Major Self-mutilation in the First Episode of Psychosis
Matthew Large1,2, Nick Babidge3, Doug Andrews4,5,
Philip Storey6, and Olav Nielssen2,7
2Private Practice, Paddington, New South Wales, Australia;
3Sutherland Hospital, Kingsway, Caringbah 2229, New South
Wales, Australia;4Rural Clinical School, Faculty of Medicine
University of New South Wales, Australia;5North Coast Area
Health Service, New South Wales, Australia;6Rotary Ambassa-
dorial Scholar, Evanston, IL;7Clinical Research Unit for Anxiety
Major self-mutilation (MSM) is a rare but catastrophic
MSM have a psychotic disorder, usually a schizophrenia
spectrum psychosis. It is not known when in the course of
wasassessedusing theresultsof a systematic review of pub-
eye or a testicle, severed their penis, or amputated a portion
of alimbandwerediagnosed with aschizophrenia spectrum
in 143 of 189 cases (75.6%) of MSM, of whom 119 of 143
(83.2%) werediagnosed with a schizophrenia spectrum psy-
chosis. The treatment status of a schizophrenia spectrum
psychosis could be ascertained in 101 of the case reports,
similar symptoms to those who inflict MSM later in their
illness. Acute psychosis, in particular first-episode schizo-
phrenia, appears to be the major cause of MSM. Although
MSM is extremely uncommon, earlier treatment of psy-
chotic illness may reduce the incidence of MSM.
Key words: self-mutilation/schizophrenia/first-episode
Self-mutilation has been defined as the direct and delib-
erate self-destruction of a part of a person’s own body
without the intention of suicide.1Minor self-mutilation
is quite common, does not usually cause significant dis-
ability, and may even be part of recognized cultural prac-
tices. In contrast, major self-mutilation (MSM) is rare,
usually only occurs in association with serious mental ill-
ness and often results in permanent loss of an organ or its
function.2The 3 main forms of MSM are ocular, genital,
and limb mutilation. Patients who have removed an eye
or cut off a limb are almost always psychotic, as are three
quarters of patients who severely injure their genitals.3
The published accounts of MSM are almost all either
single-case histories or small case series, from which it is
difficult to make valid causal inferences. Even quite re-
cent publications sometimes explain MSM in terms of
the patients’ reaction to passages in religious texts or un-
conscious sexual conflicts. The few authors who have
reviewed more than a small number of cases have attrib-
uted MSM to the direct effects of psychotic illness.3–7In
a recent review of self-inflicted eye injures, we found that
almost all cases of serious self-inflicted eye injuries result
from schizophrenia spectrum psychosis and half the inju-
ries that caused permanent loss of vision occurred in the
first episode of psychosis (FEP).7
Studies that have examined prior treatment at the time
of another uncommon and catastrophic complication of
psychosis, homicide, generally report that between 30%
and 50% occur during the FEP,8usually in response to
frightening symptoms.9These studies also provide suffi-
cient information to demonstrate that the risk of homi-
cide in FEP may be as much as 20 times the subsequent
annual risk after treatment.10The hypothesis for this
study was that MSM is similar to homicide in psychosis
and may also be more likely to occur during the FEP.
We aimed to use published case histories to estimate
what proportion of the MSM that is associated with
schizophrenia spectrum psychosis occurs in the FEP.
Our hypothesis was that there may be a greater propor-
tion of MSM in the FEP than would be expected by
chance, assuming that the risk of MSM is equal in
FEP and previously treated psychosis (PTP). We in-
cluded case reports of patients who had a diagnosis of
schizophrenia spectrum psychosis and who had com-
pletely removed an eye or a testicle or severed their penis
or alimb. The findingswere used toexaminethe extentto
which psychosis meets epidemiological criteria for causa-
tion of MSM.
1To whom correspondence should be addressed; Private Practice,
Paddington, PO Box 110, Double Bay, NSW 1360, New South
Wales, Australia; e-mail: email@example.com.
