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 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 2  |  Issue : 2  |  Page : 119-121

A Rare Form of Major Self-mutilation in a Patient with Delusional Disorder


1 Department of Surgery, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India
2 Department of Psychiatry, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India
3 Department of Pathology, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India

Date of Web Publication16-Jun-2016

Correspondence Address:
Shahbaz Habib Faridi
Department of Surgery, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2349-5014.155547

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  Abstract 


Self-mutilation is defined as the intentional, direct injuring of body tissue without suicidal intent. In this article we report the case of a 45-year-old male who presented to the emergency department with a history of incising his abdomen and chopping his intestines into pieces. The patient also brought the chopped pieces along with himself. He was operated on, and a resection and anastomosis was done. Postoperative recovery of the patient was uneventful. After a psychiatric assessment was done, it was found that he was suffering from delusional disorder. Owing to such rare presentation of major self-mutilation in a patient with delusional disorder, this case is being reported here.

Keywords: Delusional disorder, self-mutilation, psychosis


How to cite this article:
Faridi SH, Usmani MA, Siddiqui B, Aslam M. A Rare Form of Major Self-mutilation in a Patient with Delusional Disorder. J Forensic Sci Med 2016;2:119-21

How to cite this URL:
Faridi SH, Usmani MA, Siddiqui B, Aslam M. A Rare Form of Major Self-mutilation in a Patient with Delusional Disorder. J Forensic Sci Med [serial online] 2016 [cited 2019 May 20];2:119-21. Available from: http://www.jfsmonline.com/text.asp?2016/2/2/119/155547




  Introduction Top


Major self-mutilation is defined as “deliberate alteration or destruction of body tissue without suicidal intent and the behavior is not socially or culturally accepted.”[1] It has been classified into two types. The first is the superficial or moderate type, which is more common and found in patients with personality disorders and mental retardation. The other type is severe or major self-mutilation, which is commonly seen in psychotic disorders.[2] First-episode psychosis and male subjects are important risk factors for major self-mutilation.[3],[4] The commonly reported forms of major self-mutilation are enucleation, genital self-mutilation, and limb amputation.[4]


  Case Report Top


A 45-year-old male, a hawker by occupation, presented to the emergency and accident department with a history of penetrating injury to the abdomen 3 h back and prolapsed intestine from the incised wound over the abdomen. Further history revealed that he did this act himself. He had also brought three pieces of chopped intestine wrapped in a cloth [Figure 1]. Formal psychiatric consultation could not be done at the time of presentation owing to the unstable condition of the patient. On examination, his vitals were pulse rate 130/min and blood pressure 96/68 mm Hg. On inspection of the abdomen, there was a transverse incision predominantly on the left side of abdomen, about 4 cm below the umbilicus, through which multiple transections of the small intestine could be seen [Figure 2]. There were also multiple old and new hesitation cut marks surrounding the main wound [Figure 3].
Figure 1: The pieces of chopped intestine which the patient brought

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Figure 2: Hemostats pointing at the transections in small intestine

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Figure 3: Hesitation cuts over the skin (arrows)

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The patient was immediately shifted to operating room after optimization. On exploration, it was found that there were three segmental defects in the small intestine, each about 6 in apart, which correlated with the segments of intestine which the patient brought with him. The first segmental defect was about 3 ft distal to the duodenojejunal junction and the last defect was 5 ft proximal to ileocecal junction. The resection of the all the defects and a single anastomosis with interrupted polyglactin sutures was done. Postoperative recovery of the patient was good and bowel function returned within 48 h of surgery and he was orally allowed food after 72 h.

The patient was then referred for psychiatric evaluation, along with his brother as an informant. On evaluation, it was found thatfor the past 3 months the patient was almost confined to a room as he was of firm belief that people outside were conspiring against him and if he had moved out of his home, he would have been arrested despite not committing any criminal act. He also had a firm belief that the neighbors are talking about him and used to confirm this from his brother.

