BRIEF REPORT
Self-Cannibalism (Autosarcophagy) in Psychosis A Case Report Randi Libbon, MD,* Gareen Hamalian, MD, MPH,*† and Joel Yager, MD* Abstract: Only nine previous cases of self- or auto-cannibalism (autosarcophagy) have previously been reported in the literature. Here, we report a 29-year-old man with psychosis and a history of polysubstance use who presented after his second attempt to self-cannibalize. This case raises questions about the underlying causes and dynamics of self-cannibalism in psychiatric illness and its relation to other types of self-harm behavior. Key Words: Self-cannibalism, Auto-cannibalism, Autosarcophagy (J Nerv Ment Dis 2015;203: 152–153)
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eports of self-cannibalism are rare. To date, self-cannibalism has not been associated with any one particular psychiatric disorder. The most recent literature review reported one case and reviewed seven others (Monastario and Prince, 2011). Three of the reviewed cases occurred in the setting of severe psychosis and associated behavioral disorganization, one in the context of amphetamine abuse, and two in the absence of psychosis, one of which occurred in a patient with recurrent depression, without psychosis, and in the context of the patient's goal of attempting to capture attention from mental health professionals (Monastario and Prince, 2011). We found one more article regarding self-cannibalism (Ahuja and Lloyd, 2007) that was not included in the previous review paper (Monastario and Prince, 2011). Here, we describe an additional case to add to the literature on this inadequately described phenomenon.
REPORT OF A CASE Mr MM, a 29-year-old Caucasian homeless man, estranged from his aunt (his only identified social contact) for several months, was brought to the hospital by ambulance after reporting to a medical clinic. Although he presented primarily to apply for Medicaid, the intake clinician noted that he had tried to cut off his right pinky finger with a steak knife, with the intention of eating it. He had made a 1.5-cm laceration around the proximal interphalangeal joint, requiring three sutures and treatment with oral antibiotics. He also sustained a metacarpal shaft fracture but denied pain. He described wanting to eat his raw “tissue” and not his “flesh,” differentiating the two by referring to his skin as “flesh” and the lower layers of subcutaneous tissue and muscle as “tissue.” He reported to the emergency department physician that he wanted to save the bone and mentioned repeatedly that his finger “was not working” and “I don't need it.” MM consistently denied suicidal ideation in relation to his attempt to self-cannibalize. He was unconcerned and apathetic about his actions and described his behavior with emotional detachment. In the past, he had cut out a tattoo on his hand and ate the tissue; a scar on the dorsal side of his hand between the thumb and first finger was *Department of Psychiatry, University of Colorado School of Medicine, Aurora; and †Denver Health Hospital, Colorado. Send reprint requests to Randi Libbon, MD, Department of Psychiatry, University of Colorado School of Medicine, 13001 East 17th Place, Building 500, Room E2322, Mail stop F546, Aurora, CO 80045. E-mail:
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[email protected]. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0022-3018/15/20302–0152 DOI: 10.1097/NMD.0000000000000252
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noted on examination. He further volunteered that “I wanted to be able to say I ate two body parts.” His additional history of self-harm behavior consisted of stabbing himself in the neck and chest in 2011 and lacerating his wrist in 2013, requiring five sutures in the emergency department. His aunt also reported that he stabbed himself in the groin about 4 years before but did not require hospitalization. He did not comment on his motivations for the noncannibalistic self-harm actions. He explicitly stated that he has no interest in eating the flesh of others. MM reported that he learned about self-cannibalism from a street gang that practiced cannibalism, and he expressed fear of becoming a victim of this gang. He had no direct involvement in this gang and we were unable to find any further information about the gang with the name he provided. He implied that by eating his own tissue, he would appear to be “psychologically superior,” which in turn might deter others from attempting to harm him. He expressed pride in autosarcophagy, described it as his “pursuit,” and felt that selfcannibalism made him unique. MM was raised by his aunt. Interviewed on the telephone during his hospitalization, she independently reported that he sustained a head injury during infancy. He was labeled as being a “slow learner” in school, which she attributed to his head injury. As a child, he had been diagnosed and treated for attention deficit hyperactivity disorder and learning disabilities but was able to graduate high school. Although he initially denied a history of violence, he later reported participating in gang activity, involvement in fights, and legal charges for trespassing and mischief. To our knowledge, MM had no previous psychiatric admissions or trials of psychiatric medications. There were no acute safety concerns related to his behavior during his admission. On admission, MM tested positive for tetrahydrocannabinol but otherwise had a negative blood alcohol level and urine toxicology screen for amphetamines, benzodiazepines, cocaine, methadone, and opiates. He admitted to daily marijuana use and twice weekly consumption of alcohol. He also reported periodic spice (synthetic marijuana) and methamphetamine use several times per year but would not give an approximation of his most recent use, including not reporting whether he had used on the day he attempted to self-cannibalize. MM's affect was flat and blunted throughout hospitalization. Although he denied paranoia, delusions, or hallucinations, his thought processes were illogical and disorganized, he displayed paranoid thinking, and at times, he appeared to be responding to internal stimuli. He expressed paranoid ideas about the treatment team, asking questions and taking notes during interviews. He also reported concern about how the information would be used, and he insisted that notes not be taken. At times, he appeared so overwhelmed or annoyed by our questions that he would abruptly end the interview. Notably, he repetitively touched his nose, an act that he reported was intended to avoid the spread of syphilis (for which he tested negative) and of bed bugs, which he in fact had on admission. The nose touching was thought to be part of a delusion that MM did not further explain. Although initially resistant to our recommendation for starting an antipsychotic medication, he eventually agreed to do so because he felt that accepting medication would expedite his discharge. Olanzapine was initiated and titrated up to 10 mg at bedtime over a period of 6 days, leading to some improvement in his disorganization but not in his
The Journal of Nervous and Mental Disease • Volume 203, Number 2, February 2015 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
The Journal of Nervous and Mental Disease • Volume 203, Number 2, February 2015
paranoid thinking or flat affect. Despite receiving a great deal of psychoeducation about the potential value of medication, he stated on multiple occasions that he would not take medication as an outpatient because he was concerned about potential interactions with marijuana and alcohol.
