Letters to the Editor
Autoamputation in Psychosis: Diagnostic Issues
Dear Editor:
Self-mutilation (SM) is a rare but extreme manifestation of mental illness. A review on the topic defined this act as “the commission of deliberate harm to one’s own body severe enough to cause tissue damage,” excluding conscious suicidal attempts or acts associated with sexual arousal (1). SM is most commonly seen in 4 populations: persons with mental retardation, persons suffering from psychosis, persons in prison (where it is associated with antisocial personality disorder [APD]), and persons with borderline personality disorder (BPD).
Case Report
A 38-year-old man with a history of psychosis was transferred from a Christian retreat. He had amputated his left thumb with a paring knife because a voice that he said was God’s told him he had sinned by “holding [his thumb] up to God.” On initial presentation, he had a blunted affect, severe thought blocking, and obvious interaction with internal stimuli, as well as a fixed hyperreligious delusional system. He had no insight into either his physical or psychic symptoms and denied any suicidal ideation. A drug screen and organic workup were negative, and antipsychotics were started. The plastic surgery service was consulted to reattach the severed digit. After surgery, his hallucinations improved dramatically, although his delusional beliefs were slower to recede.
During the admission, the Minnesota Multiphasic Personality Inventory (MMPI) was administered. Scores suggesting psychosis were high and “consistent with [the possibility that] people who have very deviant religious convictions acting out in asocial or antisocial ways may be obsessed with sexual thoughts” (psychologist’s report, unpublished). These interpretations were consistent with a past diagnosis of APD, a history of cross-dressing, and an arrest for public masturbation. The patient was very troubled by his “sinful” sexual urges in the context of the extremely puritanical Christian belief system that he held when not suffering from psychosis.
Autoamputation of limbs or digits, one severe aspect of SM, is very rare. A case series review found 13 cases from 1966 until this case; all these individuals suffered from psychosis, and 5 endorsed religious delusion (2). A small case series found 2 statistically significant factors that predicted SM in individuals with psychosis: a self-imposed change in physical appearance, and a prior act of self-mutilation (3). Others have stated that patients with command hallucinations, particularly of a religious nature, are also at risk; however, there is little evidence to support this (4).
This case is unique, not only in illustrating the extent to which psychosis can manifest itself but also in illustrating the diagnostic challenges that such events can generate. While this patient clearly had a psychotic episode, he also had traits of an APD, and it remains unclear whether there was an antisocial element to his act. A case series of deliberate self-stabbings delineated 2 groups who committed this act: individuals suffering from psychosis and those with APD (5); however, a distinction cannot always be made. This case shows the need to take into account not only the illness present but also contributing psychosocial factors when a presentation is difficult to understand. In addition, one must be vigilant in assessing individuals at risk for SM to prevent further medical comorbidity, or even death.
References
1. Winchel S, Stanley M. Self-injurious behavior: a review of the behavior and biology of self-mutilation. Am J Psychiatry 1991;148:306–17.
2. Schlozman S. Upper-extremity self-amputation and replantation: 2 case reports and review of the literature. J Clin Psychiatry 1998;59:681–6.
3. Sweeny S, Zamecnik K. Predictors of self-mutilation in patients with schizophrenia. Am J Psychiatry 1981;138:1086–9.
4. Favazza A, Rosenthal R. Diagnostic issues in self-mutilation. Hospital Community Psychiatry 1993;44:134–40.
5. Patel V, de Moore G. Harakiri: A clinical study of deliberate self-stabbing. J Clin Psychiatry 1994;55:98–103.
Jeremy Quickfall, PGY2
Carlos Tesler-Mabe, MD, FRCPC
Calgary, Alberta
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