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| ORIGINAL CASE SERIES |
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| Ahead of print publication |
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Exploring various factors of major self-mutilation in psychosis: A case series from North India
Rohit Gondwal1, Robin Victor1, Priyaranjan Avinash1, Arghya Pal2
1 Department of Psychiatry, Himalayan Institute of Medical Sciences, Dehradun, Uttarakhand, India
2 Department of Psychiatry, All India Institute of Medical Sciences, Raebareli, Uttar Pradesh, India
| Date of Submission | 21-Jul-2022 |
| Date of Decision | 08-Aug-2022 |
| Date of Acceptance | 09-Sep-2022 |
| Date of Web Publication | 10-Mar-2023 |
Correspondence Address:
Robin Victor,
Department of Psychiatry, Himalayan Institute of Medical Sciences, Jollygrant, Dehradun - 248 140, Uttarakhand
India
 Source of Support: None, Conflict of Interest: None DOI: 10.4103/aip.aip_128_22
Self-injurious behavior can be seen in various physical and psychiatric illnesses. Violence toward self is higher as compared toward others in psychotic illness. This relationship is complex and is associated with various clinical factors such as nature and severity of delusion and hallucinations, frequency of hallucinations, certain positive symptoms, duration of untreated psychosis, social isolation, substance use, age and gender of the patient, poor compliance to treatment and lack of follow up, and sociocultural factors such as lack of insight regarding mental illness in attendants of patients, the stigma associated with mental illness and treatment, the belief of supernatural causation of psychotic symptoms, and having more faith on indigenous alternative/complementary method of treatment. Here, we present case series of people who were suffering from some form of psychosis and presented to us with a severe self-inflicted injury. We emphasize on the potential benefit of early identification and redressal of the abovementioned clinical and sociocultural factors associated with higher MSM in patients with psychotic illness and prompt intervention and treatment in such types of cases for a better outcome.
Keywords: Case series, deliberate self-harm, delusion, hallucination, psychosis, schizophrenia, self-harm
How to cite this URL:
Gondwal R, Victor R, Avinash P, Pal A. Exploring various factors of major self-mutilation in psychosis: A case series from North India. Ann Indian Psychiatry [Epub ahead of print] [cited 2023 Apr 1]. Available from: https://www.anip.co.in/preprintarticle.asp?id=371536 |
| Introduction | |  |
Self-injurious behavior (SIB) is described as an act to hurt oneself purposefully with or without the intent to die. It is known by various other names such as self-harm, self-wounding, autoaggression, self-mutilation, and parasuicidal behavior. This behavior is found in almost 40%–60% of the people who commit suicide.[1] Research suggests that deliberate self-harm is the most important factor in predicting suicide.[2] Self-harm behavior has its peak during 15–24 years of age, and suicide is the third leading cause of death among people of this age group.[3] SIB can be seen in various physical and psychiatric illnesses. Psychiatric illnesses such as major depressive disorder, schizophrenia, psychosis, bipolar disorder, substance use, and personality disorder are well associated with self-harm behavior. Sometimes, they are present in the absence of psychiatric illness in various cultures where they are traditionally accepted.
Rao et al.[4] have classified the SIB in various ways based on the severity of illness, frequency of committing the act, site of lesion, and the associated psychiatric diagnosis. Looking at the severity of the illness, mild self-injury is often found in subthreshold psychiatric illnesses or nonclinical populations.[5] Moderate SIB is often seen in neurotic psychiatric conditions or personality disorders, whereas severe self-mutilation has been associated with psychotic disorders such as schizophrenia, psychosis, and delusion disorder.[6]
Violence toward self is higher as compared toward others in psychotic illness. This relationship is complex and is associated with various factors such as the nature and severity of delusion and hallucinations, certain positive symptoms, duration of untreated psychosis (DUP), social isolation, substance use, age, and gender of the patient.
Positive symptoms such as persecutory delusion/hallucinations, the delusion of guilt, the delusion of infidelity, and commanding hallucination have most often been associated with higher rates of severe self-mutilating behavior.[7] These symptoms when present cause a considerable amount of distress to the person and suicide appears to be the only way to get relief from them. DUP is another important factor that is associated with higher rates of self-directed injury. Various studies have found a positive association between higher rates and severity of SIB with a longer duration of DUP.[8],[9]
With this background, here, we present case series of people who were suffering from some form of psychosis and presented to us with a severe self-inflicted injury. We try to explore various clinical and sociocultural factors that are associated with it.
| Case Series | | |
Case 1
A 47-year-old Hindu male from a middle socioeconomic status was brought to the emergency medical room (EMR) of our hospital with an alleged history of self-inflicted injury in the form of cutting off his tongue with a scissor [Figure 1].
