Diagnostic dilemma: A case of self-injurious behavior.

We report a case of repeated self-injurious behavior. Self injury to the operated eye had resulted in complete loss of vision in one eye. This case illustrates multiple challenges posed to the treating teams managing the causes and consequences of such self-injurious behaviors.

INTRODUCTION

Deliberate self-injury[1] or pathological self-mutilation[2] is the deliberate alteration or destruction of the body tissue without conscious suicidal intent. The diverse behaviors that constitute pathological mutilation have been categorized into the following three basic types: major-infrequent acts that result in significant tissue damage; stereotypic-fixed, rhythmic behavior seemingly devoid of symbolism; and superficial or moderate behavior such as skin cutting, burning, and scratching.[2] Self-injurious behavior is reported among patients with wide range of psychiatric disorders, notable being all types of psychoses, schizophrenia, affective disorders, substance dependence, mental retardation, obsessive compulsive disorder, dissociative disorders, and factitious disorder.[1]

We present a case with self-injurious behavior which offered significant diagnostic and management challenge as well as ethical dilemma for the treating team, as responsibility for the restoration of his vision by surgery hinged on psychiatric opinion.

CASE REPORT

A 52-year-old married Hindu male shopkeeper from middle socioeconomic status family, educated up to 7th standard, with no past or family history of psychiatric illness, with history of diabetes mellitus for past 2 years, with well-adjusted premorbid personality was referred from department of ophthalmology to seek psychiatric opinion regarding his fitness to undergo cataract surgery in his left eye. He was blind in his right eye due to self-inflicted injury.

Patient complained of “mera friend maarta hai (my friend beats me)” while the family members complained of “apne aap ko maarte hain (beats himself).”

Nine years back, patient had met with road traffic accident (RTA) while he was riding pillion on a motorbike with his friend. His friend succumbed to his injuries in the local hospital after 2 days, while he escaped with minor injuries in the form of lacerations and abrasions; there was no head injury. He missed the time he had shared with the deceased and felt worried about welfare of friend's family. He did not voice any guilt that his friend had died while he had got only minor injuries. However, he experienced fleeting anxiety during which he felt what would have happened to his family if he had died and thanked God for saving him. At home, he interacted well with family and friends, enjoyed watching TV, took care of self, had normal sleep and appetite, and did not have depressed or anxious mood. Within about a month of RTA, he gradually resumed his usual activities and started going regularly to his shop.

After about 5 months of RTA, patient was found walking alone near the railway station by a neighbor. He told the neighbor that his friend had come to his shop and had asked him to follow him. When he was confronted with the fact of his friend's death, he said that he also believed that earlier. But now as he had seen him, he believed him to be alive. Later, he told his family that his friend's appearance, voice, and dress was same as before and there was brightness around him. When asked why his friend was not visible to others, he expressed his inability to explain it. There was no history of headache, drowsiness, and confusion. However, he continued to believe that his friend had not died but stayed in the same city. Following the recurrence of similar incident after about 2 months, he was stopped from going to shop by his son. Two months later, when the patient was alone at home, he was found to be beating his head. When asked, he told that his friend had come, had asked the patient to follow him and on refusal to do so, the friend had started beating him. At that time, he was not anxious or fearful. Despite being confronted with the fact that the family members had seen him beating his own head with his hands, he continued to maintain that his friend had beaten him up. Following this incident, one of the family members would always accompany him. The family believed initially that such events of his being beaten up by his dead friend were occurring due to the influence of evil spirits, so he was shown to faith healers. Also, they shifted to another city far from their native place. However, the patient continued to experience episodes where he would injure himself by beating or scratching. The episodes of going away from home did not recur as he was never left alone by family members. After about 2 years, for the first time, medical consultation was sought at local hospital; his EEG, CT scan and MRI of head did not reveal any abnormality. The details of treatment given were not available. He continued to have similar episodes 3 to 4 times/year, lasting for about an hour during which he would sustain injuries over different parts of the body which he claimed were caused by his friend. Also during these episodes, he would touch and manipulate already existing minor wounds resulting in a large wound. There was no history of stereotyped cadence of his behavior during these episodes.