Schizophrenia Bulletin vol. 35 no. 5 pp. 1012–1021, 2009
Advance Access publication on May 20, 2008
? The Author 2008. Published by Oxford University Press on behalf of the Maryland Psychiatric Research Center. All rights reserved.
For permissions, please email: firstname.lastname@example.org.
The [Medline], [Embase], and [Psychlit] databases were
chosis OR schizophrenia OR mental disorder AND self
mutilation OR self-enucleation OR enucleation OR self-
inflicted eye injuries OR eye injuries OR oedipism OR
amputation OR penile injury OR amputation OR limb
amputation OR mutilation OR self-mutilation OR delib-
erate self-harm. The references of the located articles
were hand searched for further cases.
Definition of MSM
We included published case histories of patients with
a schizophrenia-related diagnosis in which prior treat-
mentstatus could beascertainedandwhohad completely
removed (1) an eye (2) or a testicle or severed (3) their
penis (proximal to the glans) or (4) a limb (proximal
to the hand or foot). We also collected data on cases
that met our severity criteria for MSM but were not di-
agnosed with a schizophrenia spectrum disorder or did
not provide sufficient information to establish prior
treatment status. The latter 2 groups were excluded
from the main analysis. Cases of patients with mutilation
that did not meet our injury severity criteria or removed
other body parts were not considered. Case histories of
people who required an amputation or enucleation for
medical purposes after self-injury and cases of fatal
self-amputation were also excluded.
A narrow definition of MSM was used to ensure that
all the cases were of similar severity. There was great var-
iation in the severity of other forms of mutilation, and in
some cases, the severity was difficult to assess. Moreover,
many cases of limb, neck, chest, abdomen, and penetrat-
other forms of self-injury inflicted by the patients in-
cluded in this study, in addition to their MSM, were
broadly defined as any self-inflicted physical injury
that did not meet our definition of MSM.
Definitions of Psychosis and Treatment Status
The diagnoses used by the authors of the case histories
were accepted at face value, and no attempt was made
to standardize the diagnostic criteria. Psychosis was de-
fined as any diagnosis characterized by hallucinations,
delusions, or thought disorder and included psychosis
secondary to medical conditions or substance use, affec-
tive psychosis, and schizophrenia spectrum psychosis.
The category of schizophrenia spectrum psychosis
included schizophrenia, delusional disorder, schizoaffec-
tive disorder, schizophreniform disorder, brief psychotic
disorder, or psychosis not otherwise specified (NOS).
Cases diagnosed with affective psychosis or psychosis
secondary to substance abuse were not included in the
sisting hallucinations or delusional beliefs.
We classified a case as FEP if the case history stated
that the patients had never received antipsychotic treat-
ment or if they had only recently commenced treatment
and were still in hospital. Few of the case histories pro-
vided sufficient information to use the preferred defini-
tion of the FEP, which is the period from the onset of
psychotic symptoms until the patient had a remission
after receiving an adequate trial of antipsychotic treat-
ment. Hence, patients were also classified as being in
the FEP if an otherwise comprehensive history did not
report previous treatment or if the case history clearly
stated that the diagnosis of psychosis was not made until
after the injury.
Few case histories documented the dosages and dura-
tion of prior treatment. Patients were classified as having
PTP if the case history reported that the patient had been
treated before, if the diagnosis had been made before the
injury, or if the patient was described in the history as
having chronic schizophrenia. Patients who had received
prior treatment were included in the PTP group even if
they had not been adherent to antipsychotic medication
for many years. Cases in which the treatment status was
not described or could not be determined and borderline
cases of patients who had received 3 or 4 weeks of anti-
psychotic treatment were excluded from the analysis of
We relied on the information provided by the authors
for almost all the data points, including the presence of
particular symptoms. If a paper failed to mention a spe-
cific psychotic symptom, the symptom was rated as not
tion beyond the diagnosis and previous treatment status,
absentdata pointswere leftblank.Some inferencesabout
psychomotor agitation and the patient’s indifference to
the injury were made on the basis of the descriptions
of the patient’s behavior.