After initial surgical stabilization of the patient, he was shifted to the psychiatry ward; where on detailed evaluation, it was found that he was a known case of psychiatric illness for the past 12 years. Initially, he was diagnosed as a case of obsessive–compulsive disorder (OCD) as he was having complaints of recurrent sexual thoughts about gods and thoughts of contamination of dirt with repeated cleaning activities. The patient was on started on capsule fluoxetine 60 mg and clomipramine 25 mg once a day to which he showed good response and he maintained well for the next few years. He was not having any active suicidal or self-harm thoughts/behavior at that time. After taking medication for almost 5–6 years, he stopped taking medication as he felt normal and did not follow-up at any psychiatry outpatient department.
His wife reported that for the past 6 months, he had been seen smiling and talking to himself on multiple occasions. On questioning him, he would report that he is talking to a Muslim person. His socio-occupational functioning deteriorated over course of time. Fifteen days before the SIB incident, she reports that he had visited a mosque in night which was unusual as he was a Hindu. When she tried to stop him, he grabbed her by the neck and the tone of his voice changed and he abused her. He told her that a Muslim person had entered his body and was controlling him. He could hear his voice from both his ears and they were commanding him to go to the mosque and say the name of “Allah” repeatedly. He was taken to a faith healer multiple times where he was subjected to rituals in the form of physical beating and tying of various amulets but there was no improvement. The patient at the time would appear normal and would be distressed about self. He tried to harm himself by slashing his wrist with a knife but was stopped by the family members.
On the day of the incident since the morning, he was cleaning his tongue again and again as he had said “Allah” multiple times the previous night. He was shouting that the Muslim person was taking control over his body and he wanted to take the control back. His wife being alone in the house went out to call neighbors but when returned found that he had cut off his tongue [Figure 1] and on asking, he said that the person inside him made him do it. Following this, he was brought to our hospital.
There was no history of medical illness in past. Family history was also normal.
Based on history and mental state examination, a diagnosis of schizophrenia was made. His basic investigation such as complete blood count, liver and renal function test, thyroid profile, and blood sugar were sent. His leukocytes were 11.8 thousand/mm3, while other reports were normal. He was started on tablet clozapine 25 mg which was gradually increased to 100 mg once daily along with an injection of ceftriaxone 1 g and PCM 500 mg twice daily (for 7 days). Modified electroconvulsive therapy was started along with clozapine as there was not much improvement with medication alone. After about six cycles of modified electroconvulsive therapy (mECT) and tablet clozapine 300 mg, the patient responded well and is maintaining better.
Case 2
A 25-year-old Hindu female from higher socioeconomic status was bought to the hospital in EMR with an alleged history of the cutting of her left forearm [Figure 2].
After initial surgical stabilization of the patient, she was shifted to the psychiatry ward; where on detailed evaluation, it was found she was a known case of psychiatric illness for the past 4 years. Initially, she was a diagnosed as a case of bipolar affective disorder (BPAD). She had an episode of mania 4 years back with symptoms of over-talkativeness, elated self-esteem, lack of sleep, and delusion of grandiosity that she had divine powers. She was prescribed some psychotropic medications details, of which were not available. She took medication for 3–4 months following which there was an improvement and she left it and was maintaining well.
For the past 5 months, she had low self-esteem, a low mood throughout the day, a lack of interest in any activities, talking to self when alone, and thoughts of worthlessness with the hearing of voices not being heard by others. She reported that she had been hearing voices of multiple males and females which were unknown and would often tell her that she is not of any use to society and she should kill herself. She had become withdrawn and would often remain alone in the room. Often she was found talking alone in a room by family members where she would be cursing certain people to stop talking to her. She was distressed by these voices and had often planned to kill herself either by ingestion of rat poison or by slashing her wrist. Her socio-occupational functioning and personal hygiene had decreased over time.
On the day of the incident, she reports that since the morning she was hearing unknown voices saying derogatory things and asking her to kill herself and being so distressed by them she slashed her forearm with a knife following which she was brought to us.
Family history revealed psychotic disorder in maternal aunt and BPAD in paternal uncle.
Based on history and mental state examination, a diagnosis of BPAD currently in depression with psychotic features was made.
Her basic investigation such as complete blood count, liver and renal function test, thyroid profile, and blood sugar were sent which were normal. She was started on tablet lithium 400 mg twice daily and tablet olanzapine 10 mg. She reported improvement over the next few days was discharged and since then is maintaining well on treatment.
Case 3
A 75-year-old Hindu male from middle socioeconomic status was bought to the hospital in EMR with an alleged history of self-inflicted cutting of his throat [Figure 3] and both wrists [Figure 4] and [Figure 5].