Around a year back, he was diagnosed to have cataract of right eye and was operated at the local hospital. Two days after the surgery, family members heard him shouting “mujhe chorh do (leave me)” when he was resting alone. They rushed and found that dressing from the operated eye was removed, there were nail marks and bleeding from the operated eye which he claimed were done by his friend. Though he was rushed to the hospital immediately, vision in his right eye was completely lost. Despite complete loss of vision in the right eye due to self-injury (injury by the friend as he believed), he remained indifferent to his inability to see and the resultant disability.

Throughout this period, the patient continued to believe that his friend was alive despite evidence to the contrary. However, his sleep, appetite, mood, personal care, social interaction, involvement in recreational activities, and helping in household chores remained normal. There was no history of persistent anxiety, depression or elation, depressive cognitions, guilt feelings, anniversary reactions, or first-rank symptoms.

About 2 months back, due to failing vision in the left eye as well, he was advised cataract surgery for the left eye at the local hospital. But in view of the injury to right operated eye and eventual complete loss of vision, doctors there referred him to ophthalmology department, All India Institute of Medical Sciences for the surgery. He was examined by ophthalmologist and due to possibility of repeating the same behavior after the surgery of left eye which would have resulted in his becoming completely blind, he was referred to the psychiatry department for the opinion.

On physical examination, multiple healed scar marks over various part of the body were found, he had cataract in left eye and opacity over pupillary area in right eye. Rest of the general and systemic examination was within normal limits. On mental status examination, he was cooperative, spoke relevantly and coherently. He was oriented to time, place, and person, attention was aroused and well sustained, had intact comprehension and memory, could do simple and complex calculations, and abstract thinking was intact. His verbal fluency, simple and complex verbal calculations, abstraction were intact. He did not have echolalia and dressing apraxia. He could identify his fingers, name objects held in his hands, and identify letters and numbers traced on his hands. His affect was euthymic with normal range and reactivity. He had delusion that his dead friend was alive and blamed his friend for beating him. La belle indifference was noted as he was observed to be indifferent to the fact that he was not working; he had lost vision in his eye and his life was restricted to his home. He had no perceptual disturbances, and had 1/5 insight. His blood sugar was well controlled with insulin. Psychological testing was attempted but could not be done because of his poor vision.

He had episodic behavioral disturbances in the form of wandering (at least in first two episodes and further prevented by the family), hallucination-like experiences, self-injurious behavior causing injuries and visual loss, consistent delusional attribution of the behavior to his friend, emotional indifference, relatively intact personal, social and biological functioning despite chronicity, and no features suggestive of organic cause on history, examination, and investigations. Over the years, his problems had resulted in not pursuing his occupation (due to wandering away from his shop), him being always accompanied by one of the relatives (due to hitting himself), and more involvement of family members in his care (due to loss of vision in one eye). At the time of presentation, he needed help from family members for activities of daily living because of poor vision. The family had come from a distance of more than 800 km just to seek second opinion regarding the safety of performing surgery on his only eye (left) as his other eye was lost due to self-injurious behavior; they were unwilling to stay for long time due to logistic reasons like the only earning member of the family, his son, was accompanying him.

This patient's presentation could not be explained on the basis of single diagnostic entity, so differential diagnoses were considered (ICD–10 classification system).[3]

Persistent delusional disorder (F22): The patient had single well-systematized delusion, firm false belief of his friend being alive (during and in between the episodes), not shared by others. He had relatively intact functioning. Transient hallucinations do not invalidate this diagnosis.

Factitious disorder (F 68.1): The patient had history of manipulating his wounds and injuring himself on his own and then ascribing it to another person for which he was brought to medical attention on several occasions. He was also relieved of all his responsibilities as the head of the family and was not working for several years. However, the patient himself would never show any active interest in seeking treatment for any of his problems and would accept whatever treatment was offered to him.

