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 Table of Contents  
CASE SERIES
Year : 2022  |  Volume : 6  |  Issue : 3  |  Page : 278-281

Self-Injurious Behavior in Alcohol Withdrawal State Complicated by Delirium – A Case Series


Department of Psychiatry, Kodagu Institute of Medical Sciences, Madikeri, Karnataka, India

Date of Submission19-Jul-2021
Date of Decision29-Jul-2021
Date of Acceptance05-Aug-2021
Date of Web Publication31-Oct-2022

Correspondence Address:
Dr. S V Sathish Kumar
Department of Psychiatry, Kodagu Institute of Medical Sciences, Madikeri - 571 201, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aip.aip_91_21

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  Abstract 


Regular and excessive use of alcohol can produce dependence over a period of time. Individuals who stops or reduces the alcohol use suddenly can have withdrawal symptoms ranging from tremors, altered sensorium, Delirium and seizures. Few cases of self injurious behavior were also reported during Delirium due to alcohol withdrawal. This is a rare and a severe form of inflicting injury to one's own body part, usually described in psychotic disorders, with delusions and hallucinations. The present case series describes the self injurious behavior during alcohol withdrawal complicated by Delirium.

Keywords: Alcohol dependence, delirium, limb amputation, psychosis


How to cite this article:
Sathish Kumar S V, Roopesh Gopal N V. Self-Injurious Behavior in Alcohol Withdrawal State Complicated by Delirium – A Case Series. Ann Indian Psychiatry 2022;6:278-81

How to cite this URL:
Sathish Kumar S V, Roopesh Gopal N V. Self-Injurious Behavior in Alcohol Withdrawal State Complicated by Delirium – A Case Series. Ann Indian Psychiatry [serial online] 2022 [cited 2022 Dec 10];6:278-81. Available from: https://www.anip.co.in/text.asp?2022/6/3/278/360085




  Introduction Top


Alcohol use is a major problem in most of the countries which are taking an increasing toll on people and indirectly on their family members as well. Regular and increased alcohol consumption can lead to the development of a dependence pattern that is associated with withdrawal syndrome when alcohol consumption is suddenly ceased or substantially reduced.[1]

Alcohol withdrawal has a broad range of symptoms which varies from mild tremors to a serious condition known as delirium tremens (DT), seizures and could progress to death if not recognized early and treated promptly.[2] Alcohol withdrawal is commonly encountered in general hospital settings. It forms a major part of psychiatry referrals in consultation-liaison psychiatry.[3]

Self-injurious behavior is a rare and severe form of behavior usually seen in psychotic disorders, mostly in schizophrenia as a result of Delusions and Hallucinations.[4],[5],[6]

In alcohol withdrawal, a person can have hallucinations and accompanying delusions, and they typically commence 2–3 days after the last consumption of alcohol. This may be frightening to the individual. False beliefs and hallucinatory voices may be convincing, even commanding the person to behave in a way that would be out of character, including self-harm. Such commands may be acted upon and may result in severe injury to various body parts.[7]

The present reports describe three cases of self-injurious behavior during an alcohol withdrawal state including self-amputation of a lower limb, self-inflicted injury over the neck, and self-harm attempt by poisoning.


  Case Reports Top


Case-1

A 35-year-old, right-handed daily wage worker, was brought to casualty a few hours after he amputated his right leg above the ankle joint with a sharp object which was used to trim coffee plants. His past history suggested that he had seizure episodes twice after stopping alcohol for 3–4 days for which he took treatment from a nearby doctor.

Exploration of the history revealed that he had been taking alcohol for the past 18 years with a dependence pattern for the past 10 years characterized by craving, tolerance, and withdrawal symptoms. Before the presentation, he was consuming about 540 ml of whisky/day. Lockdown was announced due to the second wave of the COVID-19 pandemic in the state (i.e. April 23, 2021) with relaxation for 3 days in a week from 6 am to 10 am for procurement of essential materials. During this time, liquor shops were also open and the patient used to go and buy the alcohol in this period due to craving and to avoid withdrawal symptoms. However subsequently, because of financial difficulties, he was not able to procure the alcohol and developed withdrawal symptoms in the form of sleep disturbance, restlessness, and decreased appetite.

