Multiple self-inserted pins and nails in pericardium in a patient of schizophrenia: Case report and review.

This report is the case of multiple self-inserted pins and nails in chest and pericardial cavity in a young male suffering from schizophrenia. This act of self-mutilation was done to get relief from burning sensation in chest and palpitations. Review of the relevant literature revealed that self-inflicted intra-cardiac needle injuries occur mainly in young and middle-aged adults suffering from psychiatric disorders, commonly depression, schizophrenia, and substance use disorders. In one-fourth of the patients, it is due to deliberate self-harm. About 70% use a single needle but 30% may use multiple needles. Second attempts are rare. Majority of the patients (85%) are managed by surgery and recover from the injury. The condition has a low mortality rate of 5%.

Self-mutilation (SM) is a term that is used very often in psychiatry. It refers to the deliberate destruction of a part of one's own body without conscious suicidal intent.[1] SM may be observed in various psychiatric disorders, including post-traumatic stress disorder, borderline personality disorder, factitious disorder, substance use disorders, depression, and schizophrenia. SM may be of two types, minor SM and major SM (MSM). Minor SM is fairly common, but usually does not cause significant disability, and in certain countries it is part of cultural practices. On the other hand, MSM is rare but catastrophic complication of a serious mental illness and often results in permanent loss of an organ or its function. MSM occurs in three main forms viz. ocular, genital, and limb mutilation. MSM in the form of ocular and limb SM are mostly seen in psychosis associated with schizophrenia, and about three-quarter of patients who severely injure their genitals are schizophrenics and about one-quarter of patients have depression usually with psychosis. There is no specific stage during the course of schizophrenia when SM may occur. Most of the case reports of SMs in schizophrenia are in the form of facial SM, including eyes and nose, or of limb and genital mutilation. Self-insertion of needles in the thorax is an unusual form of self-injury. An earlier review of the literature in 1986 observed that of more than 160 reported cases of needles in the heart, many reported in the 19th century, 70 were due to transthoracic insertion, whereas others were the result of direct penetration from adjacent organs or of migration through the bloodstream from distant sites and till date only 10 cases involved multiple needles. Even though in these early reports precise injuries were not well-documented, but in 23 cases reviewed in 1899, the mortality rate was 61%, which probably reflected the untreated natural history of this type of injury.[12345] We report a case of multiple self-inserted pins and nails in chest and pericardial cavity in a young male suffering from schizophrenia because of its rarity and briefly review the relevant recent literature.

CASE REPORT

A 26-year-old Hindu male educated up to class 8th without any past and family history of psychiatric disorders, well-adjusted pre-morbidly, presented to the hospital with the history of being treated by cardiothoracic surgeon for multiple self-inserted nails in pericardium. History revealed that the patient had continuous illness of 4 years characterized by symptoms of muttering and smiling to self, being suspicious towards family members, decreased sleep, aimless wandering behavior, aggressive and assaultive behavior against family members, which was mostly unprovoked, poor self-care, and impaired biological functions. Mental status examination revealed blunted effect and prominent auditory hallucination in the form of people discussing among themselves about him and his actions. For the above symptoms, he was seen by a psychiatrist two years back, but the patient did not show much improvement as he remained poorly compliant to prescribed medications. In the mean time, the patient started having self-injurious behavior in the form of piercing nails and safety pins in his chest wall just adjacent to his left nipple. This behavior was not evident to his parents as he would do this mostly when he would be alone. His injury was noted by his uncle when he had fever and was taken to a doctor who noticed an infective swelling over left chest wall on the side of nipple. When inquired about any chest injury, the patient admitted about his self-mutilating behavior of piercing his chest wall with nails and safety pins. Radiological examination of the chest showed multiple foreign body in the chest wall and pericardial cavity. He was referred to a cardiothoracic surgeon for treatment. After being treated for foreign body in chest and pericardial cavity, patient's guardian came to the hospital for treatment of psychiatric symptoms. On asking the reason for the self-mutilating behavior, patient told that he did it to relieve his feeling of burning sensation in left side of chest and palpitation. The patient did not attribute his self-injury behavior as a response to auditory hallucination. He also said that he did not have much perception of pain during this behavior. Physical examination revealed multiple scar mark over left chest wall and postoperative scar marks over sternum [Figure 1]. Patient was prescribed with tablet trifluperazine 10 mg and trihexyphenidyl 2 mg, and was asked to follow up after 1 month. After 1 month of treatment, patient showed good improvement in psychopathology, and there were no reports of self-injurious behavior during this period.

