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 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 4  |  Issue : 1  |  Page : 78-81

Complete self-mutilation of male genitals as a severe form of psychiatric manifestation of HIV: A case report with review of literature


1 Department of Surgery, ESIC Model Hospital, Hyderabad, Telangana, India
2 Department of Surgery, Jawaharlal Nehru Hospital and Research Centre, Bhilai, Chhattisgarh, India

Date of Web Publication2-Jun-2016

Correspondence Address:
Sriharsha Bokka
Department of Surgery, ESIC Model Hospital, Hyderabad, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2321-4848.183365

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  Abstract 

Genital self-mutilation (GSM) is a rare event that is commonly associated with psychotic disorders. However, such injuries have also been reported in nonpsychotic patients as a result of either bizarre autoerotic acts and attempts at crude sex-change operation by transsexuals or secondary complex religious beliefs and delusions regarding sexual guilt. We report a case of GSM in a human immunodeficiency virus (HIV)-positive individual who not only severed his penis, scrotum, and testes completely as a result of internal conflict and frustration but also refused any further treatment toward reconstruction owing to his guilt.

Keywords: Human immunodeficiency virus (HIV)-positive, psychiatric manifestations, self-mutilation


How to cite this article:
Bokka S, Sharma S. Complete self-mutilation of male genitals as a severe form of psychiatric manifestation of HIV: A case report with review of literature. Arch Med Health Sci 2016;4:78-81

How to cite this URL:
Bokka S, Sharma S. Complete self-mutilation of male genitals as a severe form of psychiatric manifestation of HIV: A case report with review of literature. Arch Med Health Sci [serial online] 2016 [cited 2019 Dec 7];4:78-81. Available from: http://www.amhsjournal.org/text.asp?2016/4/1/78/183365


  Introduction Top


Psychiatric case reports of male genital self-mutilation (GSM) in the literature are rare and mostly anecdotal. Most of them are associated with personality disorders and recognizing the psychiatric manifestations of human immunodeficiency virus (HIV) is challenging. Some of the risk factors for this act are: Presence of religious delusions, command hallucinations, low self-esteem, and feelings of guilt associated with sexual offences. Other risk factors include failures in the male role; problems in the early developmental period, such as experience of difficulties in male identification and persistence of incestuous desires; depression; and a history of GSM. The eponym “Klingsor syndrome,” which involves the presence of religious delusions, is proposed for GSM.[1] The significance of these findings is magnified by emerging evidence that certain symptoms, such as depression, may be associated with nonsuicidal self-injury that may range from minor cuts at one end of the spectrum to self-mutilation of organs at the other end that at times proves to be fatal.


  Case Report Top


A 38-year-old male was brought to the casualty of our hospital with complaint of bleeding from private parts. On examination, to our surprise, his penis, scrotum, and testes were all completely severed and there was bleeding from the cut ends of spermatic cords and base of the penis [Figure 1]. The bleeders were all immediately ligated and urethral catheterization was done [Figure 2]. On inquiry, the patient revealed that he was tested positive for HIV 1 month ago and he was married for 8 years but has no children. After this, he took his wife to a local hospital and she was also tested positive for the same condition.
Figure 1: Completely severed genitalia

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Figure 2: Bleeding controlled and urethra catheterized

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As narrated by the patient himself, though he did not face any discrimination from the society on account of the disease, yet he was depressed and took the extreme step of self-mutilation of his genitals and threw them away considering them as the cause of his and his wife's suffering. While recording the history of the patient, the following facts were noted:

  1. He was depressed most of the day.
  2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day.
  3. Insomnia.
  4. Feelings of worthlessness or excessive or inappropriate guilt.


The scale used to quantitate depression in our case was Inventory of Depressive Symptomatology — self report (IDS-SR) and the score was 84 (0-84) indicating severity of 4 (0-4).



Mental state examination findings were as follows:

After the bleeding was controlled, the patient refused any further treatment and left against medical advice from the casualty. Hence, it was not possible for us to evaluate the patient thoroughly in psychiatric perspective and to initiate treatment not only in terms of depression but also for HIV.


