Journal of Mental Health and Human Behaviour

CASE REPORT
Year
: 2014  |  Volume : 19  |  Issue : 1  |  Page : 37--38

Self-mutilation of nose in schizophrenia


Divya Sharma, Swapnil Agrawal, Devendra K Sharma, Devendra K Vijayvergia 
 Department of Psychiatry, Government Medical College, Kota, Rajasthan, India

Correspondence Address:
Dr. Divya Sharma
Department of Psychiatry, Government Medical College, Kota, Rajasthan
India

Abstract

Self-mutilation is not a single clinical entity and occurs in various psychiatric syndromes. Major self-mutilation is rare and catastrophic complication of severe mental illness. Patients with command hallucinations, religious preoccupations, substance abuse and social isolation are the most vulnerable. We report and discuss a case of complete self-mutilation of nose in a patient with schizophrenia.



How to cite this article:
Sharma D, Agrawal S, Sharma DK, Vijayvergia DK. Self-mutilation of nose in schizophrenia.J Mental Health Hum Behav 2014;19:37-38


How to cite this URL:
Sharma D, Agrawal S, Sharma DK, Vijayvergia DK. Self-mutilation of nose in schizophrenia. J Mental Health Hum Behav [serial online] 2014 [cited 2021 Jul 30 ];19:37-38
Available from: https://www.jmhhb.org/text.asp?2014/19/1/37/143890


Full Text

 Introduction



Self-mutilation, the deliberate destruction or alteration of body tissue without conscious suicidal intent, occurs in a variety of psychiatric disorders. Major self-mutilation includes amputation of limbs or genitals and eye-enucleation. [1] Minor self-mutilation includes self-cutting and self-hitting. Instances of deliberate self-injury are observed in both psychotic and non-psychotic individuals. Patients with command hallucinations, religious-preoccupations, substance abuse and social isolation are the most vulnerable.

Male genital self-mutilation in schizophrenics and autophagia of amputated penis in a case of schizophrenia has been reported. [2],[3] Krasucki et al. reported female genital self-mutilation in a case of schizophrenia. [4] Similarly, ocular self-enucleation [1] and a case of hammering multiple nails into own head each week has also been reported. [5] Ghaffari-Nejad et al. reported self-mutilation of the nose in a patient of schizophrenia with Cotard syndrome. [6] Self-induced nasal ulceration and septal perforation due to nose-picking (rhinotillexomania), [7],[8] were the types of self-induced nose injury but none of them described mutilation involving bony part of nose as seen in the patient described below.

 Case Report



Mr. R, a 30-year-old married male, educated up to 5 th standard, of rural background and lower socioeconomic status was referred from ENT Department, after management of epistaxis to seek psychiatric opinion regarding severe self-inflicted injury to his nose. He was accompanied by his mother who was 60 years old and living with patient.

On detailed history, patient reported that for the past 3 months, he had been hearing voices of some people clearly, even when alone and in an awake state. These voices would mostly discuss about him in third person. As per mother, he was convinced that some people were planning to take his son away from him and were trying to kill him. Patient would occasionally complain that "whatever I think, people come to know about it," however he did not elaborate further. Over this period, patient had been very suspicious towards other people and would confine himself to a room, not allowing any visitors. He would be seen talking to himself when alone. His predominant mood was fearful and irritable. There was a gross socio-occupational dysfunction and he would not pay much attention to self care. His sleep had decreased considerably. On the day of incident, he was sitting alone in his room, when he started hearing voices commanding him to cut his nose ("kaat-le, kaat-le"). He picked up a sharp piece of metallic sheet and slowly cut the tip of his nose. Still when the voices did not stop, he picked up the metallic sheet again and cut his nose this time. According to patient, he did not experience any significant pain during the commission of the act.

In the past psychiatric history, 5 years back, he suffered from an episode of psychotic illness for nearly 2-3 weeks. As per available information, it was characterized by suspiciousness, fearfulness, aggressive behaviour and socio-occupational dysfunction for which he was admitted and put on psychotropic medication. He became symptom-free over next month, after which treatment was discontinued. He remained asymptomatic till the current episode.

There was no family history of any mental illness. He was married at the age of 17 years, and has two children (daughter 12 years, son 10 years). His wife left him to stay at her maternal place after past psychotic episode 5 years back. There was history of intermittent alcohol intake, mostly in social context, with no harmful/dependent pattern of use. Pre-morbid personality appears to be well-adjusted. General physical examination revealed no abnormality except for the wound over his nose [Figure 1]. Mental state examination revealed that he is conscious and oriented. Eye to eye was made but not sustained. Psychomotor activity was within normal limits. Speech was occasionally irrelevant. Thought content revealed delusion of reference, delusion of persecution and thought broadcast. Both 2 nd person (commanding) and 3 rd person (discussing) auditory hallucinations were present. The higher mental functions were intact with absent insight. A diagnosis of schizophrenia was made and further management was done in ward setting. Patient was discharged after improvement with three sessions of modified electro-convulsive therapy and an atypical antipsychotic (olanzapine) and advised for follow-up.{Figure 1}

 Discussion



Self-harm, self-injury and self-mutilation are often used interchangeably. Favazza and Rosenthal [9] classified three different types of self-mutilation viz., (a) superficial or moderate self-mutilation as seen in the individuals with personality disorders, posttraumatic stress disorder, factitious disorder and schizophrenia; (b) stereotypic self-mutilation often found in mentally challenged individuals; and (c) Major self-mutilation which is most commonly associated with severe psychopathology, often resulting in permanent loss of an organ or its function. [9] The three main forms of major self-mutilation are ocular, genital, and limb mutilation, and are almost always seen in psychotic patients. [10] Patients with a history of such self-harm attempts have greater symptoms of depression, greater suicidal thoughts, increased number of hospitalisations, and longer duration of illness, compared to patients without a history of self-harm. [11] Patients with schizophrenia are known to attempt self-harm under command hallucinations, catatonic excitement or because of associated depression, depersonalization, dysmorphophobia and delusions. [6]

Self-amputation of nose is a relatively rare entity. In another case report from Iran, [6] a schizophrenia patient with Cotard's syndrome believing that she is already dead, resected the tip of her nose. She explained it as a form of cosmetic surgery, as misinterpretation of her face was one of starting points in her complex symptoms. The present patient, however, had done a complete amputation of nose under influence of commanding hallucinations. Such patients are increased risk of recurrent epistaxis, wound infection, chronic osteitis and myiasis and need coordinated multispeciality management and greater degree of social support. Long term psychiatric therapy consisting of behavioral, pharmacological, and psychotherapeutic interventionsshould be implemented to prevent further self-injurious behaviour, and to meet their highly complicated treatment needs.

The site or body part on which the injury is caused may have a symbolic significance for a particular patient. Understanding of these clinic-psychopathological issues related to self-mutilation is of help in management of such cases. Efforts should be directed at early institution of treatment, periodic risk assessment and prevention of harm to self or others in psychotic patients.

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