The mean and 95% confidence intervals (CIs) for the pro-
portion of case histories documenting each characteristic
were calculated for the whole group. The secondary hy-
pothesis of possible clinical difference between FEP and
PTP groups was examined with a chi-square test for cat-
egorical variables or a Fisher’s exact test if N was less
than 5 in any cell. A 2-tailed Student’s t-test was used
to compare age in FEP and PTP groups.
Female cases were excluded for penis amputation and
castration. A Bonferroni correction was calculated to be
0.0024 for the 21 comparisons that were independent of
chotics were not regarded as independent of treatment
status. SPSS version 15.0 was used for all statistical
Estimation of the Incidence of MSM
An attempt to estimate the incidence of MSM and pro-
portion of cases that were the subject of a published
report was made using acquaintance chains, in a method
that was loosely adapted from that described by Stanley
Milgram.11The authors initially contacted 8 senior clini-
cians in key positions in mental health, forensic psychi-
atry, rehabilitation, and hospital-based ophthalmic
services in New South Wales (NSW), a state of Australia
with a current population of just under 7 million. Each
clinician was asked about their knowledge of patients
with MSM and was also asked to nominate other clini-
cians who may know of cases. The nominated clinicians
were then contacted in a sequence that continued until
no new names were suggested.
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 amputa-
tion. These publications contained a total of 305 case his-
tories 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 psychi-
atric 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 diag-
nosed 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 in-
cluded 25 patients who had amputated one or both tes-
ticles, 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 gen-
psychotic disorders, and there were 9 cases in specialist
surgical journals that only reported the presence of psy-
chiatric 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 sui-
cidal but not necessarily psychotic.12There 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
etrating, 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
Third, 24 case histories of patients with a nonschizo-
phrenia 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
tobe secondarytosubstance use.Exclusion ofthese 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 pro-
vide 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 an-
tipsychotic medication but who remained unwell.
ment status or the presence of a schizophrenia spectrum
psychosis and were excluded from the main analysis.
Reliability of Data Collection
sion orexclusion.There were two disagreementsaboutthe
inclusion of cases, 1 due to accidental double counting by
one author and the second as a result of multiple publica-
tions about the same patient.
M.L. and N.B. also independently collected clinical
data using spreadsheets of data points versus case histo-
ries. 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. Dis-
agreement 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 diagnosedin 143 of180 (79.4%)casesof MSM
in which a specific psychiatric diagnosis was mentioned.
Of these, 119 (83.2%) were diagnosed with a schizophre-
nia spectrum psychosis. Treatment status could be
ascertained in 101 of 119 (84.9%) schizophrenia spectrum
M. Large et al.
psychosis cases, of which 54 were classified as FEP
(53.5%, 95% CI = 43.7%–63.2%).
Table 1 is a summary of the characteristics of the in-
cluded and excluded cases.
The sample has a predominance of younger men, most
of whom were in the FEP. Most of the cases were of gen-
ital amputation or enucleation, with comparatively few
cases of limb amputation. The excluded cases were sim-
ilar 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)
der, 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
ence of a delusional belief. The most common delusions
involved a false belief about the amputated organ includ-
cial, usually threatening supernatural powers such as the
ability to spread evil (28%), or that it needed to be sac-
rificed 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 (Tables
1 and 2). A third of PTP patients were reported to be tak-
ing antipsychotic medication at the time of MSM.
Table 2 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
Table 1. Characteristics of Patients With Psychosis and Self-enucleation, Limb, or Genital Amputation
Schizophrenia Spectrum Psychosis With
Documented Treatment Status
N = 101 95% CI
N = 42
In hospital, jail, or care facility
Cases with more complete data
Delusion about the amputated organ
Reference to a religious text
Command hallucinations to remove an organ
Behavior indicating indifference to injury
Habitual substance abuse
Intoxicated at the time
Previous stimulant or hallucinogen use
Violence toward others
Suicidal thoughts or acts
N = 89
N = 24
a5 cases of psychosis secondary to a medical condition, 12 cases had affective psychosis, 7 cases of psychosis secondary to substance
abuse, and in 18 cases a schizophrenia spectrum psychosis with undocumented treatment status.