  Discussion Top


Psychiatric manifestations of HIV

Recognizing the psychiatric manifestations of the HIV disease can be complicated by the complex biologic, psychologic, and social circumstances associated with this illness, and psychiatric symptoms often go unrecognized and untreated. The significance of these findings is magnified by emerging evidence that certain symptoms, such as depression, may be associated with an increase in mortality rate among HIV-seropositive women [2] and with disease progression in HIV-seropositive men.[3]

Depression is recognized as a cause of increased morbidity and mortality in many chronic medical illnesses and it remains undiagnosed and untreated in the HIV-infected population. In the context of HIV infection, the diagnosis of depressive disorders can be even more challenging because many vegetative symptoms of depression (e.g., fatigue, pain, anorexia, and insomnia) are observed in many patients throughout the course of their HIV illness, even when depression is not present.

Major depression is an illness with objective physical signs occurring with some consistency. These signs are retardation of movements and diminished gestures and expressions. The patient may appear tired, self-concerned, bored, and inattentive and may display a loss of interest in the surroundings. Anxiety is a conspicuous and an integral element of an affective state and may be expressed by severe restlessness and agitation. Muscle tension, wringing of hands, weeping and moaning, repeating over and over in a monotonous and stereotyped way phrases expressive of misery are all important clinical signs of major depression. Similarly, tachycardia, dry tongue/mouth, sweaty palms and/or bodily extremities, cold clammy skin, pallor, pupillary dilatation, tremor, and the fluctuations in blood pressure with wide pulse pressure are all important signs that give away the underlying distress.

Higher rates of mania have also been noted with progression of HIV infection. In early HIV infection, 1–2% of the patients experience manic episodes, which is only slightly higher than the rate in the general population. However, after the onset of acquired immune deficiency syndrome (AIDS), 4-8% of the patients appear to experience mania.[4] This increased frequency of mania around the time of onset of AIDS has been closely associated with cognitive changes or dementia and is thought to be a secondary manic syndrome due to HIV infection of the central nervous system (CNS).

Psychosis is a recognized but — Relative to the mood disorders — Uncommon psychiatric manifestation of AIDS and is found more frequently in patients with AIDS-related neurocognitive impairments [5] Even less commonly, antiretroviral therapy may precipitate psychosis.

Self-harm and genital self-mutilation (GSM)

The term “self-aggression” (self-destruction) refers to a complex range of behaviors. One of the definitions that have been put forward states that “all voluntary, intentional and more or less deliberate behaviours jeopardising one's health or life” should be regarded as self-harming. Two main groups of this kind of behavior, that is, self-injury or self-poisoning (medications or other substances) can occur over the course of mental disorders.

Favazza [6] distinguishes three groups of self-mutilation:

  1. Major (amputation of limbs or castration etc.) — It is the least common self-mutilation, it is followed by severe consequences for life and health, and it is usually inflicted upon the self while in an acute alcohol intoxication or a psychosis;
  2. Stereotypic (rhythmically banging one's head against the wall etc.) — Relatively rare, mostly accompany autism, mental retardation, and psychoses;
  3. Moderate/superficial/delicate self-mutilation — Pao described it for the first time in 1969[7] It is the most common self-mutilation. It is usually superficial and does not require medical interference.


The majority of cases of GSM reported in the literature have been in patients with psychosis or psychiatric disorders, with either functional or organic brain disease. However, a few cases have been reported in nonpsychotic persons that result either from bizarre autoerotic acts or from attempts at crude sex-change operation by the transsexuals.[8] A verse suggesting autocastration is found in Mathew 19:11 “For these are some eunuchs, which were made eunuchs of men, and there be eunuchs which have made themselves eunuchs for the kingdom of heaven's sake.” Ames suggested the eponym of the “Klingsor syndrome” to apply to the occurrence of autocastration as a consequence of religious delusions.[9] Thus, self-mutilation of the male genitals seems to be a pathway out of diverse psychological disorder or behavior and cultural beliefs.