After initial surgical stabilization of the patient, he was shifted to the psychiatry ward; where on detailed evaluation, it was found that the patient had gradually progressive psychiatric illness from the last 30 years. Early symptoms were suggestive of withdrawn behavior, poor interpersonal relations, preferring solitary activities, and being suspicious about neighbors that they are planning and plotting against him and his family. He often used to prohibit his family members to mingle with nearby people. During later stages, he used to engage in verbal and physical fights with the neighbors and would state that they have made a plan to kill him and take away his money and property. His family members used to counter his thoughts because of which often he used to have an altercation with the family members. Toward the end stages, he held a belief that he is impoverished and his future was dark as the neighbors had done black magic on him. He also started remaining preoccupied with thoughts that his body was getting rotten from inside and his organs were not functioning and attributed all this to the black magic. He went to a faith healer who performed multiple rituals on him and his home. However, the symptoms persisted and there was no relief. Neither he nor his family members at any point seek any kind of medical help for his problems.
On the day of the incident, his family members alleged he had a fight with the neighbors following which came back home, took a knife from the kitchen, and locked himself in the room where later he was discovered lying on the floor with a lacerated wound to the anterior aspect of the neck [Figure 3] and both the wrist following which he was immediately brought to EMR of our hospital. The patient does not provide any information regarding how the incident happened but says that he might have done this under the influence of black magic done by neighbors.
Family history was normal. He was a known case of type 2 diabetes mellitus and hypertension for the past many years but was on irregular medication.
Based on history and mental state examination, a diagnosis of persistent delusional disorder was made.
His basic investigation such as complete blood count, liver and renal function test, thyroid profile, and blood sugar were sent. His blood glucose level was 345 mg/dl, while other investigations were normal. He was started on tablet pimozide 2 mg which was gradually increased to 4 mg over the next few days. He reported improvement and was discharged after 2 weeks and since then is maintaining well on treatment.
| Discussion | | |
Our case series presents cases with major self-mutilation in patients who were suffering from some form of psychosis with predominant persecutory delusions/hallucinations, delusion of control, and commanding hallucination. They performed SIBs either directly under the commands of the hallucinatory voices or under the delusion of control. Case 1 cut his tongue to escape from the distress that was happening due to the delusion of control. Another important common point in all our cases is long DUP. One of our patients (case 3) was treatment-naïve while the other two had stopped taking medication years ago and did not come for follow-up. Cases 1 and 2 were known cases of nonpsychotic disorders (OCD and BPAD) but they did not have any kind of self-aggressive behavior during the previous phase of the illness. Two of our cases initially went to a faith healer multiple times for treatment and presented to us only after self-mutilation.
All these points highlight various factors that can be associated with MSM namely the presence of MSM predominantly in psychotic disorders as compared to the neurotic nonpsychotic disorders, nature and type of delusion and hallucinations, the severity of positive symptoms, long DUP, poor compliance to treatment and lack of follow-up, and sociocultural factors such as lack of insight regarding mental illness in attendants of patients, the stigma associated with mental illness and treatment, the belief of supernatural causation of psychotic symptoms, and having more faith on indigenous alternative/complementary method of treatment that further adds to DUP.
Harvey et al.[10] state higher prevalence of MSM in patients with a longer duration of DUP which is consistent with our findings. In their study, patients with mean DUP ≥66 days had a likelihood of SIB. Haddock et al.[6] have pointed out various clinical factors related to violence toward self in psychotic patients. They found a strong positive correlation of SIB with the severity of delusion and frequency of hallucination. Self-directed violence was almost two-fold higher in patients who had as threat control override symptoms (TCOSs) at baseline. TCOS is essentially referred to as the presence of delusions related to a perceived threat or an overriding of one's internal controls. Two of our patients had TCOS where they had the delusion of control/being taken over and commanding hallucinations directing them to cause harm to themselves. Another finding of their study was higher distress regarding the delusion to be significantly associated with higher self-harm which was similar to our Case 1.
Looking at various sociocultural factors, Dutta et al.[11] in their study from India report that people have a stigma about being labeled as a patient of mental illness which may lead to their social isolation and treatment delay. Often, there is a lack of social and financial support for patients in psychosis and frequent treatment dropouts. The multiple shared belief system prevalent in different communities and the widespread credence of supernatural causation of mental/psychological illness also act as roadblocks to early treatment of illness leading to higher severity and intensity of psychotic symptoms which in turn leads to higher MSM. A study was done by Thirthalli et al.[12] concluded that in India, people of lower and middle economic status have a longer DUP and poorer symptomatic and functional outcomes while Haddock et al.[6] from the United Kingdom found a positive association between higher socioeconomic class and self-harm in patients with schizophrenia. Two of our cases were from the middle socioeconomic class, whereas one was from higher socioeconomic status.
Our case series is a humble attempt to add to the limited literature exploring the various clinical and sociocultural factors of MSM in patients suffering from psychotic disorders, especially from North India and we emphasize on the benefit of early intervention and management of these types of cases.
Informed consent
All the patients had given written informed consent for the study.
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 name 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.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
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