel distant and emotionally unavailable to you. He may say he is not sure what love really is or that he is incapable of experiencing love. This is the guy who comes right out and says that he does not believe in love and marriage or getting serious and settling down with one person.No matter how much love he feels, this is a man who is terrified of jumping fully into a long-term relationship. Bottom line: he believes he can’t be himself and fully be with a woman. In his view, he has to give up the lead role in his own life if he is stuck in a supporting role with you and/or the children. It seems like his golf, buddies, bar days, sports, even the Super Bowl are going to be ripped away by the all-powerful, all-controlling vortex of the couple. For this man, commitment, love and marriage mean being trapped in a cage from which there is no escape.article continues after advertisementFear of Being Controlled: The Story of JonJon, a 40-year old businessman had a series of relationships each lasting around six months to a year. He fell madly in love with brunette after brunette and pursued each of them vigorously until the moment things became serious and “her thoughts of marriage” were in the air. At that moment everything would reverse and he would feel like the hunted one instead of the hunter. Jon would become anxious, agitated and feel like he had to get away from each woman at all costs, as if his very life depended on it. In his last relationship, Jon claimed that he was forced into an actual engagement. But he was saved by an unlikely ally. He told me that right after he gave her the ring, he started having full-blown panic attacks. Jon described them as attacks in which he couldn’t breathe and his chest became so tight and painful that he thought he was having a heart attack. With these frightening symptoms, Jon felt like he had the excuse he needed. He told his girlfriend that something was really wrong with him and he broke up with her.During therapy, Jon came to realize that his fear of being smothered had destroyed his last relationship and would prevent him from any chance at real love. Only then did he begin working seriously on facing and overcoming his severe commitment fears.Fear Of Being Controlled Warning Signs: He may act like a super confident captain of industry until he has to say the three magic words or you want a definite date or commitment. Then he turns and runs for cover. Or he may act like your knight in shining armor where he takes orders from you, always looking to please you in a way that feels like he is one-down in the relationship. Until he balks when it comes to moving in together or getting engaged. Only then do you realize that his cooperation was an illusion.3. Fear of Not Being LovableBecause of not being prized and validated growing up, a man may have a core unconscious fear that he is simply not lovable. He feels insecure and not-good-enough. This type of guy is looking to you for approval, asking what you think, before he makes decisions. In the beginning, he tries hard and works overtime to make you happy. His feelings depend on what you think and feel. If you are sad, disappointed, afraid, he is really upset and takes it as a measure of his fundamental lack of worth.article continues after advertisementThe net effect is that he feels emotionally uncomfortable in the relationship, like it is not a good fit for him. He may feel like the woman is out of his league. So when it comes time to take that next step to commitment, to say the "L" word or talk about a future, he is passive, quiet and tends to pull away from you.Another sign of this particular type is the man that cannot tolerate your innocent flirting with guys or talking about your ex. He gets depressed, moody and withdraws. If you cheat, forget about it: this man will not fight to win you back. Instead he will collapse internally under a mountain of self-hate.Fear of Not Being Lovable: The Story of JasonJason, a 31-year-old internet marketer, suffered from a fear of not being lovable, or worthy. At a local bar, he met Felicia, a sloe-eyed and beautiful Pilates trainer. Jason was tipsy and confident as he swept Felicia away with his quick wit. They wound up sharing that first night together. Felicia pursued Jason, asking him to join her at various parties and events. Jason came along, but usually had a few drinks to loosen up. A few “good” months went by. One night, Felicia met her ex at a party and flirted with him. Seeing this, Jason sulked and withdrew from her. He was not responsive to any of her attempts to reconnect, even refusing to come over for “make-up” sex. A few weeks later, he called the whole thing off, rejecting Felicia apparently before she could reject him.article continues after advertisementFear of Not Being Lovable Warning Signs: He may be very quiet or shy. Or he seeks approval by doing things that are helpful or giving. He finds it hard to talk about his own wants and needs. He is more passive and tends to enjoy solitary activities including sports or computer games. He cannot handle any competition from other guys—it usually spells the end of the relationship.4. Fear of Not Measuring UpWhile the fear of not measuring up is closely related to the fear of not being lovable, it has its roots in men’s biology and in our culture. Men are biologically wired to perform and produce. Plus they have been taught by this materialistic culture that the measure of a man’s worth is how successful he is in terms of power and money. Men often feel they must succeed at everything they do: in school; sports; video games; relationships; as lovers; as parents; and, as breadwinners. Some men feel that if they fail in any of these arenas, that they are losers.The fear of not measuring up also has its origins in families where boys are driven to be perfect; to get all “A”s, to excel on the football field or by their mothers (often single or divorced) to be the “men of the house.” It’s very difficult if not impossible for a boy or even an 18- or 21-year-old to feel like a man. So you can understand how he might still feel like he isn’t man enough or that he doesn’t measure up.This particular fear can make it very difficult to move forward into a committed relationship with a partner, no matter how terrific she is. At his core, this type of man is terrified that he can’t give a woman what she deserves or needs. His anxiety can be magnified if he is really smitten with her—so the more he is into her, the faster he thinks he will fail in some irretrievable way.Often this type of guy needs a “trophy” girlfriend who is sexy and over-the-top beautiful to “prove” that he is measuring up as a successful man. He may or may not have real feelings for her, even if they are together for years.Fear of Not Measuring Up: The Story of WayneWayne, a 29-year-old event promoter had a strong fear of not measuring up. He grew up with a “Great Santini” father, a career military man who constantly pushed Wayne but rarely praised him. Yet, Wayne turned out to be very successful at a relatively young age winning over club owners with his brash can-do attitude. On top of that, Wayne had managed to win the heart of the stunning Li, a 30-year-old Broadway dancer, who had her choice of suitors. They had been together for two years, but as she pressed to move into his place, he nervously told her he was not sure, that he did not know what love really was. When Wayne’s business slowed down, he began withdrawing from Li so that they were down to seeing each other about once a week. Then, at one of his events, Wayne met a young model and took her right to bed. He began courting the new girlfriend while still maintaining some contact with Li. Finally, Li confronted Wayne and he confessed. Wayne tried to make it up to her but he refused to make a commitment for the future. After a few torturous months, Li told him that she was done. Li packed up the things she had left at Wayne’s apartment and slammed the door while he watched helplessly. That’s when Wayne came to see me.After a few months of therapy, Wayne realized how he had self-destructed when his business started to fail. His fears of not measuring up had grabbed him by the throat and to make himself feel like a man again he went after the model. Unfortunately, that only worked for a short period of time. Wayne told me that he was ashamed that his fears had driven away the only woman he had ever loved.With my encouragement, Wayne asked Li to come back. Actually, he begged her. Wayne also invited her to join him in a few therapy sessions. When Li saw that Wayne had true remorse and after he asked her to marry him (with a ring) she did forgive him. They continued in couple’s therapy until after they were married.Fear of Not Measuring Up Warning Signs: He brags and may exaggerate his accomplishments to the point of lying about them. Winning at work or with women is critical to his feeling OK. If this type of guy experiences a setback in work, he may slink away in shame or like Wayne find another woman to boost his ego.5. Fear of Being Found OutAs a man gets closer to a woman, he may fear that he will become exposed, because he has to reveal fears or feelings that are “unmanly” or a shameful family secret. This is especially true if he had difficult, demanding parents that shamed him when he cried or acted like a “wuss.” A similar fear of commitment can also develop when a man is ashamed about his history or family. He may harbor secrets about relatives who are in mental hospitals, in jail or just poor.You may have seen this type of guy depicted on film or TV as the man who can only get married if he completely hides his past. On the award-winning series Mad Men, the super successful hunky lead, ad executive Don Draper, has completely hidden his background and even changed his identity including his name. For a long time on the show, no one, including his beleaguered upper-middle-class wife, knows his true history. Draper’s whole life is about keeping secrets, all driven by the fear of being found out. For this type of guy, opening up and expressing his deeper feelings is impossible because he will have to come clean. And in his world, confession is definitely not good for the soul.Another variation of this fear has to do with an inner sense of having some horrible and unfix-able flaw. It might be a perceived physical defect like his height or the size of his “package.” Or it might be a feeling of intellectual