DISCUSSION This case shares both similarities and differences with previous reports regarding self-cannibalism. Mr MM presented with features of psychosis, a recent history of isolation, history of self-mutilation, paranoid beliefs, and alexithymia, all of which have been noted as risk factors for self-cannibalism (Ahuja and Lloyd, 2007). As previously hypothesized, patients may obtain relief from painful emotions following autosarcophagy (Monastario and Prince, 2011). However, because of alexithymia, as in this case, they may be unable to report any subjective awareness of causal connections. In an event, it is clear that as a psychopathological phenomenon, auto-cannibalism goes considerably beyond typical self-harm. Given MM's history of marijuana, alcohol, spice, and methamphetamine use, substance-induced self-cannibalism was part of the differential diagnosis. Methamphetamine use was an important factor in a previous related case report (de Moore and Clement, 2006), and selfmutilation and self-injurious behavior have been associated with amphetamine psychosis (Kratofil et al., 1996). MM was hospitalized and observed for 15 days, with minimal change in his presentation, which made it less likely that his presentation was substance induced. However, because of his (seemingly intentionally) vague report regarding substance use, it is impossible to know for sure. Of course, persistent psychosis after discontinuation of methamphetamine use is well known (Kratofil et al., 1996; Mikellides, 1950). Unlike other drug-induced cases of self-cannibalism where selfinjurious behavior was linked to expressions of regret (Kratofil et al., 1996), MM did not express regret and was emotionally detached when describing his actions. We postulate that this phenomenon may be related to MM's lack of insight, which is exemplified by his chief complaint at the time of presentation revolving around his desire to apply for Medicaid. His persistent concern wishing to impress the cannibalistic street gang might have also contributed to his ongoing lack of regret regarding self-cannibalism. In their article, Ahuja and Lloyd (2007) raise the interesting point that alterations or reductions in pain perception noted to occur in individuals with schizophrenia might result in decreased pain during selfinjurious behavior. This same phenomenon of pain inhibition has also been associated with methamphetamine intoxication (Yamamotova and Slamberova, 2012). MM's subjective description of not experiencing pain, and not requiring treatment for pain, supports this hypothesis and may render him more vulnerable to future risk of self-harm. Although schizophrenia was included in our differential diagnosis, we diagnosed MM with Other Specified Schizophrenia Spectrum Disorder according to Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, diagnostic criteria, owing to insufficient collateral information regarding his symptoms and timeline of social deterioration. MM's decision to remain homeless, his resistance to medications, and his lack of insight into his illness make future similar
Self-Cannibalism in Psychosis
attempts more likely. One similar case report described a man with methamphetamine use and medication noncompliance who cut off and ate his toes while in a psychotic state but who was able to have periods of functionality during which he was able to work full-time and live independently after receiving treatment with depot antipsychotic medications (de Moore and Clement, 2006). Mandated outpatient medication administration would likely have been useful in further stabilizing MM's psychosis and achieving better functionality. The limitations of the present case study (together with the familiar shortcomings of case reports overall) include our inability to acquire sufficient collateral information, the lack of important information due to the patient's limited self-reflection and unwillingness to share information, and our inability to follow-up and monitor the patient's progress after discharge from the hospital. Although seemingly an obscure topic, self-cannibalism has gained attention beyond the scientific literature; Dr. Mark Griffiths (2012), who writes a blog about extreme behavior, posted an entry on autosarcophagy in 2012 offering examples from literature and film. He indicates there are cases where no associated psychopathology was uncovered. In conclusion, MM's case highlights the importance of investigating underlying causes for acts of self-cannibalism such as substances, psychosis, alternate motivating factors, and relevant cultural or spiritual beliefs, all of which might interact concurrently in a complex fashion. Given how rarely self-cannibalism is reported in the psychiatric literature, further study is essential to help elucidate its true prevalence and the connections between self-cannibalism and psychiatric illness.
DISCLOSURES The authors declare no conflicts of interest.
REFERENCES Ahuja N, Lloyd AJ (2007) Self-cannibalism: An unusual case of self-mutilation. Aus N Z J Psychiatry. 41:294–295. de Moore GM, Clement M (2006) Self-cannibalism: An unusual case of selfmutilation. Aust N Z J Psychiatry. 40:937. Griffiths M (2012) Dinner for one! A beginner's guide to autosarcophagy. Retrieved June 30, 2014, from http://drmarkgriffiths.wordpress.com/2012/05/04/dinner-forone-a-beginners-guide-to-autosarcophagy/. Kratofil PH, Baberg HT, Dimsdale JE (1996) Self-mutilation and severe self-injurious behavior associated with amphetamine psychosis. Gen Hosp Psychiatry. 18:117–120. Mikellides AP (1950) Two cases of self-cannibalism (autosarcophagy). Cyprus Med J. 3:498–500. Monastario E, Prince C (2011) Self-cannibalism in the absence of psychosis and substance use. Australas Psychiatry. 19:170–172. Yamamotova A, Slamberova R (2012) Behavioral and antinociceptive effects of different psychostimulant drugs in prenatally methamphetamine-exposed rats. Physiol Res. 61(Suppl 2):S139–S147.
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