Abstract
Self-cannibalism as reported in the Journal [1] is certainly a very rare symptom, although there are some other case reports in the literature apart from those cited by the authors [2, 3]. There are several other reports of severe disfigurement and marked self-mutilation in schizophrenia (and other psychoses) including bilateral self-enucleation (called sometimes as Oedipism), penectomy, castration (with testes thrown away in lavatory), and intentional penetrating cranio-cerebral injury. Self-mutilation in schizophrenia in response to auditory hallucinations has often been described as Van Gogh Syndrome, in obvious reference to the self-excision of his own left ear by the famous painter.
Florid psychotic symptoms like command hallucinations, thought insertion, passivity phenomena and bizarre delusional beliefs are known to be a risk factor for self-mutilation in schizophrenia. Some of the other reported risk factors include physical abuse, sexual abuse and/or neglect (traumatic experiences) in early childhood, marked dissatisfaction with one's body, incapability of expressing emotions or alexithymia, personality disorder (e.g. borderline), past history of self-mutilation, high degree of impulsivity, psychomotor agitation, and recent history of isolation. Karl Menninger had suggested that self-mutilation was a form of attenuated suicide, and actually a “compromise formation” to avert suicide.
Typically pain (both psychic and physical) is known to be associated with a higher prevalence of self-mutilation or autotomy. A classic example is the occurrence of self-mutilations including auto-amputations by self-cannibalisation (biting but not eating own flesh) in children with brachial plexus birth injury. In a review of the literature of compulsive targeted self-injurious behaviour, this behaviour was found to be associated with painful dysesthesias occurring in a hypoesthetic area of the body [4].
However, there is considerable literature acknowledging altered (usually reduced) pain perception in schizophrenia, which could be contributory towards making self-mutilation less painful. In the case in question ‘neither amputation was reported to be painful’.
The presence of symptoms of depersonalization or dissociative states could also explain self-mutilation in many patients, some of them suffering from schizophrenia. The link between dissociation and self-mutilation is particularly relevant as many patients who self-mutilate report a higher threshold for pain at ‘certain times’. The role of endorphins has been proposed in explaining this phenomenon, although decreased levels of serotonin have also been implicated in both self-mutilation and increased impulsivity.
Whether dysesthesias, with or without delusional elaboration or other psychotic experiences, contribute to this behaviour is not certain, although it is worth exploring in an individual patient.
Concomitant use of alcohol and/or drugs, particularly stimulants like amphetamines, is also associated with increased risk of self-mutilation [5], and recent methamphetamine use appeared to be an important factor in the case described [1].
While managing this difficult presentation, it is important to remember the risk of repetition of self-mutilation, particularly in patients with multiple risk factors. Good medication adherence aided by administration of depot antipsychotic medication (particularly with a history of good treatment response in the past) and engagement with the treating team are vital in enabling continued remission of psychotic symptoms and also possibly the consequent self-mutilating behaviour. As Suyemoto [6] states, ‘isolation from others almost always precedes the actual act of self-mutilation’.