inferiority, a sense of being a “B” player who’s not good enough to be an “A.” This type of man works harder, tries harder and puts down competitors with sarcasm or contempt.In relationships, he will often project onto his partner by being super critical and judgmental and looking for her fatal flaw. Unconsciously, he doesn’t want to be with anyone who would be in a club that would have him. In therapy, he says that there are no great women out there and that he is super picky because he deserves “the perfect woman.” As he makes progress in therapy or some other growth process, he will admit that the truth is that he is afraid to commit because he’s afraid he will be found out as the imperfect man.Fear of Being Found Out: The Story of Guy, the Little NapoleonGuy was a lawyer who was somewhat short in stature, something that had bothered him since he stopped growing at 14. His brutal father, a big and burly Italian pizza restaurant owner, frequently beat him when he was a child. But Guy was tenacious, studied hard and made it into one of the top law schools. Years went by and with his hard work ethic and pitbull attitude, he became one of the top litigators in Philadelphia.When I first met him, he was dressed impeccably in head-to-toe Armani. He had dated Sherri, a quiet social worker for three years. She looked up to Guy and was very shy socially. Guy complained that even though Sherri was kind and beautiful, that she was boring, especially in bed. According to Guy, his friends really liked her because Sherri had humanized him, that he was “tolerable to be with.” Guy told me all this with a smirk as if he gave a crap about “being more human.” I wanted to meet Sherri but Guy refused because then “we would gang up on him.” Despite my jokes about how he wanted two women to gang up on him, Guy really was afraid for Sherri to find out the truth about him: that he came from a brutal and humble family of modest means.Finally, as Guy continued to waffle, Sherri got the courage to have “the talk.” Faced with what he saw as an ultimatum, Guy broke up with her. It was only then that Guy’s progress in therapy really began. He lost a great gal but the next woman he really liked learned about his sad but true history.Fear of Being Found Out Warning Signs: He denies having any needy-type feelings, like being anxious, insecure, or lonely. He may not be able to use the "L" word. He is extremely judgmental about others, especially if they make demands of him.6. Fear of Trusting A WomanIf a man had an erratic or manipulative mother and a history of being cheated on, used or disappointed by women, he may have major trust issues when it comes to making a commitment. Mistrusting all women, he vows never to be vulnerable again--because if he is, he will just be hurt. If he took a hit financially in a divorce and/or is wealthy, he may be afraid that women just want him for his money. He may fear that all women are mean, manipulative and exploitative.Sometimes this fear can develop when a guy is stuck struggling to extricate himself from an ugly divorce or an angry battle with his ex over their children. He may come right out and say that he will never marry again.Fear of Trusting a Woman: The Story of KaiKai was a flight attendant who navigated a difficult divorce from a very nasty alcoholic woman, who was very much like his raging mother. In order to get out, he basically caved in and gave his wife the house that he loved and “most” of his money. When he met Saidah, an earthy warm woman on one of his flights, he was entranced. They had a delightful six months together. But when she started asking about a future, he started to experience her as pushy, just like his ex. He said he didn’t think he would ever be able to live with a woman again—and definitely would never marry.Saidah was patient and kind. She felt Kai would come around, especially if she nurtured him. But after two years went by with very little movement on Kai’s part, she gave him an ultimatum: move in together or break up. Kai felt put upon and abused. He went MIA, finally writing her a long goodbye letter. Saidah, on the other hand, learned her lesson and went to one of my trained love Mentors. She started dating guys who were more open to creating a committed love relationship.Fear of Trusting a Woman Warning Signs: He talks negatively about his mother and/or exes. He feels like he has been victimized by women. He may come right out and say he doesn’t believe in love or will never marry.7. Fear of Growing UpA man may not feel like he is an adult who is ready to take on the responsibilities of a relationship, children and family life. This so-called Peter Pan syndrome may have its roots in various types of family dysfunction. He may have been coddled by his parents who protected him from the real world, from the possibility of failure. Any difficulty or trial at school might have been dismissed as someone else’s problem and never his responsibility. Or he may have never been encouraged to try something really hard like a competitive sport or an accelerated school subject where trying and not winning or getting a high grade is a real possibility. Or he may have been sickly and had overprotective parents who wouldn’t allow him to play with other kids and compete in sports. Other Peter Pan guys were just ignored by a divorced or missing father and an overworked Mom.As a result of any of these dynamics, the young man fails to build up his identity as a competent and solid adult male. Internally, he feels like a child, a kid who wants to play, get high, sleep late and work menial jobs with little no responsibility. No wonder then that our Peter Pan is boyish in his leisure activities. He may be a video game addict, who is glued to his game console at all times. Or he may spend many hours watching or playing sports. Or he worries about his health while smoking pot every day. He may be still living at home into his 30s. This is a guy who wants to date and have fun, but balks when it comes to having a committed ongoing and serious relationship.Fear of Growing Up: The Story of JermaineJermaine was an eternal student, with a master's degree and not a pot to pee in. He worked at Starbucks and lived with his single mom, who was a teacher. His main passion was writing and although he had never published anything, he was always starting a new novel—“his big breakthrough." When Shelly, a frustrated nurse whose dream was also to be a wife and mom, first met Jermaine in a graduate course, she was drawn to his creativity and over-the-top ability to spin yarns. He had a childish air about him that Shelly found endearing. Thus began an on-again-off-again relationship that lasted 10 years. During that time, Shelly would leave Jermaine because the relationship and his career were “going nowhere.” He would then pull his act together and get a full-time job. They would reunite, but never in a serious fulfilling way. Eventually, Shelly met with me and decided to end the relationship for good. Once she was finally free, she began dating men who actually had their own places and real careers that were also looking to be in permanent relationships. Eventually, through an on-line service, she met the “nerdy guy” of her dreams, a man who was successful and crazy about her. They are married and have adorable twin rascals.Fear of Growing Up Warning Signs: He acts juvenile, makes ridiculous jokes or even burps or farts like a little boy. In a conflict, he tends to either quickly back down or have a tantrum to get his way. He may be very concerned with his bodily functions or getting ill.8. Fear That He Can’t Make The “Right “DecisionThis type of man has a very hard time making up his mind or trusting his own judgment. When he picks one movie to see, he immediately regrets not choosing another. He is not sure that the company he works at is really the best one for him. This guy is afraid of making a decision that forecloses on all his other options including choosing you. Every time he does so, he has a burst of anxiety and thoughts about other, “better” women.Fear He Can’t Make the “Right” Decision: The Story of GeorgeLeeza, a 40-something cosmetics manager at a department store, was a stunning blonde who met George online. George was a community college professor who was close to 50 and yet had never been married. Leeza was drawn to George’s brilliant mind and loved the fact that he didn’t have an ex or kids. George took her out for dinner and bought her expensive gifts at high-end department stores. At first, Leeza was blown away. But as the months wore on, she noticed that George was really very depressed and never seemed to enjoy the fantastic activities they shared. He was always worrying about work, reading his “Crackberry,” or quipping that the service or the meal wasn’t good enough.After about nine months, Leeza wanted to know where things were heading in the relationship. George said that he just didn’t know for sure if marriage was for him, although he thought it was time and Leeza was really terrific. Leeza asked him to figure out where she stood but all he could say was that he was afraid of making a mistake. With the encouragement of her Love Mentor (see Chapter Five), Leeza finally left him and started dating other guys. George begged her to come back. After he went into therapy and attended some growth courses with her, Leeza did take him back, under the condition that they get engaged. George says it was the best decision he ever made.Fear He Can’t Make the “Right” Decision Warning Signs: He is very intellectual. He tends to overly think things through and obsess. He is always second-guessing himself. Often this type of guy needs to be left to realize what he’s lost.The Fear-O-MeterYou can think of the Fear-O-Meter as a continuum of intensity of the eight fears. They can occur at normal level, where they are being faced and overcome or they can be exaggerated to the point that the man is so neurotic as to be unable to move into a committed relationship.Signs of Extreme Commitment FearsWhen men’s fears of commitment are extreme, they can play out in many different ways. Some men become addicts: compulsive video game-players, eaters, drinkers, or workaholics. Others become argumentative, contemptuous, critical or domineering. Still others may act extremely passive or shy or withdraw from any meaningful conversations about the future. Some act more like hypochondriacs or child-like. Others disappear on