Self-enucleation and the real meaning of Oedipus

All of us blink, squint, and grimace; humans have strong reflexes to protect our eyes. Vision is our mostvaluable sense. One human culture or another has ritually mutilated every surface of the human body including the ears, nose, lips and tongue, yet no culture mutilates eyes. Paradoxically the eye is the only part of our body we can remove by hand – and occasionally someone does just that.

This issue of the journal contains a case report of a 48-year-old woman accompanied by some explicit images. The patient manually removed her right eye in response to numerous delusions, including ideas of incest with her son (Lee et al., 2015). Psychoanalysts once considered self-enucleation to be an understandable consequence of incestuous feelings. After all, this was the grizzly end met by Oedipus Rex in the implausible yet compelling fable expropriated from Sophocles by Freud for use as his central myth.

But what is the evidence that incestuous feelings have anything to do with self-enucleation? My colleagues and I systematically reviewed cases of self-enucleation published in English between 1960 and 2007 (Large et al., 2008). Including earlier and later reports, there now are almost 100 published cases. However, in no other case are incestuous acts suggested, and only a minority report any degree of sexual guilt. In every case, the patient had psychotic symptoms, frequently ophthalmic delusions, most commonly in the context of first episode schizophrenia.

Despite the waning belief in psychoanalytic theory, self-enucleation remains both fascinating and horrifying. In my view, it still has a broader meaning for psychiatrists. Philosophers of the mind question the status of delusions as real beliefs, thinking of them as metaphors used to communicate experiences, fantasies that are mistaken for beliefs or even empty speech acts (Bayne and Pacherie, 2005). However, unlike other violence or self-destruction, self-enucleation is only plausibly explained by strongly held abnormal beliefs. Moreover, the antecedent history of psychosis, the strength of the association between psychosis and self-enucleation and the plausible causal link of ophthalmic delusions can only lead to the inference that delusions are a pre-requisite for self-enucleation. The true meaning of Oedipus is that delusions are real beliefs. Delusions should not be ignored. Do not get tangled up by psychoanalytic explanations. Do not presume that delusions are harmless. Treat first episode psychosis.

See Letter by Lee et al., 49(9): 847–848.