Severe Anemia in Non Suicide Self Injury as a Complication of Major Depression Disorder

S T R A C Non suicide self injury (NSSI) is a rare case in adults. Non suicide self injury is an act of hurting himself such as cutting, burning, punching without intending to commit suicide. NSSI itself is a complication of major depression that is not treated properly from the onset of symptoms. Severe depression that lasts for a long time, can aggravate illnesses such as the appearance of symptoms of psychosis and have an impact on various complications such as NSSI and somatic complications that can reduce the patient's health condition. Reported a case of a 22 year old woman with severe anemia due to chronic bleeding. It is known that chronic bleeding in the patient is the result of habitual cutting, in which the patient slashes her left forearm. Cutting habitualis is part of the action of NSSI where the management must be holistic and sustainable, the management of patients consists of psychotherapy as starting from dialectical behavior therapy is a form of cognitive therapy that can help a person adapt to activities that can pass through distress. Psychodynamic therapy is to help someone form new habits that previously could cause pleasure to the patient. Psychotherapy accompanied by psychopharmaceuticals can accelerate improvement in patient.


Introduction Definition
Depressive disorder without psychotic symptoms is a subset of psychosomatic disorders. People with depression often come to a primary care doctor for somatic complaints that stem from depression, and it is very rare to see a psychosomatic medicine specialist.
Some patients come because of somatic complications due to their severe depression. 1,9 Depression is a mood disorder that causes constant feelings of sadness and loss of interest. Also called major depressive disorder or clinical depression, it affects feelings, thoughts, and behavior and can cause a variety of emotional and physical problems. The patient may have difficulty carrying out normal daily activities. 9

Epidemiology
Depressive disorders rank third as the cause of the world's disease burden in 2008, WHO projects that this disease will rank first in 2030. 11 Major depressive disorder is a very common psychiatric disorder. The depressive disorder has a lifetime prevalence of about 5 to 17 percent, with a mean of 12 percent. The prevalence rate in women is almost twice that of men 10 Depressive disorder is more common in people without close interpersonal relationships, people who are divorced or separated, or are widows. No differences in the prevalence of depressive disorders were found between race and socioeconomic status. People with depressive disorders often experience comorbid Biomedical Journal of Indonesia https://www.jurnalkedokteranunsri.id/index.php/BJI/index disorders such as substance use disorders, panic disorders, social anxiety disorders, and obsessivecompulsive disorder. 10

Symptoms
Symptoms of depressive disorders are generally recognized through triadic symptoms, namely, first, not being able to enjoy life, second, not paying attention to the environment, third, being tired all day long.
Another component found in depression is the impaired cognitive triad, namely: Assessing himself as useless (I'm worthless). Feelings of hostility to the environment (the environment is hostile) and a gloomy future (nothing good can happen). 1 In some patients the symptoms of depressive disorder are severe enough to cause real problems in daily activities, such as work, school, social activities, or interpersonal relationships. In adolescents, symptoms include sadness, irritability, feeling negative and worthless, anger, poor performance or poor attendance at school, feelings of being misunderstood and very sensitive, using drugs or alcohol, eating or sleeping too much, selfharm, loss of interest. in normal activities, and avoiding social interactions. 8,9 Etiology and risk factors Self mutilation is part of the complications of major depressive disorders, therefore depressive disorders need to be an important concern to prevent the occurrence of NSSI disorders such as cutting habit. 9

Management
Depressive disorders can be treated with a variety of treatment modalities, including pharmacological modification, psychotherapy, intervention, and lifestyle. The initial treatment for depressive disorders consists of medication and / or psychotherapy.
Combined treatment, including medication and psychotherapy, has been shown to be more effective than this treatment alone . 13 The food and drugs administration (FDA) publishes medications for the management of depressive   A: Self-administered actions such as cutting, burning, or punching intended to cause moderate physical damage to the body (for example, bruising, bleeding, or pain) that occurred for 5 or more days during the past year.
B: Engaging in self-injurious behavior in the hope that at least one of the following consequences will occur soon after: 1. Relief from negative feelings or thoughts.
3. Creation of a positive mood.
C: At least one of the following occurred immediately prior to intentional self-harm: 1. Negative thoughts or feelings (eg, distress, depression, anger, anxiety, tension, or self-criticism). The self-damaging behavior cannot be better explained by another mental disorder or medical diagnosis. It is also required that the self-injurious behavior not occur only during psychotic episodes, intoxication, periods of delirium, or be stereotyped and repetitive.

Discussion
One reported case was a 22 year old woman, the patient was treated for severe anemia ec chronic bleeding. Chronic bleeding in this patient is the result of habitual cutting that is often done by the patient.
Cutting performed by the patient is to cut the left forearm whenever the patient feels depressed, sad, and anxious. The first cutting of the patient was done in 2018 until the patient was treated in 2021.
Cutting habitualis is part of non suicide self injury

Conclusion
Cutting habitualis is a rare part of non suicide self injury. This case is a complication of major depressive disorder that was not treated properly since the first symptoms appeared. Depressive disorders need to be detected early before the symptoms get worse and cause further complications. Patients come for treatment often because of their somatic complaints so that psychosomatic specialists are the first providers to receive patients' somatic complaints and then need interdisciplinary collaboration, namely primary care doctors, psychiatric specialists, nurses, therapists and social activists for early detection and treatment of depressive disorders.