you. Still others cheat. When fears are extreme and the guy is acting out in response to those fears there is often nothing that can be done. Their fear is operating at an unconscious level and therefore controls the outcome of any love relationship. In other words, it goes nowhere.Once the deeper fear is triggered, whether it is by the prospect of seeing each other more regularly, discussing a future together, moving in or getting engaged, a man with extreme fear will at a fundamental level do all he can to pull back. He is not willing to examine himself, his motives or his fears. Here’s what you need to get: this type of guy is fundamentally happy with the status quo of his love life and does not want to change. Therefore, it’s best to get out quickly and cut your losses. No matter how hard or unfair it seems. You’re better off leaving because if you stay, all you will end up with is a lot of wasted years you can never get back, not to mention bitter disappointment and heartache.Normal FearsAll of us are faced with two conflicting urges: to merge and become one vs. being independent and free. When a man and woman fall in love and come together, it is normal and common to have fears come up about losing one’s separate sense of self, one’s space, one’s own identity, and unique pursuits and interests. Both men and women experience these fears. This is reasonable—compromises have to be made in order to have a relationship. Time needs to be set aside. After all, how many times has it happened that you get involved with some guy and wind up having little time for your girlfriends?It is normal in the development of a new relationship for your boyfriend to have doubts, to have some measure of virtually all the fears we have been talking about. The key variable here is this: If a man’s fears are at the normal level, they do not stop him from moving forward over time into increasing intimacy and commitment.Sometimes it is hard to tell if a guy has an unworkable commitment phobia or more normal fears that he is willing to work on. You have to examine whether your boyfriend is trying to be self-reflective and willing to grow. Is he taking growth courses, on a spiritual path, or in therapy? In the last several months or year, is he making progress in his ability to move forward with you? In opening his social world of friends and family to you? In sharing his physical space? In his ability to discuss what he wants for the future? In his willingness to express love for you? Is he growing more open to taking the next step in moving forward together, i.e., moving in together or getting engaged? If he is moving forward in many of these ways, it shows that his fears are more manageable and in the normal range.Helping Him Overcome Normal FearsIf a guy is truly into you and willing to grow, he will face down his fears and make it work with you. Especially if you accept his need for space and independence, validate his worth and continue to nurture yourself. Remember, he will tend to project his fears and negative expectations onto you and even unconsciously provoke you into being angry, critical or distant. If you understand this, you can practice loving kindness and not engage in that negative pattern from his past. You can show him that love is possible. You can gently let him know that, as James Baldwin says, To defend oneself against a fear is simply to ensure that one will, one day, be conquered by it; fears must be faced.[iii]Helping a guy face his demons is not so easy to do. Especially when you have your own issues about love and commitment, as well as your own needs, as we all do. In my newly revised book, Love in 90 Days, I show you how to handle the baggage from your pastivthat will allow you the freedom to not drag old wounds or bitterness into your future. So you will be able to love from your best and highest perspective of self and, in so doing, inspire your beloved to find his strength and courage.

Self harm. 9 out of 10 questions here can be answered with a Google search.The Primary Care Companion to CNS DisordersPhysicians Postgraduate Press, Inc.Insertion of Foreign Bodies (polyembolokoilamania): Underpinnings and Management StrategiesBrandon T. Unruh, MD, Shamim H. Nejad, MD, [...], and Theodore A. Stern, MDAdditional article informationLESSONS LEARNED AT THE INTERFACE OF MEDICINE AND PSYCHIATRYThe Psychiatric Consultation Service at Massachusetts General Hospital sees medical and surgical inpatients with comorbid psychiatric symptoms and conditions. Such consultations require the integration of medical and psychiatric knowledge. During their twice-weekly rounds, Dr Stern and other members of the Consultation Service discuss the diagnosis and management of conditions confronted. These discussions have given rise to rounds reports that will prove useful for clinicians practicing at the interface of medicine and psychiatry.Dr Unruh is an attending psychiatrist at McLean Hospital, Belmont, Massachusetts, and an instructor in psychiatry at Harvard Medical School, Boston, Massachusetts. Dr Nejad is an instructor in psychiatry at Harvard Medical School, Boston, Massachusetts, an attending physician on the Psychiatric Consultation Service at Massachusetts General Hospital, Boston, and the director of the Burns and Trauma Psychiatric Consultation Service at Massachusetts General Hospital, Boston. Mr Stern is a research assistant in the Department of Psychiatry at Massachusetts General Hospital, Boston. Dr Stern is chief of the Psychiatric Consultation Service at Massachusetts General Hospital, Boston, and a professor of psychiatry at Harvard Medical School, Boston, Massachusetts.Dr Stern is an employee of the Academy of Psychosomatic Medicine, has served on the speaker's board of Reed Elsevier, is a stock shareholder in WiFiMD (Tablet PC), and has received royalties from Mosby/Elsevier and McGraw Hill. Drs Unruh and Nejad and Mr Sternreport no financial or other affiliations relevant to the subject of this article.Clinical Points▪ Establishing the motivation for foreign object insertion helps to guide successful patient management.▪ Patients should be counseled about harm-reduction strategies (including less dangerous means of object insertion).▪ Staff reactions (eg, of perplexity, disgust, titillation) can impinge on compassionate care; reactions should be addressed so that the patient's problems can be unearthed and managed.Have you ever had to evaluate and manage a patient with polyembolokoilamania (inserting a foreign body into 1 body orifice or more)? Have you wondered why he or she did it and been surprised by your reactions to their behavior? If you have, then the following case vignette and discussion should prove useful with your approach to and management of patients who insert foreign bodies into themselves.Although insertion of foreign bodies into bodily orifices is not uncommon, relatively little has been written about its predisposing factors, its complications, or its management. Care required is often collaborative, involving primary care physicians (who oversee the patient's care), surgeons (who assess the need for surgical removal or management of its complications, eg, perforated viscera), infectious disease specialists (re: infections), and psychiatrists (mental status and psychiatric assessment of reasons for foreign body insertion, eg, psychosis, self-injury, erotic pleasure, malingering, factitious illness).In addition, such individuals and their behaviors evoke intense emotional reactions (eg, disgust, anger, embarrassment, fear) that threaten to interfere with medical care (eg, via avoidance, a lack of compassion or empathy, hostility). Psychiatric consultation may facilitate a greater understanding of the patient and his or her dilemma so that timely treatment and effective care can be initiated.CASE VIGNETTEMr A, a 51-year-old man, brought himself to the emergency department (ED) when he was unable to remove a flower vase from his rectum. On several occasions he had inserted the same vase and had removed it without difficulty. Unfortunately, this time it had penetrated so far that he could not grip the edge and remove it. Months earlier, he had inserted a hanger into his rectum to remove the vase; this procedure led to rectal perforation that required an exploratory laparotomy and repair.In the ED, examination revealed that the mouth of the glass was palpable and intact at the anal verge. A kidneys, ureter, bladder radiograph confirmed the presence of an 11.7 cm by 7.6 cm radioopaque foreign body within the rectum. Since it could not be removed under conscious sedation at the bedside, Mr A was sent to the operating room for an exploratory laparotomy and foreign body removal.When asked why he inserted the vase, Mr A replied, in hushed tones, that he “would rather not get into it” and gestured toward the patient behind the curtain, as though he preferred not to be overheard. Later, he reported that over the past decade he had regularly inserted (“once every few months”) a variety of household objects (including the plastic top of an aerosol container into his rectum [removed via anoscopy]) for sexual pleasure. He denied that foreign body insertion was ever an intentional self-injurious act. He identified himself as a heterosexual; however, he had never had genital intercourse.He denied any active neurovegetative symptoms of depression but acknowledged that he had a bout of depression as a teenager. He also reported having social anxiety that improved dramatically with use of fluoxetine.Mr A denied substance use or abuse or having been the victim of abuse or trauma. His medical history included asthma, glaucoma, scoliosis, a congenital deformity of his right arm, and an exploratory laparotomy for rectal perforation following insertion of a hanger.His vital signs were stable. On mental status examination, he was awake, alert, oriented, comfortable (sitting up on the stretcher), and cognitively intact. His right arm had marked malformations (proximal and distal, including his hand and fingers). His mood was “good,” but he appeared ashamed. There was no evidence of a thought disorder.His laboratory values were notable only for a white blood cell count of 17.9 cells/mm3.WHO INSERTS FOREIGN OBJECTS INTO BODILY ORIFICES?Individuals who insert foreign objects into their own bodily orifices span disparate backgrounds, ages, and lifestyles. Children (under the age of 20 years) commonly swallow foreign bodies, accounting