Figure 1

Picture of patient showing scar at site of insertion of pins and needles and midline thoracotomy scar

DISCUSSION

SM is proposed as a fast self-aid action, providing temporary relief from inner tension and confusion,[6] depersonalization, feelings of guilt, negative feelings of being rejected, hallucinations, and preoccupation with sexual matters.[16] Even if the patient attains temporary relief after the SM behavior, pain is said not to be perceived. Schizophrenia patients show more tolerance to pain than healthy people though the sense of pain is known not to have completely disappeared.[7] It has been suggested that pain insensitivity in schizophrenia may be a result of antipsychotic medication or reflects a motor deficit in responding to painful stimuli. An excess of endorphins may also explain clinical and experimental pain insensitivity in schizophrenia. Another possibility is suggested by research indicating that a dysregulation of N-methyl-D-aspartate receptor-mediated neurotransmission might be responsible for pain insensitivity in schizophrenia.[8] Examples of self-injurious behavior in schizophrenia patients include unilateral and bilateral eye enucleation,[5] self-laceration, and self-amputation of various parts of the body, including the hand, breast, ear, penis, and testicles.[8] Example of SM to the extreme extent probably is mutilation of the entire face.[9] Our case is an example of SM involving both superficial skin and deep tissue mutilation: Superficial injury involving multiple pricking of skin just by the side of left nipple and deep tissue injury in the form of inserting pins and nails in left chest cavity and pericardium.

The reason for self-mutilating behavior as told by the patient was to relieve his feeling of burning sensation of chest and palpitation. Abnormal bodily sensations are frequently described psychopathological symptoms in schizophrenia.[10] These abnormal bodily sensation may include sensations of pain, numbness, stiffness and feeling strange, abnormal heaviness, lightness, extension, diminution, shrinking, and enlargement of limbs and other body parts along with palpitation, light headedness, epigastric burn, etc.[1112] SM in response to bodily symptoms has been described in case reports.[1] The SM of the patient was in response to above feeling so as to get relief. The reason for not receiving much pain even after performing SM to such an extent may be due to some of the biological factors such as hyper-endorphin state, dysregulated NMDA receptor-mediated neurotransmission and motor deficit in responding to painful stimuli in schizophrenic patients. It has been suggested that absence of pain may be related to the blunted affect that is characteristic of schizophrenia and noted that it would be unexpected for the emotional aspects of pain to be spared when the affective expressions of fear, anger, love, etc., are so grossly distorted or blunted.[13] It has also been noted that during their acts of SM, these individuals seem to have been in what has been termed a state of “psychotic analgesia”(9).

Literature review

On review of the literature, we could locate 40 case reports of self-inflicted intra-cardiac needle injuries during the period from 1967 to 2013 [Table 1]. There was a preponderance of females compared to males (females = 23, males = 14, not mentioned = 3). Age of the patients ranged from 12 years to 71 years. Distribution of the patients according to age was: 6 aged 12 − 19 years; 8 aged 20 − 29 years; 7 aged 30 − 39 years; 9 aged 40 − 49 years; 2 aged 50 − 59 years; 3 aged 60 − 69 years, and 1 aged more than 70 years. Thus, the majority (75%) of the patients were in the age group of 12 to 49 years.

Table 1

Reported cases of self-inflicted intra-cardiac needles

A single needle was found in 27 patients while 13 had inserted multiple needles. One patient had inserted several needles in her chest on two occasions. In the majority the needles were inserted through the chest wall but four patients had swallowed the needles while one inserted the needle in the arm from where it migrated to the heart.

Psychiatric disorders were seen in 34 patients and included: Depression (n = 11), schizophrenia (n = 7), substance use disorder (n = 5), personality disorder (n = 2), mental retardation (n = 2) and one patient each with schizoaffective disorder, acute psychosis, dementia, neurosis, and factitious disorder. In 10 patients, the injury occurred due to deliberate self-harm. The most common presenting symptom was chest pain in 32 patients. However, 8 patients were asymptomatic. In 34 patients, the needles were successfully removed by surgery. Two patients refused treatment, two patients died, while in one patient the management was not mentioned.

In conclusion, we can state that self-inflicted intra-cardiac needle injuries are seen mainly in young and middle-aged adults suffering from psychiatric disorders, commonly depression, schizophrenia, and substance use disorders. In one-fourth of the cases, it is due to deliberate self-harm. About 70% use a single needle but 30% may use multiple needles. Second attempts are rare. Majority of the patients (85%) are managed by surgery and recover from the injury. The condition has a low mortality rate of 5%.