Oedipism in a patient with frontal lobe encephalomalacia

The Vision of Blindness-Sight Versus Insight: A Case Report and Literature Review of Self-enucleation (Oedipism)

Self-enucleation or "Oedipism" is a rare ophthalmic and psychiatric emergency. Given the severity of its consequences, it requires proper medical management and that clinicians understand and be aware of the psychiatric presentation. Important clinical considerations include identification of various etiologies leading to self-enucleation, awareness of possible complications, and provision of appropriate care. We present a case of bilateral self-enucleation by a young male patient in the context of his first episode of psychosis and review the literature on this clinical entity. Ocular damage interferes significantly with activities of daily living and is associated with decreased quality of life so that identifying risk factors is of major importance to prevent this dangerous behavior.

Psychosis in a case of encephalomalacia

We report an adult female who had changes suggestive of encephalomalacia in bilateral temporal and basifrontal region in the magnetic resonance imaging of the brain but presented with psychiatric symptomatology suggestive of psychosis instead of neurological manifestations. Encephalomalacia is softening of the brain tissue which may lead to the brain changes and present with varied clinical manifestations. Most of the cases reported previously were in infants and children and almost all of them were related to neurological disorders. However, cases with psychiatric symptomatology were rarely reported, that too in adults. The authors discussed the psychiatric symptom profile, their management and emphasized the importance of imaging of the brain and its association with psychiatric manifestations.

Self-inflicted chronic bacterial keratoconjunctivitis using self semen

This case report describes a case of self-inflicted chronic bacterial keratoconjunctivitis involving the patient's own semen. A 20-year-old male soldier was referred to our clinic for the evaluation of refractory chronic bacterial conjunctivitis. Over the previous 4 months, he had been treated for copious mucous discharge, conjunctival injection, and superficial punctate keratitis in both eyes at an army hospital and a local eye clinic. Despite the use of topical and systemic antibiotics according to the results of conjunctival swab culture, there was no improvement. During the repeated smear and culture of conjunctival swabs, surprisingly, a few sperm were detected on Gram staining, revealing that the condition was self-inflicted bacterial keratoconjunctivitis involving the patient's own semen. Thus, in cases of chronic keratoconjunctivitis that do not respond to appropriate antibiotic treatment, self-inflicted disease or malingering should be considered.

A general neuropsychological model of delusion

INTRODUCTION

Neurocognitive accounts of delusion have traditionally highlighted perceptual misrepresentation, as the primary trigger in addition to other cognitive deficits that maintain the delusion. Here, a general neurocognitive model of delusional disorder (DSM-IV) is proposed, not so much based on perceptual or cognitive deficits after right hemisphere damage as on cognitive propensities, specifically excessive inferencing (especially jumping to conclusions) and excessive reference to the self, due to left hemisphere overactivity.

METHOD

The functional imaging, topographic EEG, and experimental imaging literatures on delusional disorder are reviewed, and 37 previously published cases of postunilateral lesion delusion (DSM-IV type, grandeur, persecution, jealousy, erotomania, or somatic), are reviewed and analysed multivariately.

RESULTS

Functional imaging and EEG topography data were slightly more indicative of left hemisphere overactivity in delusional disorder. In addition, 73% of the postunilateral lesion cases (χ(2)=7.8, p=.005) of delusional disorder (DSM-IV type) had a right hemisphere lesion, whereas only 27% had a left hemisphere lesion.

CONCLUSION

Left hemisphere release appears to be a more primary cause of delusional disorder than right hemisphere impairment, the latter merely entailing loss of inhibition of delusional beliefs. We propose that most patients with DSM-IV diagnoses of delusional disorder could be afflicted by excessive left hemisphere activity, but further research is necessary.

Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition symptoms of mania: which one(s) result(s) more often from right than left hemisphere lesions?

Previously published single case reports of patients with a unilateral lesion were assembled. After the lesion, each of the 244 cases presented at least one of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) symptoms of a manic episode, namely, elated or irritable mood, grandiosity, talkativeness, flight of ideas, hyperhedonism, reduced need for sleep, agitation, or distractibility (all optional in DSM-IV). As expected, the subgroup of 59 manic patients had a right hemisphere lesion far more often than a left one. However, this was also true of various sets of the nonmanic cases. Furthermore, elation was not the symptom most strongly associated with lesion side. Elation without mania was not significantly predicted by lesion side. However, talkativeness was strongly predicted by right lesion side whether in manic or nonmanic patients or even when the symptom was the only symptom observed. Agitation was consistently and robustly associated with right lesion side, but not completely distinctly so (it fell short of significance when not accompanied by elation or other symptoms). It is proposed that prevalence of right hemisphere lesions causing mania is primarily related to mental and behavioral disinhibition rather than a shift of mood and that it consists of release of left hemisphere influence.

Self-inflicted eye injuries in first-episode and previously treated psychosis

The purpose of the present paper was to describe the circumstances and phenomenology of patients who remove or pierce their eyes or orbits during psychotic illness. In particular, the aim was to determine if patients in their first-episode psychosis (FEP) carry an increased risk of self-inflicted eye injury when compared to patients with previously treated psychosis (PTP). Data were extracted from all of the case reports published in English since 1960 and from two unpublished Australian cases. More than half of the cases of self-inflicted eye injury that resulted in permanent loss of vision occurred during FEP. Serious self-inflicted eye injuries are rare, but the risk appears to be greatest during FEP. Earlier treatment of emerging psychosis and close attention to patients who attempt to injure their eyes may occasionally prevent blindness.

Self-inflicted eye injuries: a review

PURPOSE

To review the pathogenesis, clinical characteristics, and management of self-inflicted eye injuries.

METHODS

Review of the medical literature.

RESULTS

Psychiatric theories of pathogenesis for self-inflicted behaviour include religious and sexual ideation, symbolism, guilt, and displacement. Biological theories include disorders of serotonergic, dopaminergic, and opiate neurotransmitters. Clinical characteristics of self-mutilators include acute or chronic psychoses, drug-induced psychoses, other psychiatric conditions, and certain organic states. The majority are young-to-early middle-aged male subjects, though it can also rarely occur in children. Management of self-inflicted eye injury requires close cooperation between ophthalmologists and psychiatrists as well as other medical specialists, to ensure quick resuscitation of the patient, prompt diagnosis and treatment of any injuries, and treatment of the underlying behaviour that led to the injuries.

CONCLUSIONS

Self-inflicted eye injuries are a rare but important group of ophthalmic conditions that require close cooperation between different medical specialties to ensure optimum care of the often severely disturbed patient.

Oedipism

BACKGROUND

Oedipism or self-enucleation is a rare form of self-mutilation, and most often described in acutely psychotic patients, who have religious or sexual delusions.

CLINICAL RECORD

A 47-year-old Chinese man with a history of chronic schizophrenia enucleated his own left eye and mutilated his right eye. The reason for his behaviour was unknown. The history and legends surrounding autoenucleation and the medical literature are reviewed.

RESULTS

The patient was managed jointly with the psychiatrist. He suffered extensive injury to his right eye, resulting in loss of vision.

CONCLUSION

The management of Oedipism requires close cooperation between ophthalmologists and psychiatrists. Precautions must be taken to prevent repeated attempts or other self-mutilatory behaviour.