Abstract
Our patient, a 38-year-old man working full time in the building industry, had a 3 year history of paranoid schizophrenia. He was well maintained on flupenthixol 20 mg IMI monthly and olanzapine 5 mg per day. He was asymptomatic, enjoyed his work, had a close circle of friends and was well liked by staff.
After his medication was changed to oral olanzapine only, he remained well for a further 8 months. His medication compliance was poor and he became preoccupied with numbers and experienced delusions of influence. As his psychosis deepened he resorted to inhaling methamphetamines every few days.
In this psychotic state he cut off his left and right small toes.
He cut off the first toe at night in a busy street with a single blow of a chisel; the second toe was cut off 3 weeks later. He sought no medical treatment but wrapped his toes in a bandage and used pine o clean to cleanse the wound. Neither amputation was described as painful. At no stage was there any suicidal intent.
He recalls that he amputated his toes in response to a special meaning he attached to certain dates and to the number Pi.
After he cut the first toe, he first showed it to his flatmates before he ate it raw while he walked the streets. He chewed as much of the bone as possible and then spat it out. He recalls eating it ‘for the experience’ and that it was a ‘once in a lifetime opportunity to eat human flesh’. He was excited by the shock value of doing so. The second toe was cooked in an oven before eating. In between cutting his toes he continued to work on renovating houses.
In the 3 weeks between self-mutilations he painted a massive sign on the top of a disused building in which he proclaimed his psychotic beliefs to the world.
After an inpatient stay and reinstitution of depot antipsychotic medication he was remarkably well, living independently and working full time.
When he discussed this episode a year afterwards and with his psychosis in remission he was not dismayed by his behaviour. He did not regret eating his toes. He made the point that several years previously he had cut off his little finger and at that time contemplated consuming it but did not carry out this action.
Various types of self-mutilation are described in the literature [1]. Some of the more tragic and dramatic are associated with psychosis. This patient's methamphetamine use exacerbated his psychosis. Self-mutilation in the context of amphetamine psychosis has also been reported though in this case it is unclear how important amphetamine use was in the actual behaviour of eating his toes [2].
The eating of flesh by patients suffering psychosis has been recognized but only rarely in the psychiatric literature and to date no reference has been found to eating oneapos;s own flesh [3, 4].
The behaviour of our patient had a profound affect upon the treating team. Despite the patientapos;s nonchalant attitude towards his self-mutilation, the memory of this episode continued to dominate ongoing discussions about treatment options and shaped a very conservative approach to any proposed medication changes.