for approximately 80,000 cases each year; most of these are accidental ingestions in children between the age of 6 months and 4 years.1Younger boys swallow foreign bodies more often than do younger girls. In adolescents, intentional foreign body insertion often reflects risk-taking, attention-seeking, or poor judgment while under the influence of drugs or alcohol or as a manifestation of psychological abnormalities.2Adolescent girls with eating disorders (ie, bulimia or anorexia nervosa) exhibit a propensity for toothbrush swallowing.3Adults who insert foreign objects often suffer from mental illness, harbor lingering curiosities that manifest as experimentation or as efforts to rekindle past experiences or relationships, or do so to enhance sexual stimulation.WHAT DO PEOPLE INSERT INTO ORIFICES?While the list of objects that patients insert into their orifices is long and sundry, most are common household objects (eg, beans, dried peas, popcorn kernels, hearing-aid batteries, raisins, beads, coins, chicken bones, fish bones, pebbles, plastic toys, pins, keys, buckshot, round stones, marbles, nails, rings, batteries, ball bearings, screws, staples, washers, pendants, springs, crayons, toothbrushes, vases, razor blades, soda cans and bottles, silverware, hinges, telephone cable, and guitar picks).WHICH ORIFICES ARE USED FOR FOREIGN BODY INSERTION?Foreign bodies can enter the human body by swallowing (the mouth/upper gastrointestinal [GI] tract), insertion (eg, nose, ears, penis/urethra, vagina, rectum (lower GI tract), fistulas, ostomy sites), or traumatic force, either accidentally or on purpose.1WHAT COMPLICATIONS DEVELOP AFTER FOREIGN BODY INSERTION?Once past the esophagus, the majority of swallowed foreign bodies pass through the alimentary canal without sequelae.4–7However, in approximately 1% of patients4operative interventions are necessary. The properties of involved objects often determine the complications associated with ingestion. Long, thin objects (especially if more than 1 object has been ingested)6,8tend to have more difficulty traversing the GI tract and are more likely to become entrapped. Objects wider than 2 cm tend to lodge in the stomach (and do not pass the pylorus); objects longer than 5 cm tend to get caught in the duodenal sweep.6,9In addition, risk of perforation (leading to peritonitis, abscess formation, obstruction, fistulae, hemorrhage, or even death) is associated with ingestion of sharp objects; therefore, these should be removed, even in asymptomatic individuals.4,7,10,12Of traumatic rectal injuries (perforating, nonperforating, and either intraperitoneal or extraperitoneal)13seen in the ED, 19% were secondary to foreign body insertion. Although most foreign bodies fail to cause significant anorectal injuries, complications can arise from their insertion or removal, or from the content they introduce.14–17The complications of foreign bodies inserted into the penis are generally evident; most affected individuals seek care for relief of pain (eg, from testicular torsion or scarring of the penis) or inability to void.18Even when the penile skin appears dark or necrotic, reported salvage rates have been high.19–21Similarly, foreign bodies inserted into the vagina, when not discovered in a timely fashion, may lead to complications of pelvic pain, urinary retention, damage to the bladder or intestines, or an infection with septic shock.22Complications of genitourinary (GU) foreign body insertion include acute cystitis, dysuria, urinary frequency, hematuria, and strangury.23–25In addition, urinary retention, poor urinary stream, and swelling of the external genitalia may arise, along with ascending GU infections. Some patients experience tears of the urethra, with periurethral abscesses, fistulas, and urethral diverticula.23,26,27Complications of foreign bodies inserted into subcutaneous tissue are largely dependent on the type of object used along with the location of injury. Objects inserted into abdominal tissue carry the risk of stomach or bowel perforation, while insertion into the extremities may result in abscess formation or nerve injury; these may result in permanent functional impairment.WHY DO PEOPLE INSERT FOREIGN OBJECTS INTO THEMSELVES?Establishing the motivation for foreign object insertion is crucial to successful patient management (Table 1). This may be facilitated by eliciting the patient's description of the psychological circumstances (mental state) preceding the insertion, by comparing the intended and actual effects of the insertion, and by taking a general psychiatric and developmental history.Table 1.Differential Diagnosis of the Motivation for Foreign Object InsertionSexual GratificationSexual gratification is commonly reported by patients (and accepted by clinicians) as the reason for autoerotic or consensual sexual acts involving the insertion of foreign objects into the erogenous zones of the urethra,23,24,28–30vagina,31or rectum.32However, there are reasons to take a wider view and resist equating these insertion activities with mere orgasm-seeking behavior. Psychoanalysts have long observed that psychosexual energy (libido) can become invested in actions that do not lead directly to orgasm, such that some behaviors may be primarily reinforced by a compelling emotional payoff that has become layered upon a secondary outcome of orgasm, or occurs in the absence of orgasm.33This insight prompts a search for less reductionistic explanations of behaviors with complex psychological origins. A deeper understanding of the patient's situation may also distinguish between nonpathologic sexual preferences and the paraphilic disorders. When a patient's sexual history reveals a pattern of recurrent behaviors, fantasies, or urges involving nonhuman objects that causes significant distress or functional impairment, a paraphilic disorder (fetishism) may be diagnosed.34Foreign object insertion resulting in sexual gratification linked with a sense of being made to suffer suggests another paraphilic disorder (masochism). While the diagnostic approach of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision34to sexual disorders exemplifies a “disease model,” other perspectives within psychiatry emphasize the social construction of paraphilic behaviors. A clinician who employs multiple theoretical approaches would consider whether the insertion behavior represents a nonpathologic sexual preference, reflective of the diversity of human behavior, and not a “disease.”35Nonsuicidal Self-Injurious BehaviorNonsuicidal self-injurious behavior serving an emotional regulatory function is strongly associated with borderline personality disorder (BPD). Such behavior can take the form of foreign body insertion (eg, 76 needles and hair pins self-inserted under the skin of a woman's arms, head, and neck, which required surgical excision,36or straightened paper clips inserted into the forearm37). Nonsuicidal self-injurious behavior in the context of BPD seeks to modulate unbearable emotions, to externally mark for oneself or others an internal experience of being “bad,” to feel physical pain, or simply to feel.38Foreign body insertion may play a similar emotional regulatory role for those with other personality disorders,29mental retardation,39or developmental disorders (eg, Smith-Magenis syndrome40).Suicide AttemptSuicide attempts by foreign body insertion usually involve oral ingestion of toxic solids (eg, batteries or sharp objects such as pins).41–43Suicidal insertions through other routes (eg, transurethral insertion of a cylinder resulting in bladder perforation44and transnasal intracranial insertion of a ballpoint pen45) have been reported.Psychosis With or Without Mood DisturbancePsychosis with or without mood disturbance can lead to foreign object insertion (either directly in response to a delusional belief or command hallucination or indirectly via impaired judgment).22Atypical psychotic states devoid of mood symptoms can lead to foreign object insertion, as with a monosymptomatic hypochondriacal delusion about having a urethral stricture that led a man to insert knitting needles to overcome the feared stricture.46Depressive Disorder With Psychotic FeaturesDepressive disorder with psychotic features has been reported in association with more bizarre insertions (eg, ingestion of 50 pins41and insertion of needles through the chest wall47). Recurrent depressive illness without psychosis has also been diagnosed in some insertions leading to hospital attention.30,48Factitious DisorderFactitious disorder (marked by the deliberate production of physical or psychiatric symptoms or signs to obtain the sick role)49has been manifest by rectal insertion of a glass bottle neck50in the context of similar presentations for feigned or simulated illness, peregrination (wandering or traveling), and pseudologia fantastica (pathological lying); endoscopic retrieval detected that the object had been packed with paper, likely by the patient to afford himself some protection from internal trauma.MalingeringMalingering (where physical or psychiatric symptoms or signs are intentionally feigned or produced to achieve tangible “secondary gain,” such as disability benefits, shelter, or avoidance of military duty or legal consequences) occurs most often in men between adolescence and middle age. One illustrative example of malingering and social contagion51involved 6 males (3 met criteria for antisocial personality disorder and 3 for BPD) living in a maximum-security hospital who copied each other's urethral self-insertion technique in a deliberate attempt to control hospital staff. All 6 inserters reported that their behavior released tension, while the initial inserter reported a sadistic fantasy during insertion in which he imagined the damage being inflicted to the urethras of other people.Cognitive DisordersCognitive disorders may lead to foreign object insertion or influence its course. In one case series of 17 men who presented with urethral insertion, substance intoxication was detected in 6 men.52Dementia and delirium causing confusional states may similarly complicate the course of foreign object insertion, as occurred in a woman who inserted a pencil into her urethra while masturbating; it slipped into the bladder causing perforation.53Finally, foreign bodies may be inserted for reasons not inherently psychopathological. These include nonpathologic sexual preference; exploratory misadventures occurring