History from the family members also revealed that, after 2–3 days of the stoppage of alcohol, he was abusive and said that few people in the surroundings are against him and trying to harm him. He also said that he could hear the voices of people talking about him and wanted to hurt him. According to family members, this was his false belief as no such people existed in the surroundings. On the 3rd day of stopping alcohol, during nighttime, when his mother was asleep, he took a sharp object, and by the time his mother woke up, he amputated his right leg above the ankle joint [Figure 1]a and [Figure 1]b.
Figure 1: (a) Proximal part of the right amputated Limb (b) Distal part of the right amputated Limb

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He was attended by the orthopedician in the casualty and necessary management was done for the amputated stump of the right leg. As vitals hours were lost in reaching the hospital, the treating doctor expressed difficulties to rejoin the amputated leg with the main stump. Psychiatry help was sought for alcohol withdrawal. On examination in the casualty, the patient was oriented to the time, place, and person, bilateral tremors of the hands were present.

He reported that he himself amputated his right lower limb as he saw a snake biting his leg and to prevent further spread of poison into the body. However, the possibility of the presence of a snake in the house and biting the patient was completely ruled out by the family member.

Diagnosis of Mental and Behavioral disorder due to use of alcohol currently in withdrawal state complicated with delirium (resolving) was made as per the International Classification of Diseases (ICD-10).[8]

Alcohol withdrawal was managed with benzodiazepines along with Thiamin supplementation. His review on the next day shows improvement in sleep, tremors and was well oriented. No psychotic symptoms were reported. Intervention in terms of the management of craving and motivation enhancement along with oral Thiamin supplementation was done and also advised for regular follow-up to prevent relapses in future.

Case-2

A 25-year-old male working as a laborer was brought to the emergency room by his mother with a history of injuring his neck by himself with a knife. He was admitted under the ENT department and after managing neck wound with suturing and antibiotics, he was referred to the Psychiatry department for evaluation and treatment of his alcohol abuse.

His history revealed that he has been taking alcohol for the past 8 years. Initially, it started with around 150 ml of alcohol and gradually increased to 600–800 ml in the past 2 years, as he was not getting the desired effect with the earlier amount. On few occasions, such as festivals, whenever he reduces or stops the alcohol for 2–3 days, he used to develop tremors of hands, palpitations, sweating, and disturbed sleep. They used to subside after taking alcohol.

Over a period of time, he also lost control over the amount of alcohol use and spending the money to procure the same. He gradually neglected his duties both at work and at home and used to pick up frequent quarrels with his mother and ended up in financial debt. Because of the above problems, he decided to stop alcohol and stopped it all of a sudden. From the next day onward, he developed tremors of hands, irritability, restlessness, fearfulness that someone is coming to ham him, police people are coming to arrest him and hearing threatening voices of people, even though no one was there in the surroundings.

As his fear worsened on 3rd day, he cut his throat with a kitchen knife to escape from the people who were trying to harm him. Her mother saw this incident and prevented him from further injury and brought to the hospital [Figure 2].
Figure 2: Image of healed wound over the neck (inflicted injury over neck during alcohol withdrawal state complicated by delirium)

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ENT team opined that there was no injury to deeper structures of the neck and managed the wound with suturing, antibiotics, and pain killers.

Based on history and mental status examination, diagnosis of mental and behavioral disorder due to use of alcohol currently in withdrawal state, complicated with delirium was made as per ICD-10.[8]

His alcohol withdrawal was managed with Lorazepam and Thiamin supplementation. Low dose antipsychotic was added for psychotic symptoms. On the 4th day, his withdrawal symptoms were completely resolved and threatening voices and persecutory beliefs were also resolved.

Brief motivation enhancement therapy was done and advised for regular follow-up and continued on low dose of antipsychotic and thiamin supplementation.

On follow-up at 2 weeks, he was abstinent from alcohol and did not report any complaints. Antipsychotic was stopped. Motivation enhancement therapies along with craving management techniques were thought.

At 1 month follow-up, he maintained abstinence and resumed socio-occupational functioning.

Case-3

A 32-year-old female daily wage laborer was brought to the emergency ward by her daughter with a history of consumption of organophosphorus compound (OP) poison.

