Letters to the Editor
Assessing Pain Tolerance in a Patient With Acute Psychosis
Increased pain tolerance in patients with psychosis has been recognized
in the literature (1,2), but few studies have determined the etiology of
this phenomenon. Rather, they present conflicting evidence suggesting psychological
(3), biological (4), and pharmacologic (5) explanations. Regardless of
its etiology, however, the careful assessment of how pain tolerance interacts
with delusional ideation in patients recently hospitalized during an acute
psychotic episode cannot be stressed enough. Simply diagnosing and assessing
for psychotic symptomatology is not adequate. Failure to adequately assess
the intricacies of a patient’s delusion system and pain sensitivity can
result in serious medical consequences. The following case report will
illustrate this important matter.
Mr A is a 38-year-old Haitian-American with a 16-year history of schizoaffective
disorder. He was admitted to an inpatient psychiatric hospital during his
most recent psychotic episode.When admitted, Mr A was experiencing auditory
command hallucinations and suicidal ideation. His command hallucinations
were instructing him to commit suicide by overdosing on his prescribed
neuroleptic (haloperidol) while consuming alcohol. He denied previous substance-abuse
issues. Fifteen years earlier, he had followed command hallucinations to
self-amputate his penis as a punishment for not yet having had sexual intercourse.
During his most recent hospitalization, he complained to the nursing staff
about problems with urination. (Although difficulties with urination can
occur as a result of penile amputation, he had not reported any prior difficulty.)
When evaluated after this complaint, the patient reported that his problems
with urination had ceased and that he was able to urinate adequately without
difficulty. However, although he initially denied any problems, a careful
inquiry revealed that he was also experiencing mild abdominal pain which
had commenced after he had experienced auditory hallucinations a few hours
earlier. During this inquiry, the patient admitted to additional command
hallucinations instructing him to “make [his testicles] numb.” He reported
that the auditory hallucinations instructed him to squeeze his testicles.
Since squeezing did not provide adequate numbness, he subsequently tied
the top of his scrotum with a shoelace, which he had not yet untied. A
physical examination revealed a shoelace tied around the apical part of
the scrotum. The shoelace was then subsequently cut. A sonogram revealed
a hydrocele of the testicles, which might eventually have led to vascular
In this case report, the patient’s ability to minimize his experience of
pain and the consequences of his behaviour could have led to severe medical
repercussions. During an acute psychotic episode, patients can experience
significantly increased pain thresholds, a factor that should be considered
as part of a complete assessment of delusional ideation. In this case,
failure to thoroughly assess the extent of this patient’s delusion and
pain threshold might have resulted in the loss of his testicles. Further
research investigating the etiology and epidemiology of increased pain
tolerance in patients with psychosis will improve assessments in this area
and may also help to prevent serious medical consequences.
1. Dworkin RH. Pain insensitivity in schizophrenia: a neglected phenomenon
and some implications. Schizophr Bull 1994;20:235–48.
2. Dworkin RH, Clark WC, Lipsitz JD, Amador XF. Affective deficits and
pain insensitivity in schizophrenia. Motivation and Emotion 1993 17:245–76.
3. Guieu R, Samuelian JC, Coulouvrat H. Objective evaluation of pain perception
in patients with schizophrenia. Br J Psychiatry 1994;164:253–5.
4. Davis GC. Endorphins and pain. Psychiatr Clin North Am 1983;6:473–87.
5. Serafetinides EA. Perception and tolerance of pain as a measure of antipsychotic
treatment. Agressologie 1971;12:357–60.
Ricardo Mujica, MD
Jeffrey W Braunstein, Ph.D
Brooklyn, New York