in children as isolated acts driven by simple curiosity54–57; insertions by other people during sexual assaults or pranks58–61(eg, a man's friends inserted tennis wire into his urethra at a stag party and another man's roofing colleagues forced cylindrical rolls of tar into his urethra to have fun at his expense); drug concealment or smuggling62,63; and misguided attempts at contraception, abortion, or self-treatment of anal or urinary symptoms.64,65WHERE DO PEOPLE INSERT FOREIGN OBJECTS?Although case reports of foreign body insertion are not uncommon, only a few large reviews on the subject exist; most were written before 1950.66–69In 1880 Poulet67included several chapters on the topic in his book, A Treatise on Foreign Bodies in Surgical Practice, and in 1897 Packard66reported 221 cases of foreign bodies introduced into the male bladder (via the urethra). How people insert, embed, or ingest foreign bodies depends largely on the type of objects used, and the anatomic location of the object's placement.Upper Gastrointestinal TractUpper GI tract foreign body ingestions are more common in those who are either young, have comorbid drug or alcohol use histories, have psychiatric illness, or are prisoners.4,10,70Most published studies indicate that the majority of ingestions in the pediatric and adult populations (52% and 97%, respectively) are accidental. However, Palta and colleagues71–74found that 92% of intentional ingestions occurred in patients with psychiatric problems and were associated with similar prior presentations. Intentionally ingested items were typically common household items (eg, pens, plastic spoons, toothbrushes, or pencils), whereas accidentally ingested items were often food impactions, bones, or coins.74,75Lower Gastrointestinal TractSmiley (in 1919)76published one of the earliest reports of foreign body insertion into the rectum; it involved a glass tumbler. Since then the incidence of colorectal foreign body insertion has been increasing; it is no longer considered an uncommon reason for ED care.77Kurer and colleagues’ review78noted that the ratio of men to women with foreign body insertion was 37:1. They also reported that sexual arousal was the reason for nearly half of cases, while personal care or self-treatment of constipation, hemorrhoids, and pruritus ani resulted in 25%, 12% were due to assaults, and 9% were due to “accidents.”78Other reasons included psychosis (5%) and the consequences of drunken wagers.78Similar to the pattern seen with upper GI insertions, the most common objects inserted into the lower GI tract were household objects (mainly bottles of various sizes and shapes, and drinking glasses).VaginaMany reports of foreign bodies placed into the vagina involve children and are usually associated with premenarchal vaginal discharge or sexual abuse.79In adults, vaginal foreign bodies are primarily described in the gynecologic literature and have not been associated with mental illness; instead, they are linked with drug smuggling and with sexual stimulation.62,80Nonetheless, insertion of foreign objects by women with psychiatric illness has been described.22,81Genitourinary TractThe medical literature contains a vast array of case reports of foreign bodies (including fish hooks, glass stirrers, a coyote's rib, a razor blade, and even a 45-cm decapitated snake) inserted into the GU tract.26,82–87In addition, almost every household tool or appliance that is physically capable of being inserted into the urethra has also been described.67While most cases have been associated with self-exploration and with increasing sexual pleasure, some reports feature contraceptive efforts (eg, sealing the meatus by gum or candle wax), drug intoxication (intraurethral administration of cocaine), violence or assault, gastrovesical fistulas, or accidental insertion (objects, such as thermometers, propelled into the bladder by inadvertent insertion into the urethra).88–95Foreign bodies (including umbilical tape after a cesarean section, parts of a surgical glove, bone cement, and even a pacemaker generator) linked to medical intervention have also been described.83,96,98Subcutaneous TissueCase reports of foreign body (eg, staples, pencil lead, crayon, pins, sewing needles, glass, and teeth from a comb) insertion into the soft tissues of the hand, arm, foot, leg, buttocks, groin, abdomen, breast, heart, neck, and orbit have been described.37,99–109Most cases are associated with the self-injurious behavior characteristic of BPD; however, some cases have been thought secondary to Munchausen's syndrome or syndromes involving secondary gain.5,99HOW OFTEN DO PEOPLE INSERT FOREIGN OBJECTS INTO THEMSELVES?The actual prevalence of foreign object insertion in the general population or in specific psychiatric populations is unknown. However, many of those who seek medical attention on account of foreign object insertion report a history of the same behavior. A smaller but significant proportion have a history of medical complications from foreign object insertion, suggesting that developing medical complications and being hospitalized are insufficient to arrest insertion activity.In one series of 17 men seeking management following urethral foreign object insertion, all reported a history of urethral insertions.52In another case series of 38 patients with GI foreign body insertion, 8 patients had been previously evaluated for the same problem.58One study of a specific psychiatric population (ie, mental retardation) supported the conclusion that incidents of foreign object insertion are likely to be followed by subsequent insertions.39These data are consistent with our patient, Mr A, who reported a history of recurrent insertion activity over 4 decades and who had presented twice before due to medical complications related to this activity.HOW DOES STAFF REACT TO PATIENTS WHO INSERT OR INGEST FOREIGN BODIES?As both Bibring110and Groves111have remarked, if an appropriate relationship cannot be established between the patient and the physician, it is not always because the physician does not understand the patient, but because the physician does not understand his or her own reaction to the patient. Reactions by hospital staff to patients who insert foreign bodies are varied, ranging from genuine concern to revulsion and avoidance. As has been described in patients with self-mutilation, medical or surgical house staff who care for patients with foreign body insertion may experience dysfunctional behavior, clouded cognition, and labile affects, either due to disruptive patient behavior or due to the uniqueness of their medical or surgical presentation.112Undoubtedly, some cases awaken “morbid curiosity” and titillation within staff, leading to breaches of privacy (by discussion of the case by staff members with individuals not involved in the care of the patient, or, in cases of “shocking” radiologic images, inappropriate distribution of digital images via cell phones or the Internet).Consultation psychiatrists may assist in averting these potentially harmful outcomes by providing education and awareness of common countertransference reactions.HOW CAN SUCH INDIVIDUALS BE INTERVIEWED, MANAGED, AND PROTECTED FROM REPEATED INJURIES?Rationale for Psychiatric ConsultationAt present there is no consensus about when psychiatric consultation should be sought (or what it should involve) for the management of patients admitted for foreign object insertion. Some have suggested that consultation should be ordered on a case-by-case basis, appropriate only for patients with a history of psychiatric problems30,58or for cases involving unusual foreign objects or a history of foreign object insertion.113–115However, psychiatric problems associated with insertion behavior may go unidentified without routine psychiatric consultation,52leading to the recommendation for prompt psychiatric evaluation for all who self-insert foreign objects.114Given the benefits of elucidating the behavior's motivation for guiding management, we suggest that psychiatric consultation should be obtained in all cases of foreign object insertion resulting in hospitalization (Table 2) so that care can be optimized. By doing so, psychiatric problems that may have contributed to the insertion behavior can be identified and treated. Even in the absence of psychiatric illness, harm-reduction strategies may be taught to psychologically normal individuals who embrace the insertion behavior as a lifestyle preference.Table 2.Goals of Psychiatric Consultation for Foreign Object InsertionIn addition, psychiatric consultation may minimize harms associated with traumatic affective states caused by interactions with the hospital and its staff. Numerous reports attest that anxiety and shame are commonly experienced by inserters (particularly those who do so for sexual gratification) on initial presentation to the hospital.46,52,115Since the statement “I feel ashamed” often means “I do not want to be seen,”33inserters who feel ashamed typically hide their faces (and their stories) from inquisitive staff because being looked at is readily equated with being despised.Mr A initially declined opportunities to explain his insertion behavior to the primary team, leading them to seek psychiatric consultation. He waved off the psychiatric consultant when he initially arrived. He hid his face from the gaze of those passing through the room, telling the consultant that being looked at felt like “being frowned upon.” As an unexpectedly lengthy (17 day) hospital course (complicated by postoperative ileus) wore on, Mr A became aware that staff talked about him (with titillation and disgust) within his earshot. He began to dread daily rounds by the primary team and nurse encounters. He reported feeling more anxious and ashamed—even when no external audience was present—and he became less receptive to conversations with anyone.Countertransference reactions by caretakers may intensify unpleasant affective experiences of inserters during the hospital course. Staff reactions of perplexity, disgust, and titillation in regard to Mr A appeared to stem from the discovery that he practiced a sexual behavior considered perverse. In a large-scale repetition of earlier shame-inducing discoveries of Mr A's behavior, x-rays showcasing the flower vase circulated around the hospital to (and possibly by) staff not directly caring for him.An important and underappreciated function of the psychiatric consultant