Results of the Searches and Case Selection
One hundred and ninety six publications were examined after the exclusion of case histories describing superficial mutilation, finger amputation, cases of MSM of the tongue, breasts, or nose and 4 histories of fatal amputation. These publications contained a total of 305 case histories of probable MSM, including 189 case histories in which there was complete amputation or removal of an organ. The case histories were then coded according to whether (1) injuries met inclusion criteria, (2) the psychiatric diagnosis, and (3) if there was an adequate account of previous treatment.
First, case reports of patients who had self-inflicted injuries that were not reported in association with a diagnosed psychotic illness were excluded. This included 39 cases of less severe eye or genital injuries and 44 cases of major genital injury. The major genital injury cases included 25 patients who had amputated one or both testicles, 13 patients who had amputated their penis, and 6 cases of complete genital amputation. Seventeen of the 44 genital mutilation cases were reported to have gender identity disorder, 6 alcohol dependence, 12 other nonpsychotic disorders, and there were 9 cases in specialist surgical journals that only reported the presence of psychiatric disorder without providing any further details. There were several cases of men from Asian backgrounds who believed that penile amputation would result in death and who were regarded by the authors to be suicidal but not necessarily psychotic.12
There were 2 cases of upper limb self-amputation in patients who were not diagnosed with a psychotic illness but there were no case histories of nonpsychotic patients who had performed an enucleation or a lower limb amputation. A total of 42 publications were excluded on this basis.
Second, cases of patients with psychosis whose self-inflicted injuries did not meet the inclusion criteria were excluded. These consisted of 53 case histories of penetrating, superficial, and blunt force self-inflicted injury to the eye, 19 reports of genital self-injury that fell short of amputation, 2 reports of genital mutilation by females, and 3 reports of incomplete upper limb amputation by psychotic patients. As a result, a further 38 publications were excluded.
Third, 24 case histories of patients with a nonschizophrenia spectrum psychosis who had inflicted MSM were excluded. These consisted of 5 self-enucleating patients with psychosis that were secondary to various medical conditions, 12 cases in which the diagnosis was affective psychosis, and 7 cases of psychosis reported to be secondary to substance use. Exclusion of these cases resulted in the exclusion of a further 22 publications.
Finally, we excluded case histories of 18 patients with a schizophrenia spectrum psychosis who had amputated or removed an eye, limb, or genital part but did not provide sufficient information to establish if the patient had been previously treated. These comprised 18 cases in 15 publications and included 2 patients who inflicted MSM after several weeks of hospital treatment with antipsychotic medication but who remained unwell.
One hundred and one cases of MSM from 79 publications were included.3,13,90
There were 42 cases that met our criteria for MSM and psychosis but did not document the treatment status or the presence of a schizophrenia spectrum psychosis and were excluded from the main analysis.
Reliability of Data Collection
M.L. and N.B. independently examined the cases for inclusion or exclusion. There were two disagreements about the inclusion of cases, 1 due to accidental double counting by one author and the second as a result of multiple publications about the same patient.
M.L. and N.B. also independently collected clinical data using spreadsheets of data points versus case histories. There were no disagreements about the injuries, the psychiatric diagnosis, demographic details, or the setting of the injury. There was 1 disagreement about the rating of previous treatment in a history that was subsequently excluded because of the uncertainty on this point. Disagreement about 5% of other data points was resolved by a further review of the cases.
Results of Examination of the Cases
We located 189 cases of patients who had removed an eye or testicle or had severed their penis or limb. A psychotic illness was diagnosed in 143 of 180 (79.4%) cases of MSM in which a specific psychiatric diagnosis was mentioned. Of these, 119 (83.2%) were diagnosed with a schizophrenia spectrum psychosis. Treatment status could be ascertained in 101 of 119 (84.9%) schizophrenia spectrum psychosis cases, of which 54 were classified as FEP (53.5%, 95% CI = 43.7%–63.2%).
is a summary of the characteristics of the included and excluded cases.