A review showed that guilt feelings associated with sexual conflicts were the most important factors in the act of psychotic self-mutilation and were also related to religious psychotic experiences that were often the direct motives for the act. Self-mutilators with sexual guilt feelings were likely to mutilate themselves more severely than those without the guilt feelings.[10] Even excluding the transsexuals, disturbance of sexual identity was most participating in the act of nonpsychotic self-mutilators. In addition to these, previous history of self-injury took part in the act independently. Male GSM is exceedingly rare in psychiatric practice, even if it is not as uncommon as the paucity of published literature on the subject would suggest.

Cases of GSM are urological and surgical emergencies, therefore it is more likely that patients will have a surgical assessment first rather than a psychiatric assessment. The high rate of repeated mutilation could probably be attributed to the fact that patients do not come under the scrutiny of psychiatric services. Therefore, it is important that surgical and psychiatric teams liaise closely while managing cases of GSM. It is also important that there is more awareness among medical practitioners of the underreported phenomena of GSM and repetitive GSM [11] so that it can be treated effectively and its recurrence can be prevented. Case reports of such GSM in a person with hypochondriacal delusion of infection with HIV precipitated by erroneous and anxiety-provoking miscommunication during HIV testing remind us of the need for systematic and appropriate pre-test and post-test HIV counseling, to help prevent such outcomes.[12]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Ozan E, Deveci E, Oral M, Yazici E, Kirpinar I. Male genital self-mutilation as a psychotic solution. Isr J Psychiatry Relat Sci 2010;47:297-303.  Back to cited text no. 1
    
2.
Ickovics JR, Hamburger ME, Vlahov D, Schoenbaum EE, Schuman P, Boland RJ, et al.; HIV Epidemiology Research Study Group. Mortality, CD4 cell count decline, and depressive symptoms among HIV-seropositive women: Longitudinal analysis from the HIV Epidemiology Research Study. JAMA 2001;285:1466-74.  Back to cited text no. 2
    
3.
Leserman J, Petitto JM, Gu H, Gaynes BN, Barroso J, Golden RN, et al. Progression to AIDS, a clinical AIDS condition and mortality: Psychosocial and physiological predictors. Psychol Med 2002;32:1059-73.  Back to cited text no. 3
    
4.
Mijch AM, Judd FK, Lyketsos CG, Ellen S, Cockram A. Secondary mania in patients with HIV infection: Are antiretrovirals protective? J Neuropsychiatry Clin Neurosci 1999;11:475-80.  Back to cited text no. 4
    
5.
Evans DL, Mason KI, Bauer R, Leserman J, Petitto J. Neuropsychiatric manifestations of HIV-1 infection and AIDS. In: Charney D, Coyle J, Davis K, Nemeroff C, editors. Psychopharmacology: The Fifth Generation of Progress. New York: Raven Press; 2002. p. 1281-99.  Back to cited text no. 5
    
6.
Favazza AR. The coming of age of self-mutilation. J Nerv Ment Dis 1996;186:259-68.  Back to cited text no. 6
    
7.
Pao PN. The syndrome of delicate self-cutting. Br J Med Psychol 1969;42:195-206.  Back to cited text no. 7
    
8.
Wan SP, Soderdahl DW, Blight EM Jr. Nonpsychotic genital self-mutilation. Urology 1985;26:286-7.  Back to cited text no. 8
    
9.
Carroll PR, Lue TF, Schmidt RA, Trengrove-Jones G, McAninch JW. Penile replantation: Current concepts. J Urol 1985;133:281-5.  Back to cited text no. 9
    
10.
Nakaya M. On background factors of male genital self-mutilation. Psychopathology 1996;29:242-8.  Back to cited text no. 10
    
11.
Catalano G, Catalano MC, Carroll KM. Repetitive male genital self-mutilation: A case Report and discussion of possible risk factors. J Sex Marital Ther 2002;28:27-37.  Back to cited text no. 11
    
12.
Mishra KK, Reddy S, Khairkar P. Genital self-mutilation in a suicide attempt: A rare sequela of a hypochondriacal delusion of infection with HIV. Int J STD AIDS 2014;25:312-4.  Back to cited text no. 12
    


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