‘My Limbs are Not Mine’ A Case of Penile Amputation Secondary to Commanding Hallucination in Schizophrenia Volume 45- Issue 1

Chong Siew Koon* and Zafrie Izzat bin Zakaria

• Hospital Sultanah Nur Zahirah, Malaysia

Received: July 04, 2022;   Published: July 13, 2022

*Corresponding author: Chong Siew Koon, Hospital Sultanah Nur Zahirah, Terengganu, Malaysia

DOI: 10.26717/BJSTR.2022.45.007149

Abstract PDF

One form of bizarre act from those suffering from Schizophrenia is pathological self-mutilating behavior. In general, there are three types of pathological selfmutilation. Among them, major self-mutilation (MSM) probably receives the most attention because of its rarity and severity. MSM is an uncommon act but often result in serious injury to the patient. It is almost always caused by psychotic illness. Some exotic examples of MSM include eye-enucleation, self-castration and self-amputation of limb. In this case report, we will discuss on a patient having schizophrenia with who performed self-amputation on his own penis using a knife after suffering from command auditory hallucinations.

Keywords: Major Self-Mutilation; Self-Amputation of Penis; Command Hallucination

Pathological self-mutilation Is usually defined as deliberate alternation or destruction of body tissue without obvious suicide intent. Such encounters are often associated with a wide range of psychiatric illnesses, such as psychosis, substance intoxication, mood disorders, intellectual disability, and personality disorders [1,2]. Pathological self-mutilation can be categorized into three types – major, stereotypic, and superficial/moderate as each type is closely related to certain mental disorder. Commonly seen in psychosis and substance intoxication, major self-mutilation (MSM) is an isolated and infrequent act which results in significant tissue damage. Examples of these acts include eye-enucleation and amputation of penis or part of the limb [1]. Here, we will describe a case of MSM where the patient, following the command hallucination, walked to a secluded area before amputating his penis. He was rushed to hospital for emergency surgical intervention and subsequently received psychiatric attention.

Mr S is 30-year-old Malay man who was working as a labourer and lived in a secluded village in company with his father. On the day of the event, he recalled that he was suffering from auditory hallucinations commanding him to amputate his penis. He walked away from his village towards a river and with the aid of a machete amputated his penis. Upon presentation to the casualty, he appeared to be calm and was not in distress. He was clad in a sarong around his waist which was soaked in blood. Examination revealed that he had severed his private parts directly at the root of the penis. The scrotal sac was intact. Bleeding had stopped at time of examination. Mr S appeared to be pale but calm and collected. Surprisingly, he did not appear to be suffering from pain. He even cooperated during wound inspection and did not flinch when gauze was applied to the severed stump. He was orientated to time, place and person. He described a mixture of male and female voices commanding him to carry out the act; one in which he felt was compelled to oblige. According to him, he had experienced similar auditory hallucination in the past which was commanding in nature. Voices would tell him to perform various acts, ranging from menial day to day chores to self-harm. However, he admitted that he could control himself most of the time except for this fateful day. Upon returning home, his father noted the blood stains at his sarong and inquired what happened.

After patient confessed the commission of his act, his father desperately went to the river side in search for the severed penis. His father managed to retrieve the severed penis and was kept in an ice box in an attempt to preserve the appendage. Inspection revealed the penis to be intact but covered with dirt from the ground from which it was retrieved. The cut was ragged in nature. He was tested negative for drugs at time of presentation.

Mr S denies any form of mood symptoms. He says that he felt well and was not suicidal. However, he was totally convinced that he should carry out the act as commanded by the voices. This is the first time he has committed self-mutilation. There was no such history in the past. Mr S was also evaluated by the surgical department and referred for vascular repairs. The surgical team was unable to manage the extent of damage inflicted to his penis and patient had to be referred to Selayang for vascular repairs. Unfortunately, the severed appendage could not be salvaged. He had to undergo extensive debridement as the wound was soiled by a blade tainted with rust. Mr S’s wounds healed without complications. He was treated with long acting injectables; Intramuscular Fluphenazine 25mg monthly in view of his propensity to default follow-up and Amisulpride 400mg twice daily. He remained well under our followup. Further history revealed that Mr S’s first psychiatric contact to our centre was on 9th of February 2015 and was diagnosed with Schizophrenia at the age of 24.

During his first presentation, he was already suffering from auditory hallucinations which was commanding in nature. He described voices speaking to him as a second and occasionally third person. The voices were a mixture of male and female voices, speaking amongst themselves and at times directly to him. He had co-morbidity of abusing amphetamines on an occasional basis. He was treated with Olanzapine and his symptoms gradually improved but he defaulted treatment several times throughout his follow-up with us.

There was a similar case report of recurrent self-mutilation from our psychiatric department where a Chinese man suffering from schizophrenia amputated his own hand. He was also suffering from commanding hallucinations during the commission of the act and had history of defaulting medications [3]. Another local institute reported similar event in a refugee suffering from Schizophrenia who totally amputated his penis due to such hallucinations [4]. This harkens to a popular debate of old; do Schizophrenia patients possess high pain tolerability? Certain studies propose the Rill reflex mechanisms as a possible underlying pathology whilst some other proponents postulate dysfunctional NMDA receptors as a possible causation. Some studies found that natural occurring analgesics such as B-endorphins and CGRP were significantly higher in patients with schizophrenia compared to controls [5]. Some studies found a correlation between the severity of psychosis and pain endurance. In other words, the greater the psychosis, the greater the overall pain threshold [1,6]. On the other hand, some studies fail to demonstrate significant difference between pain tolerability of people suffering from schizophrenia and their normal counterparts. Some studies contended that chronic patient tend to demonstrate a negative affect and therefore less likely to ‘report’ pain. The apparent analgesia would be the result of a denial “attitude”, a different manner of expressing pain in relation with the non-verbal communication difficulties, and not an alteration in the brain functions nor a biological anomaly [7,8].

Diverse methodological biases arise from the studies of pain in patients with schizophrenia. Most of these studies are not properly standardized and the ethical issue of subjecting pain to further evaluate this phenomenon makes it more difficult to draw a proper conclusion. Another interesting topic in question is the motivation behind dismembering a particular appendage. Some studies reported that Schizophrenia patients find a particular limb to be ‘foreign’ and therefore must be disposed of [9]. If the former is true, then recurrent self-mutilation of patients with Schizophrenia may be motivated by the psychopathology which underlies the disease itself. Generally, there are three known groups of genital mutilators: those with psychotic disorders, transvestites and those with complex religious beliefs [10]. As for our case, Mr S was kept under long term follow-up and frequent review. He was also treated with long acting injectables as he had the propensity of missing his medications. During our last review, he was maintaining well and could perform his daily tasks. He could also continue his work as a labourer. From a surgical point of view, the injury healed well. The surgical team had done a proper refashioning which allows the patient to micturate from the stump.

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