A rare case of imitation injury.

The impact of media on cognitions and behaviors of adolescents is well-known. High frequency of exposure to media may distort the reality testing among predisposed youth, hence the rise in risk taking behaviors among this population. We present a rare manifestation of risk taking behavior in an adolescent who injected mercury in his body after exposure to a Hollywood film. The results of investigations and possible explanation to understand risk taking behavior in the present case are discussed.

INTRODUCTION

The differentiation between fantasy and reality develops around 3 years of age among children.[12] Yet this distinction may be blurred under some circumstances like in the absence of adults, evocation of intense emotions, due to cultural traditions or presence of psychiatric morbidities.[34] Drawing from Piaget's[5] examples of circumstances like involuntary imitations, intense desire for or fear of presumed outcomes; Woolley[6] argued that adults also engage in fantasy about certain things and in certain situations. Research has shown that high frequency of media exposure[7] reinforces a child's belief in the true-to-life nature of media. Deviation from reality appraisal pre-dispose to risk taking behaviors, which refers to “one's purposive participation in some form of behavior that involves potential negative consequences or losses as well as perceived positive consequences or gains.”[8] Risk taking behaviors may manifest as impulsive decision-making, reckless behavior, promiscuous sexual relations, experimenting with substances, antisocial or even criminal activities and extreme sports.[9] Deliberations on risk taking among adolescents are pertinent because of the strong link between risk taking and mortality.[10]

CASE REPORT

We present a case of a 15-year-old male, not formally educated, member of Muslim nuclear family of lower socio-economic status and resident of a village in North India. He first presented to surgery outpatient department of community health center and was subsequently referred to Surgery Department of All India Institute of Medical Sciences, New Delhi with multiple granulomas over his left forearm along with skin ulcerations [Figures 1 and 2]. On interviewed, it was discovered that he recently tried to inject Mercury into his forearm, after watching a fictional character Logan in the movie “Wolverine” of the X Men series, undergoing an operation to reinforce his skeleton with adamantium (a hypothetical silvery shiny metal). On detailed assessment, it was found that right from childhood, he emulated in acts shown through electronic media including television and cinema. Retrospectively, patient reported dissecting frogs after seeing some educational program. Though, patient could not elaborate the cognitions, but reported the intentions to imitate. He had an interest in watching science fictions and would relate to the actions of the heroes and would wish to get such powers. When he saw the movie, Spiderman (at the age of 13 years), he tried to eat cob webs and repeatedly put spiders caught by him on his wrist thinking that he would also become Spiderman. Some of these acts would be solitary while others would be in the company of peers. His peer group consisted of adolescent and adults of different ages who worked together as laborers. Recently, they saw a movie in which the superhero was injected with silvery metal in his body after which he became invincible. Patient from that time thought of doing the same, but could not find any such material in his vicinity. Later when he saw a sphygmomanometer in his father's junkyard, he thought of taking the mercury out and injecting in his body. At that time, he reported that he thought he would get the super powers if he does it correctly and subsequently injected the same. Though, because of lack of skill in injecting, he ended up injecting mercury in subcutaneous tissue of his left forearm. Patient reported that he felt minimal pain similar to the hero in the movie and tried manipulating the resultant swelling from injection to show its effects. He did not report the incident to anybody and continued with his daily life. When his family members realized there was a swelling over his forearm, he was brought for treatment. He also tried smoking cigarettes after seeing on television, along with peers, despite not liking the effects. His usual cue for smoking would be watching movie heroes smoke on TV. On the suggestion of his friends he also tried alcohol and cannabis, but did not like the taste and effect of it. He would often fantasize having a physique like famous Bollywood actors and would purchase clothes similar to the ones worn by them. A thorough psychiatric evaluation was carried out, though the possibility of mania, psychosis, borderline and schizotypal traits were considered eventually were ruled out in the face of lack of evidence from history and present interview and observations. His psychological evaluation was performed during hospitalization with Bhatia's Battery of Performance Test of Intelligence to assess his cognitive functioning, Multidimensional Iowa Suggestibility Scale (MISS), Draw a person test (DAPT), Children's Apperception Test-H (CAT-H), and Rorschach Inkblot Test to assess the pattern of behaviors and traits. His IQ was found to be in the range of 112-116, suggesting above average intellectual functioning. The MISS had to be read aloud to him as he was illiterate. It was applied to assess his suggestibility to social messages. He was found to be suggestible to consumer media messages (z = 1.83) with high psychosomatic control (z = 1.53). DAPT revealed that he had physical power drive and over concern for impulse expression. Rorschach findings revealed poor organizational capacity and weak ego strength. Test showed that his emotional state tended to be of impulsivity. Findings on CAT-H revealed the need for power, recognition and existence; content analysis revealed his wish to possess special powers to exhibit to others, he seeks novel adventure that gives him emotional stimulation and his inner state is that of conflict between the need to exhibit self-worth which frequently meets with restraints. On Rorschach, there was evidence of fantasy thinking indicating impediments to adjustments. CAT-H showed his tendency for acting out and fantasy. However, his orientation to reality was adequate.

Figure 1

Image showing multiple granulomas over index patients left forearm along with skin ulcerations

Figure 2

X-ray showing subcutaneous penetrated mercury in the forearm of patient

DISCUSSION

The present case report is a rare example of risk taking behavior involving injecting mercury into one's body as an attempt to become a superhero. Such form of risk taking though appears to be bordering with poor reality testing; however psychiatric and psychodiagnostic evaluation ruled out that possibility. The case, then, brings to light the risk of imitation injury among youth. To the best of our knowledge, this is the first case of injecting mercury as a copycat act in the published literature. Another reason for which we found this case interesting is that it advocates the interplay between personal predisposition and effect of media. Patient had suggestibility to media messages and the portrayal of risk glorification by media interacted to make him engage in such a life-threatening act. A temporal relationship between committing the act and watching the movie is evident. Given his personal pre-disposition for impulsivity, seeking novel experiences and need for power, he may have been especially impressionable to the process of making an ordinary person a super-hero by a simple act of injecting somebody with a “shiny silver liquid.” The cognitive processes such as “availability heuristics”[11] in the form of repetitive exposure to the movie could have potentially blurred the fantasy reality differentiation in this case. To conclude, media has an impact on cognitions and behavior of children[9] and it not only has grave consequences like fatalities, injuries or death for population at greatest risk,[1213] but also has high economic costs. Though a single case is limited in offering generalizations, the present case provides an evidence of media influence on more impressionable individuals.