Diagnostic Dilemma: A Case of Self-Injurious Behavior
Sood, Mamta, Agrawal, Alok, Sivaraman, S., Khandelwal, Sudhir, Indian Journal of Psychiatry
Byline: Mamta. Sood, Alok. Agrawal, S. Sivaraman, Sudhir. Khandelwal
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.
Deliberate self-injury [sup] or pathological self-mutilation [sup] 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. [sup] 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. [sup]
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.
A 52-year-old married Hindu male shopkeeper from middle socioeconomic status family, educated up to 7 [sup]th 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. …