After medical stabilization, she was referred to psychiatry for the management of alcohol use. Her history revealed that she was taking alcohol for the past 5 years. She initially started alcohol use in family rituals with 30–60 ml of country-made liquor, as use of alcohol among females was culturally accepted in their community where she was residing. From the past 2 years, the amount of alcohol use was gradually increased to 200–300 ml/day on daily basis to get the desired effects. At many occasions, she herself went to liquor shop to procure, as she started experiencing restlessness, irritability, anxiety, palpitations and sleep disturbance on stopping alcohol for one or 2 days. Her family members objected for daily use of alcohol and when they could not convince her to stop, they decided to change the residential area and shifted to another area, where the possibility of procuring and consuming alcohol was less and its use among women was considered taboo in new locality.

Because of these changes, she stopped alcohol all of a sudden. Two days later she developed behavior like talking to self, not taking food properly, not recognizing family members, with fluctuating orientation. She also started complaining that, she could hear voices of male and female when no one was around. The voices were commanding in nature and abusing the patient in bad words and she also started saying that people in the new locality may harm because of her alcohol use. However, no such people were existed according to family members.

In order to avoid these fearful experiences, she consumed OP compound poison which was kept for the purpose of farming use. As family members were vigilant, they immediately stopped her from consuming larger quantity. By that time, she consumed around 30–50 ml and immediately brought to hospital. After medical management with stomach wash and antidote for OP poison, the psychiatry team attended her for alcohol use.

Based on the history and clinical presentation, the diagnosis of mental and behavioral disorder due to use of alcohol currently in withdrawal state complicated with delirium was made as per ICD-10.[8]

Her alcohol withdrawal was managed with tapering dose of benzodiazepines, thiamin supplementation along with monitoring for vitals and respiratory depression.

Two days after medical management, she was reviewed in the outpatient department. By that time, her tremors and psychotic symptoms were reduced completely and she was well oriented. The management of craving and motivation enhancement was done. Thiamin supplementation continued. After 2 weeks, she reported back with complete abstinence from alcohol and advised for regular follow-up to prevent future relapses.


  Discussion Top


Some of the unusual features of the above cases are as follows.

Self-injurious behavior to the extent of amputating one's own limb during alcohol withdrawal was not reported in the past.

Self-injury to the neck was unusual, even though injury to other parts of the body such as abdomen, genital self-mutilation during alcohol withdrawal was previously reported.

Alcohol withdrawal-related self-harm behavior among women was rarely reported in the past.

Literature on various forms of self-injurious behavior during alcohol withdrawal is discussed below:

DT is a serious yet treatable complication of alcohol withdrawal. Timely diagnosis is critical as there are well-established treatment regimens which provide symptomatic relief and resolution of symptoms within hours to days.[9]

A case report which described that an individual during DTs sustained major self-inflicted abdominal stab wounds and extracted a meter of small bowel as a result of command hallucinations.[9]

Few Indian studies have reported self-injurious behavior during alcohol withdrawal state. Patra et al.[10] described the patient who inflicted multiple stab injury to his own abdomen during complicated alcohol withdrawal in response to alcoholic hallucinosis. Roig et al., described a 44-year-old patient who removed 2 m of small intestine while experiencing command hallucinations during an episode of DT.[11]

Charan and Reddy reported a case of genital self-mutilation in alcohol withdrawal state complicated with Delirium where the individual inflicted injury to his scrotum with sparing of the penis.[12]

Rani et al. reported a case of alcohol-related self-harm due to COVID-19 pandemic where an individual attempted suicide by hanging after stopping alcohol for 3 days due to nonavailability during the lockdown.[13]

An editorial has highlighted grave risks associated with DTs, including suicide and self-mutilation.[7]

Women and alcohol use

Alcohol use among women has received the widest attention all over the world.[14] women seem to progress faster during alcoholism (e.g., regular drinking or loss of control) and experience greater medical, physiological, and psychological impairment earlier in their drinking career which is commonly referred to as “telescoping”[15],[16] It has been observed that when women enter substance abuse treatment, they typically present with a more severe clinical profile than men, despite lesser frequency as well as the quantity of alcohol use.[17]

This may be due to less body water in comparison to size, which means they achieve higher blood concentrations than do men after drinking an equivalent amount of alcohol along with lower levels of alcohol dehydrogenase enzymes in their stomach.