bProportion in FEP based on an N of 19 cases only.
criteria are reported elsewhere.7A 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 diag-
nosed with a schizophrenia spectrum psychosis (24
cases), because treatment status was not documented
(18 cases) or for both of these reasons (5 cases). The non-
schizophrenia spectrum psychosis cases included 5 cases
of psychosis secondary to a medical condition (including
systemic lupus erythematosus, hypothyroidism, and epi-
lepsy), 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 am-
putated part of the genitals, were older, with a mean age
of 40 years, and 9 of 12 were considered to have patho-
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 sec-
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 ampu-
tation were not remembered in as much detail as the oc-
ular and limb cases, but there were at least 11 cases, all
but one of which was in association with a psychotic ill-
ness. Of the 13 cases in which treatment status was clearly
remembered, 6 were thought to have occurred in the FEP
pital. The clinicians also described a number of severe
cases that fell short of amputation, including 3 almost
Table 2. Comparison of Previously Treated Psychosis and First-Episode Psychosis Patients
Demographics and circumstances of the injury, n = 101
95% confidence interval
In hospital, jail, or care facility
Psychotic symptoms, substance use, and evidence of dangerousness, n = 89
Delusion about the amputated organ
Referred to religious textd
Command hallucinations to remove an organ
Behavior indicating indifference to injury
Habitual substance abuse
Intoxicated at the time
Previous stimulant or hallucinogen use
Violence toward others
Suicidal thoughts or acts
aUnpaired 2-tailed t-test, t = 2.8.
bFisher’s exact test.
cReduced n in brackets.
dNo patient was reported to have mentioned any religious text other than the gospel of Matthew.
M. Large et al.
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 pene-
trating 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.
Based on reports of 28 cases in NSW between 1990 and
2007, we estimated the incidence of very extreme severe
forms of MSM to be at least 1 case per 4 million of pop-
ulation per year during that period. The true figure may
have been greater because it is likely that we did not have
information about every case, and we did not include
cases of less severe MSM. Only 2 of these cases were
the subject of a published case report.19Hence, despite
its rarity and confronting nature, published case reports
of MSM are only a limited and semirandom sample of
MSM events, and the results of this review of published
cases should be treated with some caution, because biases
and some types of error are possible.
Possible Sources of Error and Bias
The predominance of ocular and genital MSM in pub-
lished cases may be because these injuries are easier to
perform, that the genitals and the eyes have special psy-
chological significance, or because of a publication bias
as these injuries may be seen as being of greater interest.
Some of the cases of penile and limb amputation were
reported because the surgical replantation methods
and some ocular cases concerned ophthalmic complica-
tions. Hence, although we found a similar ratio of injury
types in our informal survey in NSW to the ratio in
the published cases, the ratio of MSM injuries in publi-
cations may not accurately reflect their incidence in the
A more important consideration is whether diagnostic
error, the methods used to define FEP, or publication
bias influenced the proportion of cases that we counted
The number of FEP cases may have been overesti-
mated if the authors of some case histories were unaware
of previous treatment. However, 44 of 54 (81%) of the
first-episode case histories included a psychiatric and
personal history, and the remaining 10 histories clearly
stated that the patient had not been diagnosed or treated
prior to the injury. On the other hand, the proportion of
PTP patients may have been overestimated because
8 cases were classified as PTP on the basis of a diagnosis
of chronic schizophrenia, and 3 further patients were
classified as PTP because of a preexisting diagnosis of
schizophrenia. Previous treatment was assumed but
not documented in these 11 cases.
We may also have underestimated the proportion of
patients in FEP if some cases were wrongly classified
as nonpsychotic. Firstly, there were men who castrated
themselves for religious reasons,91,92a teenage student
who amputated his penis so he could concentrate on
his studies,93a man who castrated himself to treat alope-
cia, although his doctors thought he did not suffer from
this condition,94and a traumatized woman with gusta-
tory hallucinations who amputated her hand because
she believed it had done ‘‘bad things.’’95Second, all
but one of the 7 cases of drug-induced psychosis with
known treatment status was in a FEP and several had
sis was schizophrenia. Third, few of patients who were
treatment but many had bizarre delusions that are more
typical of a schizophrenia spectrum psychosis. If the in-
clusion criteria had included all psychotic illnesses, 71 of
120 (59.2%) cases would have been classified as FEP.
