From cutting to ear piercing: evolution of self-injurious behavior in an adolescent with treatment-resistant bipolar disorder: a case report

Background Bipolar disorder is frequently associated with non-suicidal self-injury (NSSI), the manifestations of which vary across the illness course. Ear piercing may represent a covert alternative form of self-injury with an NSSI-like function that is commonly overlooked in clinical practice; consequently, reports documenting this phenomenon remain scarce. Case summary This report describes an 18-year-old female with treatment-resistant bipolar disorder whose self-injurious behavior evolved from wrist cutting to periungual skin picking and, ultimately, to 11 self-inflicted ear piercings within 48 hours, complicated by localized infection. The patient reported transient relief of agitation following these procedures, with no suicidal intent. Conclusion Repeated self-inflicted ear piercing within a short period, impaired behavioral control, disregard for infection risk, and use as an emotion-regulation strategy may be consistent with an NSSI-like pattern. Ear piercing may thus represent a covert NSSI-like substitute in some adolescents with bipolar disorder; however, such behavior should not be automatically classified as NSSI. Clinicians should maintain vigilance for this practice and carefully differentiate NSSI-like behavior from routine body adornment.