Conor is an 18 year-old Caucasian man presenting with bizarrely shaped skin ulcerations on his forearms and anterior legs bilaterally. His skin lesions exhibited sharp angulations and straight edges, and some lesions had healed over with scarring, suggesting the chronicity of the condition. He had no other medical problems and was not on any medications. Upon questioning, he initially related a very vague, illogical story about the origin of the skin lesions. He neither denied nor confirmed the possible self-induced element involved.

Of note, a psychiatrist had evaluated Conor a few years prior to coming to see you, and at that point the possible diagnosis of schizotypal personality was proposed. The patient reported being very interested in magic and subject matters dealing with supernatural phenomena, having very few friends, living at home with his parents, and not having been productively employed for several years. Symptomatic care such as topical and oral antibiotics to prevent infection of his ulcerations has been provided. Most importantly, you have shown a non-judgmental, supportive stance toward his skin condition at each visit.

After several such supportive interactions, the patient finally opened up about the root cause of his self-injurious behavior, stating that he is chronically plagued by a strong, uncomfortable feeling that he does not really exist. This phenomenon, termed “de-realization,” has compelled Conor to injure himself, as the pain and the bleeding that he induced were incontrovertible proof of his existence. Unfortunately, the intense de-realization feeling always eventually returned, and he needed to repeat the behavior again to feel real.