Amphetamine psychosis and eye autoenucleation

To the Editor

Eye autoenucleation and amputation of limbs or genitals are examples of the main forms of self-mutilation that are usually associated with psychosis and intoxication (Favazza, 1989). Reports of an association between these mutilations and amphetamine-induced psychosis are very scarce. So far, cases of autoenucleation in psychosis have been mostly reported from western countries. This has made some researchers believe that this is a phenomenon specific to the West (Shiwach, 1998). This case report from Iran challenges this view.

A 47-year-old man was taken to the emergency room with a self-enucleated right eye. He had done this with his own hands. In the past 3 months he had felt changes within himself, believing that other people were using his right eye. Relatives often found him staring at an object, laughing or talking to himself while rarely participating in any social activities.

The patient’s past psychiatric history was essentially negative. However, in the past 20 years, he had abused several substances. In the past 3 years, he was especially using methamphetamine and his misuse increased dramatically during the 6 months prior to the incident.

A mental status examination revealed a calm middle-aged man, with clear consciousness and without any obvious distress or regret about his act. He had delusions of being in control and still believed that others were using his eyes; ‘They take my privacy and look at forbidden scenes’, he said. In addition, he experienced command auditory hallucinations, telling him to enucleate his other eye since there were others using it.

The patient was diagnosed with a first episode of methamphetamine-induced psychotic disorder as he had not experienced the symptoms in the absence of methamphetamine misuse. However, we could not rule out the possibility of a primary psychotic illness such as schizophrenia. To prevent further mutilation and to rapidly manage the psychosis, the patient was admitted to the psychiatric emergency ward where he received six sessions of electroconvulsive therapy. At the same time, risperidone was started and gradually increased to 8 mg over 1 week. His delusions and hallucinations faded away after 4 weeks and he was later discharged.

We have observed a high rate of methamphetamine psychosis in Iran that is paralleled by increasing substance misuse. Major physical and psychological problems occur in people misusing amphetamines, but severe self-injurious behaviors such as autoenucleation are rare (Darke et al., 2008; Jones, 1990).

This report, in line with a review by Large et al. (2008), questions claims that autoenucleation is limited to western countries (Shiwach, 1998). In addition, there was no religious or sexual justification for the act in this case, which is at odds with the review by Witherspoon et al. (1989). Therefore, this serious act may be explained by the content of delusions or hallucinations that in western religious settings may have something to do with the association of sight and the concept of sin (Shiwach, 1998). Furthermore, we should not overlook the fact that under-reporting exists to a large extent in Eastern and developing countries.

The significance of this conclusion becomes more apparent when we observe that a considerable proportion of people living in the so-called western states are born outside these countries; for example, according to the 2006 census, over 190,000 people in Australia were born in Middle Eastern countries (Australian Bureau of Statistics, 2008).