Late-onset obsessive–compulsive disorder presenting as genital self-mutilation

To the Editor

Obsessive–compulsive disorder (OCD) is the fourth most prevalent psychiatric disorder, having an onset in the second or third decade of life. A substantial proportion of patients attempt suicide at least once in their lifetime (Verona et al., 2004). Late-onset OCD is invariably associated with brain lesions (Kumar et al., 2009; Nakaaki et al., 2007). Genital self-mutilation (GSM) is a rare and extreme act, a little over 110 cases having been reported (Eke, 2000), mostly in transsexuals, psychotic individuals and those with personality disorders, or due to religious practices (Greilsheimer and Groves, 1979), with no reports in OCD individuals.

We report an older male, with late-onset OCD, who attempted to take his life using the unusual mode of GSM, in the absence of syndromal depression or organicity. The patient presented to the emergency department with a history of having severed his genitalia. Evaluation revealed an 8-month history of repeated thoughts of contamination of his body with urine, faeces, saliva and dirt resulting in repetitive acts of washing. He acknowledged that the thoughts were his own, repetitive, intrusive and not under his control. He reported that his athma, meaning soul, would become impure if he did not repeatedly clean himself, resulting in significant social and occupational impairment.

Two months after onset, psychiatric consultation was sought and the administration of 50 mg of sertraline was advised. He discontinued medication after 6 weeks due to minimal improvement, and subsequently made a suicidal attempt by jumping into a lake. For 2 days prior to the current presentation, the patient had reported suicidal thoughts. On waking that morning, he decided to end his life by cutting off his penis, regarded by him as the most vital organ, with a sickle, as he was sure no one could then save him. His shouts of pain attracted his family members who rushed him to a nearby hospital, but failed to carry the severed organ. There were no psychotic or depressive features at any time and past or family history were not contributory. Premorbidly the patient was described as being sociable, responsible and religious, and generally coped well with stress.

The Mental Status Examination revealed obsessive thoughts of contamination, with compulsive washing. His Yale–Brown Obsessive Compulsive Scale (Y-BOCS) score was 25, there were no psychotic or depressive features and his cognitive functions were intact. A diagnosis of obsessive– compulsive disorder with deliberate self-harm (GSM) was made.

His penile stump was repaired and his urethra was sutured to the stump. Sertraline 50 mg was advised, increased to 100 mg within a week. Two weeks later, his Y-BOCS score was 18. Premorbid levels of functioning were attained in 8 months.

OCD has a chronic and relapsing course, with some patients attempting suicide. In this case, severity of symptoms induced the attempt, which was carried out using an unusual mode (GSM). To the best of our knowledge, this is the first report of its kind. Late onset, absence of organicity and an unusual mode of attempt, make this a unique case.