Few Indian studies have noted that women with ADS had a later age at onset, presenting to the hospital around their 40s,[18] with alcohol dependence in 80% of the women patients among all the other substance abusers,[19] and highlighted the importance of sociological and personal vulnerabilities among women who consumes alcohol.[20]

Women who consume alcohol may experience intense stigma in the society, which acts as a significant barrier in seeking early treatment. Hence, it is necessary to assess and identify women with alcohol use in the clinical practice to prevent adverse effects and associated withdrawal-related complications.

In conclusion, based on the three cases described here and available literature, patients with a history of alcohol withdrawal can experience a range of complications including self-harm behavior during DTs and alcoholic hallucinosis. Early identification of alcohol withdrawal and timely initiation of appropriate treatment will help to reduce the morbidity and mortality associated with serious complication of alcohol withdrawal.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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2.
Patigny P, Zdanowicz N, Lepiece B. How should psychiatrists and general physician communicate to increase patients' perception of continuity of care after their hospitalization for alcohol withdrawal? Psychiatr Danub 2018;30 Suppl 7:409-11.  Back to cited text no. 2
    
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Becker H, Hartmann U. Genital self injury behavior phenomenological and differential diagnosis considerations from the psychiatric view point. Fortschr Neurol Psychiatr 1997;65:71-8.  Back to cited text no. 4
    
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Martin T, Gattaz WF. Psychiatric aspects of male genital self-mutilation. Psychopathology 1991;24:170-8.  Back to cited text no. 5
    
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Schweitzer I. Genital self-amputation and the Klingsor syndrome. Aust N Z J Psychiatry 1990;24:566-9.  Back to cited text no. 6
    
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8.
The ICD-10 Classification of Mental and Behavioural Disorders. Clinical Descriptions and Diagnostic Guidelines. Geneva: World Health Organization; 1992.  Back to cited text no. 8
    
9.
Thomasson R, Craig V, Guthrie E. Self-disembowelment during delirium tremens: why early diagnosis is vital. BMJ Case Rep 2016;2016:bcr2016217258.  Back to cited text no. 9
    
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Patra BN, Sharma A, Mehra A, Singh S. Complicated alcohol withdrawal presenting as self mutilation. J Forensic Leg Med 2014;21:46-7.  Back to cited text no. 10
    
11.
Roig TA, Cardozo Curvelo JC, Torres Hernandez MA. Intestinal self-mutilation in the context of a delirium tremens. Adicciones 2014;26:191-2.  Back to cited text no. 11
    
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Charan SH, Reddy CM. Genital self mutilation in alcohol withdrawal state complicated with delirium. Indian J Psychol Med 2011;33:188-90.  Back to cited text no. 12
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Rani S, Sahoo S, Parveen S, Mehra A, Subodh BN, Grover S. Alcohol-related self-harm due to COVID-19 pandemic: Might be an emerging crisis in the near future: A case report. Indian J Psychiatry 2020;62:333-5.  Back to cited text no. 13
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Hser YI, Anglin MD, Booth MW. Sex differences in addict careers. 3. Addiction. Am J Drug Alcohol Abuse 1987;13:231-51.  Back to cited text no. 15
    
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Randall CL, Roberts JS, Del Boca FK, Carroll KM, Connors GJ, Mattson ME. Telescoping of landmark events associated with drinking: A gender comparison. J Stud Alcohol 1999;60:252-60.  Back to cited text no. 16
    
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Hernandez-Avila CA, Rounsaville BJ, Kranzler HR. Opioid-, cannabis- and alcohol-dependent women show more rapid progression to substance abuse treatment. Drug Alcohol Depend 2004;74:265-72.  Back to cited text no. 17
    
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Malik K, Benegal V, Murthy P, Chand P, Arun K, Suman LN. Clinical audit of women with substance use disorders: Findings and implications. Indian J Psychol Med 2015;37:195-200.  Back to cited text no. 19
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Chari U, Shereens EA, Chand P, Suman LN. Society and its influence on alcohol use among women: Three case reports from India. Int J Cult Ment Health 2012;5:137-44.  Back to cited text no. 20
    


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