in a case such as ours is to attend to—and mitigate the harmful effects of—inserters’ affective experiences and staff countertransference reactions as the insertion behavior is “exposed” during the hospital experience.Principles of InterviewingFrom the outset, the patient should be approached with attention paid to his/her subjective experience about the behavior and the hospitalization itself. The consultant should do the following.Titrate the duration, frequency, intensity, and setting of consultation visits to the patient's level of anxiety and shame.Regular, predictable, brief visitations may diminish anxiety about discussing the insertion behavior, which may seem equivalent to being “caught in the act.” If shame is apparent during the initial encounter, the physical setting may be altered to put the patient more at ease. Drawing a curtain around Mr A's bed blocked visual exposure to the gaze of passersby, but his speech remained audible to his roommate. Arranging for a private office down the corridor from his room enabled Mr A to speak with less discomfort.Review initial and all subsequent iterations of the insertion behavior.What were the psychological circumstances (fears, wishes, feelings) surrounding the initial insertion? What have been the intended effects of the behavior, as compared with its actual effects? Has the behavior progressed in frequency, size, and type of objects used or its effect on the patient? What does the patient think has shaped or reinforced the behavior over time? How does the patient feel about the behavior now?Review prior presentations to medical care.Have there been medical complications of the behavior in the past? Has the patient previously delayed or avoided presentation for medical attention? How did the patient experience prior hospitalizations—did he/she feel ashamed, cared for, or judged?Elicit a psychosexual history as part of the general social and developmental history.What are the patient's preferred sexual practices and masturbatory fantasies? What are his/her actual sexual relationships with others? Is there a history of sexual abuse or trauma? What level of sexual education has the patient received? These matters may be particularly important in regard to urethral and rectal insertions, as there is anecdotal evidence that insertion by these routes may be correlated with telltale psychosexual themes (including sadistic fantasies, isolation, and a perception of having had an overbearing parent).51,85Psychoanalysts have long observed that certain character traits are preponderant in persons whose sexual life is oriented around a particular erogenous zone (eg, commitments to parsimony and orderliness in those with urethral erotic aims, and sadistic fantasy and marked shame in anally-oriented individuals).116Relate to the patient's explanation of the behavior in a symbolic as well as literal sense.To the symbolically attuned consultant, Mr A's description of “being filled up” by the inserted object was an accurate mechanistic description of the insertion itself, but also hinted at its powerful affective reward—transient, fleeting relief from a chronic painful sense of loneliness and emptiness.Consider staff's countertransference reactions, including one's own.Especially in cases of foreign object insertion performed for sexual gratification, the psychiatric consultant should remain alert to stumbling into a countertransferential mine field marked by aversive feelings (eg, disgust and titillation) and labels of a patient or behavior as “perverse.” Both are linked implicitly to judgments about what constitutes “normal” or “correct” preference, which may jeopardize one's ability to search empathically for the function of the insertion behavior and its meaning within the patient's symbolic world. The act of labeling foreign object insertion “perverse” may be more usefully viewed as a countertransferential signal that our own disapprobation or disavowal may be limiting our empathic understanding of the patient's situation.CASE VIGNETTE, CONTINUEDGuided by these principles, the consultant obtained additional history. Mr A was raised primarily by his mother, while his father maintained an active sexual life outside of the marriage. Mr A reported conflicted feelings toward his mother, fancying himself as her protector and as her victim. He viewed her as “emotionally incestuous” toward him, for she lacked other primary relationships. Surprisingly, Mr A had no explanation for his prominently malformed limb; he had never asked his mother about it, out of a sense that “it would be too sad for her to talk about.”Since leaving his mother's home in his late twenties, Mr A's life was marked by persistent loneliness. He had no visitors during his hospitalization. He lived alone in a boarding house and maintained few social contacts. He no longer felt close to his mother. He said that he had become someone who preferred “to follow rather than to lead.”Mr A identified himself as heterosexual, preferring sex with only women, but he had never had genital intercourse. He began inserting objects into his rectum as an adolescent, but said he had “blanked out” his earliest reasons for trying out this behavior. On one occasion, his mother “caught him in the act.” A recurrent emotional experience of longing preceded each insertion, which he described as “a feeling of needing to be filled up.” While the act of insertion was initially painful, this typically gave way to “a relief of tension” and a “pleasure of having it in him.” These latter sensations were short-lived and were usually followed by intense anxiety and shame. Only rarely did he experience orgasm associated with the insertion. On a few occasions, he had asked a woman (who was “just a friend”) to insert the objects for him. He was unaware of commercial products that were available for the purpose of anal stimulation.Previous encounters with the health care system on account of his insertion behavior augmented his shame. He denied any similarity between his mother's initial discovery of his behavior decades ago and the recent discoveries by his doctors on each presentation to the hospital. He said that it was his anxiety about others discovering his behavior that had prevented him from entering sex shops to purchase safe insertion toys and from presenting promptly for medical attention on previous occasions when he realized he could not remove the inserted objects. Though he had been anticipating over the preceding weeks that he would again require medical attention sooner or later, he said he “would have done anything to avoid coming here again.”Protecting Patients From Repeated InjuryThe possibility of imminent and long-term repeated injury due to recurrent foreign body insertion in the following manner should be addressed.Evaluate the risk of imminent recurrence of foreign object insertion in the inpatient setting.This means removing foreign bodies present in the hospital milieu that could be used in repeated injury, as well as treating any acute psychiatric illness that may predispose to such behavior. One 24-year-old woman with BPD who inserted 76 needles and hair pins into the skin of her head, neck, and lower arms continued to incorporate new foreign bodies following surgical excision,36suggesting that those for whom insertion is a means of regulating painful affects may be at particular risk of imminent repeated self-injury. A one-to-one sitter at the bedside may be needed to protect patients from repeated inpatient insertions.Counsel patients about harm-reduction strategies (including less dangerous means of insertion).Deaths have been reported from inherently unsafe autoerotic foreign body insertion practices (eg, vaginal insertion of a carrot causing fatal air embolism, urethral insertion of a lead pencil causing bladder perforation and peritonitis, and rectal insertion of a shoe horn causing anal canal laceration and hemorrhage).31,117Patients may be unaware of the existence of products designed for the safe pursuit of sexual gratification by foreign object insertion. Mr A eventually accepted a listing of local sexual novelty shops offering these products.Treat underlying psychiatric factors that predispose to recurrent insertion.Specific pharmacologic approaches may be indicated for acute psychiatric problems (such as psychosis, mania, and depression) amenable to medication management. Patients with recurrent self-injurious insertions serving an emotional regulatory function may be assisted in establishing initial contact with treatment teams that specialize in behavioral treatment of recurrent self-harm.37For patients who do not meet criteria for syndromal psychiatric illness, psychotherapy may be suggested to provide a means of ongoing “exposure” to and “working through” of shame or other traumatic affective states brought on by the insertion or by hospitalization itself. However, many inserters decline referral to psychiatric follow-up at the time of discharge.30Emphasize prompt presentation to medical attention following any future injury.Individuals incurring injury from foreign body insertion often delay their presentation to the hospital once injury has resulted, usually out of a wish to avoid embarrassment or guilt.52Upon entering the hospital, some remain reluctant to inform primary teams about what has happened, further delaying diagnosis and definitive intervention.28This sort of avoidance has resulted in death due to otherwise manageable injuries following foreign object insertion.24,32Those fortunate to recover from medical complications of foreign object insertion should thus be explicitly reminded before discharge to seek medical care immediately if they sustain subsequent injuries.CASE DISCUSSIONMr A's rectal foreign body insertion could well have been a consequence of several conditions. Common potential etiologies include sexual gratification, self-injury (to inflict pain, embarrassment, punishment [possibly to alleviate mental anguish]), psychosis (eg, to obey command hallucinations or to diminish some perceived bizarre threat through that bodily territory), reexperience of nostalgic memories with high affective valence, compulsivity (eg, to relieve anxiety associated with not performing this activity), and factitious illness (ie, to become a patient with a dramatic arrival to the health care system).While sexual gratification seems to have been the primary motivation for Mr A's rectal insertion of a foreign body (as he himself stated), other features of the case suggest that additional factors were in operation. Unconscious factors must also have reinforced the escalating insertion behavior—such as a wish to relive a complex experience of closeness with his mother, whom he dearly loved—but whom he also experienced as having inserted herself into his life in an “incestuous” manner. Early conflict between these feelings may have led to difficulty in separating from her (as this did not occur until his late 20s) and to an unstable self-image prone to profound bursts of shame. His earlier shame-ridden experience of being discovered by his mother while a teenager seems to have been repeated in a series of similarly shaming presentations to the attention of hospital staff, brought on by his own choices that posed unclear meaning to him. Thus, in addition to being sexually gratifying, Mr A's escalating foreign object insertion may have been a factitious, unconsciously motivated revisiting of a prior relationship with powerful, complex affective valence.The consultant identified 2 potentially useful interventions: (1) to reduce the harm of future foreign object insertion, given the likelihood that the behavior would recur, and (2) to mitigate the shaming effect of the hospital experience, so that it might begin a working through of his complex emotional experience around the insertion behavior rather than a mere repetition of prior shame-inducing exposures earlier in life. The 2 aims were related insofar as Mr A needed to tolerate thinking and talking about the insertions in order to become receptive to harm-reduction interventions and any indicated treatment recommendations.Planned, brief, confidential visitations by the consultant gradually led to a more complete understanding of the function of the insertion behavior, as Mr A spoke about his mother, his loneliness, and his wish to feel less empty inside. He was counseled on ways to equip himself with safer means of sexual gratification, but he identified shame as a substantial barrier to availing himself of these harm-reduction strategies. The consultant eventually referred him for psychotherapy due to the distressing impact of the insertion behavior and the hospitalization. Psychotherapy was explained as a setting in which he might be gradually exposed to, and eventually learn to tolerate, overwhelming thoughts and feelings related to his hospital experience, insertion behavior, and upbringing by his mother.CONCLUSIONInsertion of foreign objects into bodily orifices occurs as a result of a variety of psychosocial and psychiatric states. Unfortunately, such behavior exposes the affected individual to medical morbidity (eg, complications of object insertion, surgical removal, and its aftermath). Unearthing the etiology for foreign body insertion can lead to management strategies that target the motivation for the behavior without the infliction of bodily harm. Staff reactions (fraught with fear, shame, anger, derision, scorn, and perplexity) to such behaviors are often intense and can impinge upon compassionate care. Timely psychiatric assessment (in addition to assessment and treatment of medical surgical complications) is of paramount importance. Failures to address the underlying cause will very likely lead to an individual's remaining at increased risk of repeated occurrences.Article informationPrim Care Companion CNS Disord. 2012; 14(1): PCC.11f01192.Published online 2012 Feb 16. doi: 10.4088/PCC.11f01192PMCID: PMC3357565PMID: 22690353Brandon T. Unruh, MD, Shamim H. Nejad, MD, Thomas W. Stern, BA, and Theodore A. Stern, MDCorresponding author: Theodore A. Stern, MD, Department of Psychiatry, Massachusetts General Hospital, Fruit St, WRN 605, Boston, MA 02114.Funding/support: None reported.Received 2011 Apr 1; Accepted 2011 May 18.Copyright © 2012, Physicians Postgraduate Press, Inc.This article has been cited by other articles in PMC.Articles from The Primary Care Companion for CNS Disorders are provided here courtesy of Physicians Postgraduate Press, Inc.References1. Polsdorfer J.R., Gale T. Foreign objects. Gale Encyclopedia of Children's Health 2006Accessed May 24, 2011, .http://www.healthline.com/galecontent/foreign-objects2. Connors GP. Pediatric foreign body ingestion. http://emedicine.medscape.com/article/801821-overview Accessed May 24, 20113. Riddlesberger M.M., Jr, Cohen H.L., Glick P.L. The swallowed toothbrush: a radiographic clue of bulimia. Pediatr Radiol. 1991;21(4):262–264. [PubMed]4. Eisen G.M., Baron T.H., Dominitz J.A., et al. American Society for Gastrointestinal Endoscopy. Guideline for the management of ingested foreign bodies. Gastrointest Endosc. 2002;55(7):802–806. [PubMed]5. Young A.S., Shiels W.E., II, Murakami J.W., et al. Self-embedding behavior: radiologic management of self-inserted soft-tissue foreign bodies. Radiology. 2010;257(1):233–239. [PubMed]6. Webb W.A. Management of foreign bodies of the upper gastrointestinal tract: update. Gastrointest Endosc. 1995;41(1):39–51. [PubMed]7. Vizcarrondo F.J., Brady P.G., Nord H.J. Foreign bodies of the upper gastrointestinal tract. Gastrointest Endosc. 1983;29(3):208–210. [PubMed]8. Velitchkov N.G., Grigorov G.I., Losanoff J.E., et al. Ingested foreign bodies of the gastrointestinal tract: retrospective analysis of 542 cases. World J Surg. 1996;20(8):1001–1005.[PubMed]9. Chang J.J., Yen C.L. Endoscopic retrieval of multiple fragmented gastric bamboo chopsticks by using a flexible overtube. World J Gastroenterol. 2004;10(5):769–770.[PMC free article] [PubMed]10. Stiles B.M., Wilson W.H., Bridges M.A., et al. Denture esophageal impaction refractory to endoscopic removal in a psychiatric patient. J Emerg Med. 2000;18(3):323–326.[PubMed]11. Islam S.R., Islam E.A., Hodges D., et al. Endoscopic removal of multiple duodenum foreign bodies: an unusual occurrence. World J Gastrointest Endosc. 2010;2(5):186–189.[PMC free article] [PubMed]12. Cho H.J., Kim J.Y., Lee H.C., et al. An impacted clamshell in the duodenum mistaken for a gall stone. Korean J Intern Med. 2007;22(4):292–295.[PMC free article] [PubMed]13. Yacobi Y., Tsivian A., Sidi A.A. Emergent and surgical interventions for injuries associated with eroticism: a review. J Trauma. 2007;62(6):1522–1530. [PubMed]14. Steinman E., Cunha J.C., Branco P.D., et al. Traumatic rectal injuries. Arq Gastroenterol. 1990;27(3):120–125.[PubMed]15. Hellinger M.D. Anal trauma and foreign bodies. Surg Clin North Am. 2002;82(6):1253–1260. [PubMed]16. Fry R.D. Anorectal trauma and foreign bodies. Surg Clin North Am. 1994;74(6):1491–1505. [PubMed]17. Couch C.J., Tan E.G., Watt A.G. Rectal foreign bodies. Med J Aust. 1986;144(10):512–515. [PubMed]18. Bhat A.L., Kumar A., Mathur S.C., et al. Penile strangulation. Br J Urol. 1991;68(6):618–621. [PubMed]19. Snoy F.J., Wagner S.A., Woodside J.R., et al. Management of penile incarceration. Urology. 1984;24(1):18–20. [PubMed]20. McLaughlin T., Coyner W. Removal of a strangulating metal bearing from the penis. J Urol. 1989;141(3):617.[PubMed]21. Vähäsarja V.J., Hellström P.A., Serlo W., et al. Treatment of penile incarceration by the string method: 2 case reports. J Urol. 1993;149(2):372–373. [PubMed]22. Melamed Y., Dalyahu Y., Vaiman R., et al. Foreign objects in the vagina of a mentally ill woman: case series. Gen Hosp Psychiatry. 2007;29(3):270–272.[PubMed]23. Bedi N., El-Husseiny T., Buchholz N., et al. "Putting lead in your pencil": self-insertion of an unusual urethral foreign body for sexual gratification. JRSM Short Rep. 2010;1(2):18.[PMC free article] [PubMed]24. van Ophoven A. deKernion J.B. Clinical management of foreign bodies of the genitourinary tract. J Urol. 2000;164(2):274–287. [PubMed]25. Rafique M. Intravesical foreign bodies: review and current management strategies. Urol J. 2008;5(4):223–231. [PubMed]26. Ali Khan S., Kaiser C.W., Dailey B., et al. Unusual foreign body in the urethra. Urol Int. 1984;39(3):184–186.[PubMed]27. Trehan R.K., Haroon A., Memon S., et al. Successful removal of a telephone cable, a foreign body through the urethra into the bladder: a case report. J Med Case Reports. 2007;1(1):153.[PMC free article] [PubMed]28. Taori K., Saha B., Shah D., et al. Sonographic detection of Indian grass (Sorghastrum nutans), an unusual foreign body, in the urinary bladder. J Clin Ultrasound. 2007;35(3):174–175.[PubMed]29. Costa G., Di Tonno F., Capodieci S., et al. Self-introduction of foreign bodies into the urethra: a multidisciplinary problem. Int Urol Nephrol. 1993;25(1):77–81. [PubMed]30. Forde J.C., Casey R.G., Grainger R. An unusual penpal: case report and literature review of posterior urethral injuries secondary to foreign body insertion. Can J Urol. 2009;16(4):4757–4759. [PubMed]31. Marc B., Chadly A., Durigon M. Fatal air embolism during female autoerotic practice. Int J Legal Med. 1990;104(1):59–61. [PubMed]32. Waraich N.G., Hudson J.S., Iftikhar S.Y. Vibrator-induced fatal rectal perforation. N Z Med J. 2007;120(1260):U2685. [PubMed]33. Fenichel O. The Psychoanalytic Theory of Neurosis. New York, NY: WW Norton & Co; 1945.34. American Psychiatric Association. Diagnostic and Statistical Manual for Mental Disorders. Fourth Edition. Washington, DC: American Psychiatric Association; 2000. Text Revision.35. Linbecker M., Pottek T., Hinck D., et al. Urinary retention with ruptured fornix caused by a maggot: an autoerotic accident. Urologe A. 2005;44(6):674–677. [PubMed]36. Hermes D., Schweiger U., Warnecke K.K., et al. Incorporation of multiple foreign bodies due to borderline personality disorder. Mund Kiefer Gesichtschir. 2005;9(1):53–58.[PubMed]37. Wraight W.M., Belcher H.J., Critchley H.D. Deliberate self-harm by insertion of foreign bodies into the forearm. J Plast Reconstr Aesthet Surg. 2008;61(6):700–703. [PubMed]38. Shearer S.L. Phenomenology of self-injury among inpatient women with borderline personality disorder. J Nerv Ment Dis. 1994;182(9):524–526.[PubMed]39. Kapandji M. An unusual case of foreign bodies in the urethra. J Urol Nephrol (Paris) 1971;77(10):817–821.[PubMed]40. Gropman A.L., Duncan W.C., Smith A.C. Neurologic and developmental features of the Smith-Magenis syndrome (del 17p11.2) Pediatr Neurol. 2006;34(5):337–350. [PubMed]41. Bloch Y., Lauder A., Ratzoni G. How many pins? a case report of a girl who swallowed more than 50 straight pins in a suicide attempt. Int J Adolesc Med Health. 2005;17(3):295–297. [PubMed]42. Acham A. The interesting case—case no 69. Laryngorhinootologie. 