If the 18 case histories of schizophrenia spectrum psy-
chosis that did not document treatment status were
assumed to have received treatment, 54 of 119 (45.4%)
of the cases could have been classified as FEP. However,
some of these cases were almost certainly in the FEP be-
cause 6 patients were in their teens or early 20s and as
a group they had a mean age that was slightly younger
than the mean age of the included cases.
The number of FEP cases did not appear to have been
overestimated by reporting or publication bias. Cases in
published series of 2 or more patients, which it can be
assumed included all the cases known to the author,
had a similar chance of being in the FEP (29 of 56,
52%) than cases reported as a single case history (25 of
Although patients who enucleate both eyes in FEP
cannot do so later in their illness, it is unlikely that the
tion of all cases of schizophrenia. Furthermore, only
a few FEP patients, including those who underwent
limb, penile, or testicular replantation surgery, inflicted
The Relative Risk of MSM in FEP and PTP
spectrum psychosis had never received antipsychotic
treatment and more than half were in the FEP. This is
a notable finding because schizophrenia is a lifelong con-
dition that usually begins in early adult life.
The majority of published studies of the incidence of
schizophrenia report that between 0.01% and 0.03% of
the population will develop schizophrenia in any given
year and about 0.5% have a preexisting schizophrenic ill-
ness.96If one assumes an incidence of 0.02% per annum
and a prevalence of 0.5%, there are 25 times more previ-
ously treated schizophrenia spectrum patients than first-
episode patients in a typical population in any given year.
If the risks of MSM were evenly spread over the course of
the illness, then the ratio of PTP to FEP patients with
MSM would be about 25 to 1. In fact, previously treated
patients and those in FEP were found in about equal in
numbers, indicating that that the risk of MSM in FEP is
as much as 25 times greater than the subsequent annual
risk after initial treatment.
The finding supports the hypothesis that the risk of
MSM is significantly greater in the FEP compared
with subsequent episodes of psychosis, a finding that is
similar to recently published studies of homicide in
Psychosis and Causation of MSM
The authors of some case histories have attributed the
MSM to unconscious sexual conflicts26,32,55or knowl-
edge of the Bible.75More recently, it has been suggested
that limb self-amputation may be the result of a nonpsy-
chotic disorder provisionally named body integrity iden-
tity disorder,97and there is also a recent series of patients
with nonpsychotic self-emasculation.98These 2 series
must be viewed with some caution because they are based
on contact via the Internet and telephone-based assess-
ment rather than personal interview. However, they do
raise the question of how the causation of MSM should
We used the criteria for epidemiological causation as
of whether psychosis can be considered to be a cause of
MSM.99Hill’s criteria (in italics) and our conclusions are
Strength of association: There is a very strong association
between psychosis and MSM because at least 143 of 180
(79.4%) patients (excluding 9 cases with no with no men-
tion of the persons mental state) had a psychotic illness,
despite chronic psychotic illness affecting less than 1% of
the population. Consistency of association: Published
reports of MSM in association with psychosis have
come from all parts of the world with increasing fre-
quency since the first case was reported in the 19th cen-
tury. Specificity of association: MSM is specifically
reported in association with schizophrenia spectrum psy-
chosis. Reports of MSM in association with substance
abuse and affective psychosis are rare, but the character-
istics of these patients are similar to those with a schizo-
phrenia spectrum psychosis. Temporality: We only found
2 cases in which MSM may have preceded over psycho-
sis,28,62although it is also possible that some of the cases
in which psychosis was not diagnosed were in the prodro-
mal phase of psychotic illness. Biological gradient: The
cases examined in this study had severe psychotic illness
with numerous acute symptoms. Many were so ill that
they were indifferent to pain and to the loss of their
organs. Most had religious delusions, which may be
a marker of the severity of psychosis.100Plausibility: A
reaction to a bizarre delusion leading the patient to
remove an organ that they believed was threatening or
an experience of hallucinations directing them to remove
their organsare plausible linksbetweenthe psychosis and
types of psychosis suggests a coherent link between psy-
chosis and MSM. Experiment: The lower risk of MSM in
treated psychosis represents what Hill described as
a ‘‘semiexperiment’’ in which a modification of the cause
reduces the effect. Analogy: The risk in first-episode psy-
chosis, the threatening psychoticsymptoms,101and apre-
dominance of male patients with schizophrenia with an
average age in the early 30s are features that MSM
patients have in common with psychotic patients who
Reasons for the Decline in MSM After Treatment
Although psychosis, particularly first-episode schizo-
phrenia, seems to meet epidemiological criteria for cau-
sation of MSM, the reason for the decline in MSM after
a period of initial treatment is uncertain.