On inquiring about the injury the patient told that, he has inflicted the wound himself but he was not under his control and something else was controlling him. He was of firm belief that someone unknown to him has done some kind of magic over him and he denied intent to die. The patient was having complete memory of the episode and he denied any pain experienced during the injury. His appetite was reduced and there was problem in onset and maintenance of sleep for past few months. There was no history of feeling of sadness, lack of interest in activities or any acute substance intake. There was history of alcoholism 1 year back but the patient was abstinent for last one year. There was also history suggestive of unsupervised treatment with disulfiram.

On examination, the patient was conscious and oriented to time, place, and person; mood was euthymic, and delusion of persecution was present. There was no hallucination or thought alienation phenomenon. On investigations the MRI brain was normal scan. A diagnosis of delusional disorder, persecutory type (297.1) was made as per DSM-5 criteria which was confirmed by two consultants.


  Discussion Top


Major self-mutilation has been reported in various psychotic disorders and substance abuse.[5],[6] The above case presents an act of major self-mutilation under the influence of delusion of control. The patient denied any intent to die, differentiating the case from suicide attempts in psychotic disorders. The patient has complete memory of the episode of self injurious behavior, which also differentiates it from the episodic self-injurious behavior seen in temporal lobe epilepsy. The patient was abstinent from alchohol for the last year. Thus the self-injurious behavior cannot be explained by either alchohol withdrawal or intoxication.

The commonly described psychopathologies behind the self mutilating behavior are delusions about the amputated organ, religious delusion, and command hallucinations.[4] The Asian population with schizophrenia has greater probability of acting over the commanding auditory hallucinations.[7]

Dysregulation of three neurotransmitter system has been implicated in self injurious behavior viz opioid system, dopaminergic system, and serotonergic system,[8] but as of now the evidence is little.[9]


  Conclusion Top


The management of patients with major self-mutilation requires active liaison between the surgical and psychiatric teams. In any patient presenting with major self-mutilation, the possibility of a psychotic disorder should always be considered.

 
  References Top

1.
Favazza AR, Rosenthal RJ. Diagnostic issues of self-mutilation. Hosp Community Psychiatry 1993;44:134-40.  Back to cited text no. 1
    
2.
Favazza AR, Simeon D. Self-mutilation. In: Hollander D, editor. Impulsivity and Aggression. New York: Wiley; 1995. p. 185-200.  Back to cited text no. 2
    
3.
Harvey SB, Dean K, Morgan C, Walsh E, Demjaha A, Dazzan P. Self-harm in first-episode psychosis. Br J Psychiatry 2008;192:178-84.  Back to cited text no. 3
    
4.
Large M, Babidge N, Andrews D, Storey P, Nielssen O. Major self-mutilation in the first episode of psychosis. Schizophr Bull 2009;35:1012-21.  Back to cited text no. 4
    
5.
Haw C, Hawton K, Houston K, Townsend E. Psychiatric and personality disorders in deliberate self-harm patients. Br J Psychiatry 2001;178:48-54.  Back to cited text no. 5
    
6.
Khan MK, Usmani MA, Hanif SA. A case of self amputation of penis by cannabis induced psychosis. J Forensic Leg Med 2012;19:355-7.  Back to cited text no. 6
    
7.
Lee TM, Chong SA, Chan YH, Sathyadevan G. Command hallucinations among Asian patients with schizophrenia. Can J Psychiatry 2004;49:838-42.  Back to cited text no. 7
    
8.
Winchel RM, Stanley M. Self-injurious behavior: A review of the behavior and biology of self-mutilation. Am J Psychiatry 1991;148:306-17.  Back to cited text no. 8
    
9.
Saito Y, Takashima S. Neurotransmitter changes in the pathophysiology of Lesch-Nyhan syndrome. Brain Dev 2000;22(Suppl 1):S122-31.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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Abstract
Introduction
Case Report
Discussion
Conclusion
References
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