2005;84(3):193–195. [PubMed]43. Nielsen S.U., Rasmussen M., Hoegberg L.C. Ingestion of six cylindrical and four button batteries. Clin Toxicol (Phila) 2010;48(5):469–470.[PubMed]44. Diggs C.A. Suicidal transurethral perforation of bladder. Am J Forensic Med Pathol. 1986;7(2):169–171.[PubMed]45. Sharif S., Roberts G., Phillips J. Transnasal penetrating brain injury with a ball-pen. Br J Neurosurg. 2000;14(2):159–160. [PubMed]46. Walter G. An unusual monosymptomatic hypochondriacal delusion presenting as self-insertion of a foreign body into the urethra. Br J Psychiatry. 1991;159(2):283–284.[PubMed]47. Inoue T., Iemura J., Saga T. Delayed cardiac tamponade caused by self-inserted needles. Can J Cardiol. 2003;19(3):306–308. [PubMed]48. Zafrullah M. Unusual foreign body in the male urinary bladder and urethra. Br J Clin Pract. 1969;23(3):123–124. [PubMed]49. Khan S.A., Davey C.A., Khan S.A., et al. Munchausen's syndrome presenting as rectal foreign body insertion: a case report. Cases J. 2008;1(1):243.[PMC free article] [PubMed]50. Huffman J.C., Stern T.A. The diagnosis and treatment of Munchausen's syndrome. Gen Hosp Psychiatry. 2003;25(5):358–363.[PubMed]51. Rada R.T., James W. Urethral insertion of foreign bodies: a report of contagious self-mutilation in a maximum-security hospital. Arch Gen Psychiatry. 1982;39(4):423–429.[PubMed]52. Rahman N.U., Elliott S.P., McAninch J.W. Self-inflicted male urethral foreign body insertion: endoscopic management and complications. BJU Int. 2004;94(7):1051–1053. [PubMed]53. Bantis A., Sountoulides P., Kalaitzis C., et al. Perforation of the urinary bladder caused by transurethral insertion of a pencil for the purpose of masturbation in a 29-year-old female. Case Rep Med. 2010:2010.[PMC free article] [PubMed]54. Mukerji G., Rao A.R., Hussein A., et al. Self-introduction of foreign body into urinary bladder. J Endourol. 2004;18(1):123–125. [PubMed]55. Kenney R.D. Adolescent males who insert genitourinary foreign bodies: is psychiatric referral required? Urology. 1988;32(2):127–129. [PubMed]56. Loeser A., Gerharz E.W., Riedmiller H. Chronic perforation of the urinary bladder by self-inserted foreign body. Int Urogynecol J Pelvic Floor Dysfunct. 2007;18(6):689–690. [PubMed]57. Bichler K.H., Deppe H.U., Mewe F., et al. Foreign body injuries of urethra and bladder in the young: their psychosexual background. Urol Int. 1971;26(2):161–170. [PubMed]58. Ayantunde A.A., Oke T. A review of gastrointestinal foreign bodies. Int J Clin Pract. 2006;60(6):735–739.[PubMed]59. Cohen J.S., Sackier J.M. Management of colorectal foreign bodies. J R Coll Surg Edinb. 1996;41(5):312–315. [PubMed]60. De Tarnowsky G. A unique foreign body in the urinary bladder. JAMA. 1915;64:1495.61. Quin G., McCarthy G. Self insertion of urethral foreign bodies. J Accid Emerg Med. 2000;17(3):231.[PMC free article] [PubMed]62. Benjamin F., Guillaume A.J., Chao L.P., et al. Vaginal smuggling of illicit drug: a case requiring obstetric forceps for removal of the drug container. Am J Obstet Gynecol. 1994;171(5):1385–1387. [PubMed]63. Stewart A., Heaton N.D., Hogbin B. Body packing—a case report and review of the literature. Postgrad Med J. 1990;66(778):659–661.[PMC free article] [PubMed]64. Franzblau A.H. Itchy urethra. a case report. Rocky Mt Med J. 1973;70(11):35.[PubMed]65. Sharma U.K., Rauniyar D., Shah W.F. Intravesical foreign body: case report. Kathmandu Univ Med J (KUMJ) 2006;4(3):342–344. [PubMed]66. Packard F.R. III: an analysis of two hundred and twenty-one cases of foreign body introduced into the male bladder per urethra, with report of a recent case. Ann Surg. 1897;25(5):568–599. [PMC free article] [PubMed]67. Poulet A. A Treatise on Foreign Bodies in Surgical Practice. New York, NY: William Wood & Co; 1880.68. Hoffman H.A., Colby F.H. Incarceration of the penis. J Urol. 1945;54:391–399. [PubMed]69. Goldman M., Johnson G. "Wired for electricity" or the case of a bizarre foreign body in the bladder. Urol Cutaneous Rev. 1946;50:202. [PubMed]70. Li Z.S., Sun Z.X., Zou D.W., et al. Endoscopic management of foreign bodies in the upper-GI tract: experience with 1088 cases in China. Gastrointest Endosc. 2006;64(4):485–492. [PubMed]71. Chaves D.M., Ishioka S., Félix V.N., et al. Removal of a foreign body from the upper gastrointestinal tract with a flexible endoscope: a prospective study. Endoscopy. 2004;36(10):887–892.[PubMed]72. Kim J.K., Kim S.S., Kim J.I., et al. Management of foreign bodies in the gastrointestinal tract: an analysis of 104 cases in children. Endoscopy. 1999;31(4):302–304. [PubMed]73. Barros J.L., Caballero A., Jr, Rueda J.C., et al. Foreign body ingestion: management of 167 cases. World J Surg. 1991;15(6):783–788. [PubMed]74. Palta R., Sahota A., Bemarki A., et al. Foreign-body ingestion: characteristics and outcomes in a lower socioeconomic population with predominantly intentional ingestion. Gastrointest Endosc. 2009;69(3, pt 1):426–433. [PubMed]75. Bisharat M., O'Donnell M.E., Gibson N., et al. Foreign body ingestion in prisoners—the Belfast experience. Ulster Med J. 2008;77(2):110–114.[PMC free article] [PubMed]76. Smiley O. A glass tumbler in the rectum. JAMA. 1919;72:1285.77. Yaman M., Deitel M., Burul C.J., et al. Foreign bodies in the rectum. Can J Surg. 1993;36(2):173–177. [PubMed]78. Kurer M.A., Davey C., Khan S., et al. Colorectal foreign bodies: a systematic review. Colorectal Dis. 2010;12(9):851–861. [PubMed]79. Stricker T., Navratil F., Sennhauser F.H. Vaginal foreign bodies. J Paediatr Child Health. 2004;40(4):205–207.[PubMed]80. Jaluvka V., Novak A. Vaginal foreign bodies in women in postmenopause and in senium. Eur J Obstet Gynecol Reprod Biol. 1995;61(2):167–169.[PubMed]81. Roark G.D., Subramanyam K., Patterson M. Ingested foreign material in mentally disturbed patients. South Med J. 1983;76(9):1125–1127. [PubMed]82. Campbell E.W. Foreign bodies in the urinary tract. In: Campbell M.F., editor. Urology. 2nd ed. Philadelphia, PA: WB Saunders Co; 1963. pp. 775–795.83. Prasad S., Smith A.M., Uson A., et al. Foreign bodies in urinary bladder. Urology. 1973;2(3):258–264. [PubMed]84. Woodside J., Bergreen P.W. Coyote rib as an urethral dilator. Rocky Mt Med J. 1976;73(5):270–271. [PubMed]85. Wise T.N. Urethral manipulation: an unusual paraphilia. J Sex Marital Ther. 1982;8(3):222–227. [PubMed]86. Granados E.A., Riley G., Rios G.J., et al. Self introduction of urethrovesical foreign bodies. Eur Urol. 1991;19(3):259–261. [PubMed]87. Geyermann P.T. Medical curiosities. JAMA. 1937;108:1409.88. Baird J.M., Spence H.M. Ingested foreign bodies migrating to the kidney from the gastrointestinal tract. J Urol. 1968;99(6):675–680. [PubMed]89. Fister G.M. Chewing gum as the nucleus of a vesical calculus in the male. Urol Cutaneous Rev. 1934;38:118.90. Glenn W.F. Cocaine solutions. JAMA. 1887;9:383.91. Simon S. Rifle bullet impacted in the anterior urethra. J Urol. 1949;61(4):785–789. [PubMed]92. Carruthers R.H. An unusual urethral foreign body. Can Med Assoc J. 1959;80(10):829. [PMC free article][PubMed]93. Wykes W.N., Barker J.R. Urethral discharge associated with ingested foreign body. BMJ. 1978;2(6154):1751.[PMC free article] [PubMed]94. Jameson R.M. A case of an impacted foreign body in the urethra. Br J Urol. 1965;37(4):475–476. [PubMed]95. Barnett R.M., Wolk B.M. Laparoscopic removal of a foreign body from the bladder. Am J Obstet Gynecol. 1978;130(3):364–365.[PubMed]96. White E.W., Holm A.H. Foreign bodies from urethra and bladder. Am J Surg. 1927;52:223.97. Radford P.J., Thomson D.J. A case of methylmethacrylate bladder stone. Acta Orthop Scand. 1989;60(2):218–219.[PubMed]98. Baumgartner G., Nesser H.J., Jurkovic K. Unusual cause of dysuria: migration of a pacemaker generator into the urinary bladder. Pacing Clin Electrophysiol. 1990;13(6):703–704.[PubMed]99. Falagas M.E., Christopoulou M., Rosmarakis E.S., et al. Munchausen's syndrome presenting as severe panniculitis. Int J Clin Pract. 2004;58(7):720–722. [PubMed]100. Parker B. A case of self-mutilation by means of pins. S Afr Med J. 1964;38:116–117. [PubMed]101. Birrer R.B., Robinson T., Rao S., et al. Self-mutilation: three cases and a review of the literature. J Emerg Med. 1993;11(1):27–31. [PubMed]102. Richmond P.W., Williams L.A. Glass in the foot: negligence or a criminal act? BMJ. 1989;298(6686):1491. [PMC free article][PubMed]103. Goldman E.P., Smith T.A. Case of the amazing radiographs. J Am Podiatr Med Assoc. 1993;83(4):234–235.[PubMed]104. Paulino A.F., Krolikowski F.J. Insertion of foreign bodies into the abdominal cavity: an unusual form of self-mutilation. Am J Forensic Med Pathol. 1995;16(1):48–50. [PubMed]105. Schwartz D.L., So H.B., Schneider K.M., et al. Chronic insertion of foreign bodies into the mature breast. J Pediatr Surg. 1977;12(5):743–744. [PubMed]106. Dwivedi S.K., Gupta L.C., Narain V.S. Self inserted needle in heart—localization by cross-sectional echocardiography. Eur Heart J. 1991;12(2):286–287. [PubMed]107. Jamilla F.P., Casey L.C. Self-inflicted intramyocardial injury with a sewing needle: a rare cause of pneumothorax. Chest. 1998;113(2):531–534. [PubMed]108. Akgüner M., Atabey A., Top H. A case of self-inflicted intraorbital injury: wooden foreign body introduced into the ethmoidal sinus. Ann Plast Surg. 1998;41(4):422–424. [PubMed]109. Rubinstein A., Riddell C.E., Kafil-Hussain N., et al. Self-inserted intraorbital foreign bodies. Ophthal Plast Reconstr Surg. 2005;21(2):156–157. [PubMed]110. Bibring G.L. Psychiatry and medical practice in a general hospital. N Engl J Med. 1956;254(8):366–372.[PubMed]111. Groves J.E. Management of the borderline patient on a medical or surgical ward: the psychiatric consultant's role. Int J Psychiatry Med. 1975;6(3):337–348. [PubMed]112. Greilsheimer H., Groves J.E. Male genital self-mutilation. Arch Gen Psychiatry. 1979;36(4):441–446.[PubMed]113. Schrom T., Amm S. Unusual case of oesophageal foreign body as part of a self-harm syndrome. Laryngorhinootologie. 2009;88(4):253–256. [PubMed]114. Frozanpour D. Foreign bodies in the bladder. Br J Clin Pract. 1976;30(5):115–118. [PubMed]115. Dakin W.B. Urological Oddities.Los Angeles, CA: WB Dakin; 1948.116. Freud S. The Standard Edition of the Complete Psychological Works of Sigmund Freud, Volume 9: Jensen's "Gradiva" and Other Works. London, UK: Hogarth Press; 1908. Character and anal eroticism.117. Byard R.W., Eitzen D.A., James R. Unusual fatal mechanisms in nonasphyxial autoerotic death. Am J Forensic Med Pathol. 2000;21(1):65–68.[PubMed]