Dissociative disorder (NOS) (F 44.9): During the episodes of seeing his friend, there was loss of contact with the surroundings, he would communicate with friend, he was not able to perceive other stimuli around him, and he could only be aroused by a vigorous stimulus like shaking or patting by a family member suggesting a trance-like state. Though the patient would not assume any new identity during these episodes, there was some evidence for the loss of identity of self as he would ascribe hitting himself the actions of his friend. However, these episodes would only occur when the patient was alone. Also, there was H/o wandering (at least in first two episodes and further prevented by the family). Furthermore, he seemed oblivious to his problems and dysfunction and exhibited la belle indifference.

Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures (G40.2): Experiential hallucinations in which both visual and auditory components combine to form one single experience are usually seen in cases of temporal lobe epilepsy. However, there was no evidence of seizures either historically or on EEG.

Complicated grief (F 43.21): The patient refused to accept the death of his friend and would see his friend in the same state as he was at the time of death. However, he would not seek out his friend on his own and did not resist the change in place of residence. Also, there was no history of mummification of objects belonging to the friend or anniversary reaction.

Post-traumatic stress disorder (F 43.1): His symptoms had appeared within 6 months of the initial traumatic experience. However, there was no H/O re-living the traumatic experience and avoidance of travel by similar means. Also, there were no features suggestive of either autonomic hyperarousal or emotional numbing anytime during the history.

Working diagnoses of persistent delusional disorder and factitious disorder were made. Due to the short stay, the underlying issues concerning psychopathology in terms of his motive, primary and secondary gains could not be explored and dealt with. As immediate concern of the family was the faltering vision in left eye, it was decided to ascertain the urgency of eye surgery. Ophthalmology opinion was taken, it was opined that cataract surgery could be delayed. He was started on 2 mg risperidone which was later increased to 4 mg; he developed no side effects. His family was explained about the complexities of the case. He was discharged on 4 mg risperidone and was advised to report after 2 months. It was agreed upon by both the treating teams to keep him under close joint follow-up and supervision, to assess his mental status on subsequent follow-ups, and take decision about performing cataract surgery.

DISCUSSION

In the present case, psychiatrists had come into picture to ascertain patient's fitness for undergoing eye surgery. Though his competency to give consent for the surgery was not in doubt, the manner in which he had injured his operated eye made it essential to deal with his underlying psychopathology before advising for his next surgery. He exhibited persistent self-injurious behavior, overt motive for which had remained unclear and he attributed this injurious behavior to a friend long dead. Interestingly, similar symptom of hitting oneself but attributing it to others has been labeled as “alien hand syndrome.” In this syndrome, there is failure to recognize ownership of one's limb and the offending limb is recognized as foreign. This same phenomenon was observed in our patient; he accepted the act of beating, but shifted the blame of his “self-injurious behavior” on to his dead friend. Alien hand syndrome is reported in patients with medial, frontal, or callosal lesions; however, in our patient, neurological examination and investigations did not suggest any organic involvement.[4] In a review of 41 cases with self-inflicted eye injuries, most patients were reported to be male, and had a diagnosis of schizophrenia, drug or alcohol abuse, depressive disorders, or other psychosis; 33% of the patients also showed other types of injurious behavior.[5] In our case, diagnoses of persistent delusional disorder and factitious disorder were entertained.

For the treating teams, irrespective of the diagnosis, the management of this patient remains difficult. He may or may not improve after a trial of antipsychotics. The cataract surgery is definitely required for failing vision in his left eye. Risks and benefits of not operating and possibility of self-injury in case of an eye surgery will have to be appreciated by all the stakeholders. This will require close supervision and monitoring by the psychiatrists and the ophthalmologists. The challenge for both the treating teams will be to operate and prevent damage to the operated eye.

CONCLUSION

This case report illustrates a case of self-injurious behavior which posed multiple challenges for the treating team. Management of self-injurious behavior in such cases requires close cooperation between psychiatrists and other medical specialists, to ensure quick medical care of the patient, prompt diagnosis and treatment of any injuries, and treatment of the underlying psychopathology that led to this behavior.