Self-harm by severe glossal injury in schizophrenia.

Self-mutilation, the deliberate destruction occurs in a variety of psychiatric disorders.Many methods of self-destructive behavior have been described in literature. Patients of schizophrenia are known to attempt self-harm due to command hallucination, catatonic excitement or because of associated depression, however severe glossal injury by biting has not been reported so far.Authors report case of self-harm of glossal injury by biting in schizophrenia. Treatment and management issues are discussed.

Self-mutilation, the deliberate destruction or alteration of body tissue without conscious suicidal intent, occurs in a variety of psychiatric disorders. Major self-mutilation includes amputation of limbs or genitals and eye enucleation.[1] Minor self-mutilation includes self-cutting and self-hitting. Instances of deliberate self-injury are observed in both psychotic and non-psychotic individuals. Patients with command hallucinations, religious preoccupations, substance abuse and social isolation are the most vulnerable.

Many methods of self-destructive behavior have been described in literature, but to the best of knowledge of authors, isolated severe glossal injury by biting has not been reported so far. We report a case of schizophrenia attempting self-harm by biting the tongue forcefully causing glossal injury and dentatoalveolar fracture of mandible.

CASE REPORT

A 25-year-old central government employee, who had come on leave to get married, was noted to be behaving abnormally in the form of remaining withdrawn, lacking self-care and showing unprovoked aggression of sudden onset, few days before the scheduled date of marriage. Family members arranged for religious rituals, and since there was no improvement, they brought him to our tertiary care hospital. Family members did not give any relevant past or family history, and hence the patient was treated by the physician empirically for central nervous system (CNS) infection. All relevant investigations including cerebrospinal fluid (CSF) studies and computed tomography (CT) head were normal and then the case was referred to a psychiatrist.

Mental status examination showed him to be an ill-kempt individual; he lacked socio-military etiquettes, and his affect was blunted; he lacked self-care, was irritable, and his psychomotor activity was variable; he was uncooperative and uncommunicative, lacked insight and his biodrives were deranged. He was put on neuroleptics for behavioral control.

Next day morning, he was irritable and started biting his tongue forcefully and repetitively. He sustained severe tongue injuries and resisted all efforts to prevent further harm. In the process, his two lower incissors became loose. Urgent opinion of ENT Specialist and Maxillofacial Surgeon was sought. He was shifted to ICU to prevent aspiration and choking due to edematous bruised tongue. Endotracheal intubation was done and he was kept under sedation with Propofol infusion for about 36 h done by an anesthesiologist. Dentatoalveolar fracture of mandible was noted and loose teeth were removed. He was gradually weaned off from anesthesia and put on neuroleptics and other conservative measures. He recovered gradually in a few days, became cooperative and communicative. Subsequently, he gave a history of being already on maintenance neuroleptics medication for schizophrenia for the last two years. His initial presentation was in the form of catatonic stupor at previous duty station and he was managed with electroconvulsive therapy and neuroleptics. He had come on leave to get married, but came under significant stress on dowry issue by his family members. He had discontinued medications, and had a relapse now in the background of domestic stress.

DISCUSSION

Researchers and mental health professionals have not agreed upon one term to identify the behavior of self-mutilation. Self-harm, self-injury, and self-mutilation are often used interchangeably. Favazza and Rosenthal identified three different types of self-mutilation.[2] Superficial or moderate self-mutilation is seen in the individuals with personality disorders. Stereotypic self-mutilation is often associated with mentally delayed individuals. Major self-mutilation is most commonly associated with severe psychopathology. Patients with a history of self-harm have significantly greater symptoms of depression, greater suicidal thoughts, increased number of hospital admissions, and greater duration of illness, compared to patients without a history of self-harm.[3]

Schizophrenics are known to attempt self-harm due to command hallucination, catatonic excitement or because of associated depression. Male genital self-mutilation in schizophrenics has been reported by many authors.[45] Krasucki et al. reported female genital self-mutilation in a case of schizophrenia.[6] Koops et al. reported self-mutilation and autophagia of amputated penis in a case of paranoid schizophrenia.[7] Similarly, ocular self-enucleation has been reported[1] and a case of hammering multiple nails into own head each week to rid of evil has also been reported.[8] However, review of literature did not reveal any reported case of self-harm of glossal injury by biting in schizophrenia.

Our case was a clinical challenge as there was a fatal risk due to impending choking or aspiration. The biting attempt was so severe as to lead to mandibular fracture, teeth evulsion and sever glossal edema, necessitating prolonged intubation and sedation. The usefulness of a coordinated multispeciality management in such cases was highlighted in our case.

Nursing care in such cases becomes a nightmare. Such patients require behavioral, pharmacological, and psychotherapeutic interventions to meet their highly complicated needs. Staff will experience frustration related to the safety needs of patients and guilt whenever injury occurs.[9] They need administrative support, education and counseling to relieve quiet, personal and professional conflict and stress.