Characteristics of Patients With Psychosis and Self-enucleation, Limb, or Genital Amputation
The sample has a predominance of younger men, most of whom were in the FEP. Most of the cases were of genital amputation or enucleation, with comparatively few cases of limb amputation. The excluded cases were similar in characteristics to the included cases. However, cases that were excluded on the grounds of diagnosis were significantly more likely to be in FEP (17 of 19 in FEP, chi-square = 8.582, P = 0.003)
Eighty nine of 101 cases were diagnosed with schizophrenia, 4 schizophreniform psychosis, 2 schizoaffective disorder, 2 with a brief psychotic disorder, 1 with delusional disorder, and 3 were considered to have psychosis NOS.
Eighty-seven of 101 histories made a specific mention of at least 1 psychotic symptom and 82 described the presence of a delusional belief. The most common delusions involved a false belief about the amputated organ including that the organ was evil (43%), that the organ had a special, usually threatening supernatural powers such as the ability to spread evil (28%), or that it needed to be sacrificed in order to save the patient or others (20%). The FEP and PTP groups and the sample of excluded patients had high proportion of patients with religious delusions, disorganized thinking, and behavior, and many patients were indifferent to their injuries ( and ). A third of PTP patients were reported to be taking antipsychotic medication at the time of MSM.
Comparison of Previously Treated Psychosis and First-Episode Psychosis Patients
compares those with FEP to those with PTP. Patients in their FEP were, as expected, younger and less likely to be taking antipsychotic medication. Habitual substance use was more common in the FEP group, and more patients in the PTP group reported command hallucinations, but neither finding was significant after a Bonferroni correction. It may be that FEP patients were less able to identify voices as hallucinations.
The psychosis cases that were excluded because their eye injuries were not severe enough to meet our inclusion criteria are reported elsewhere.7
A lower proportion of the patients with schizophrenia spectrum psychosis and less serious genital or limb injuries were thought to be in FEP, but the histories were less detailed than the case histories of more severe MSM.
There were 42 cases that met inclusion criteria for MSM, but were excluded because they were not diagnosed with a schizophrenia spectrum psychosis (24 cases), because treatment status was not documented (18 cases) or for both of these reasons (5 cases). The nonschizophrenia spectrum psychosis cases included 5 cases of psychosis secondary to a medical condition (including systemic lupus erythematosus, hypothyroidism, and epilepsy), 12 cases diagnosed with an affective psychosis, and 7 cases of psychosis secondary to substance abuse. Overall, the excluded patients had symptoms that were similar to the included cases. Patients reported to have affective psychosis were just as likely to have a bizarre organ-specific delusion but were more likely to have amputated part of the genitals, were older, with a mean age of 40 years, and 9 of 12 were considered to have pathological guilt.
Estimate of the Number of Cases of MSM in NSW Between 1990 and 2007
The acquaintance chain method enabled us to locate long-serving clinicians in every mental health service in NSW after only 3 steps, and after 5 steps, no new doctors were suggested. A total of 38 clinicians or administrators were contacted directly by telephone or email. Many of the clinicians we contacted spoke to colleagues before responding, but no new cases were identified from secondary contacts.
We were able to obtain corroborated accounts of 6 enucleations and 3 completed upper limb amputations in NSW between 1990 and 2007. Cases of genital amputation were not remembered in as much detail as the ocular and limb cases, but there were at least 11 cases, all but one of which was in association with a psychotic illness. Of the 13 cases in which treatment status was clearly remembered, 6 were thought to have occurred in the FEP and several occurred soon after the first admission to hospital. The clinicians also described a number of severe cases that fell short of amputation, including 3 almost complete hand amputations, 4 self-inflicted eye injuries that resulted in blindness, and a self-amputation of a breast. A number of less severe genital cases, several failed enucleations, a case of psychotically motivated nonsuicidal self-evisceration, 3 additional cases of penetrating injury to the brain via the orbit or nose, and numerous cases of finger amputation were excluded. In total, we found 28 cases of MSM resulting in significant disability in NSW in the 17 years, including 20 cases that would have met the inclusion criteria for our study.