The lower incidence of MSM in PTP patients may be
medication. However, this is unlikely to be the sole expla-
nation because adherence to medication by patients with
the PTP patients in this review were reported to be adher-
ent to treatment.
The most obvious explanation is that once patients
have experienced a remission and have received amedical
explanation of their symptoms, they are less likely to act
in such a drastic way when the symptoms return, regard-
less of the severity of their symptoms or their apparent
loss of insight. Other possible explanations are that bi-
zarre organ-specific delusions are less common in PTP
or that the intensity of delusional beliefs declines later
in the illness. The differences may even be due to changes
in the brain after treatment with antipsychotic medica-
tion. Other factors such as an ongoing relationship
with a treating team or awareness of the patient’s illness
byfamily and friends mayresult in someprotective meas-
ures such as encouraging treatment when the patient
becomes unwell. Although we found no major clinical
differences between those who self-mutilated in FEP
and those who did so in PTP, it would have been of
interest to compare possible protective factors such as
engagement with a treating team and the level of insight
of MSM and non-MSM patients in FEP and PTP.
Risk and Management
Males in a first episode of a schizophrenic illness that is
characterized by delusions associated with a body part or
religious delusions are at the greatest risk for MSM.
M. Large et al.
predicted accurately unless there has been a previous
attempt at self-injury or the patient has spoken about
wanting to remove or injure an organ.
Threatened ocular mutilation deserves special mention
because it may occur in a hospital setting, and the case
histories suggest that one to one nursing is not always
be sufficient to prevent enucleation.7All MSM requires
urgent medical attention because genital and limb MSM
may cause exsanguination, and subarachnoid hemor-
rhage, meningitis, and pituitary failure are potentially
fatal complications of self-enucleation. Replantation of
amputated genitals and limbs can be performed with
some return of function, and testicular replantation
may avoid the requirement for long-term testosterone
therapy. Repeated MSM has been reported but seems
to be uncommon. Hence, emergency limb and genital re-
plantation can be justified in the presence of severe psy-
chosis that renders the patient incapable of informed
consent. Patients with MSM warrant a detailed assess-
ment for the presence of psychosis and even patients
who are not initially forthcoming about the reason for
MSM should be regarded as suffering from a psychosis
until proved otherwise.
are highlighted by this study. Research about MSM
reliance on memory and retrospective ways of case find-
ing, such as we used to make an estimate of the incidence
of MSM, are also unsatisfactory. Ideally, state health au-
thorities should collected data about MSM events. An al-
ternative is for networks of clinicians to gain ethical
this method and a priori hypotheses could be tested.
Future research along these lines could make a more
conclusive estimate of the risk of MSM in FEP. We
have not been able to show that the risk of MSM
increases over time if treatment is delayed. However,
this article provides the basis for a convincing argument
that earlier intervention in psychosis may reduce the
chance of MSM because adequate antipsychotic treat-
ment appears to be protective.
Rotary Foundation, Evanston to P.S.
the Winston Library at the Sydney Eye Hospital for their
assistance locating the publications and the many
clinicians in NSW who shared their knowledge of cases
of MSM. Declaration of interests: None.
1. Favazza A. Bodies Under Siege. Baltimore: John Hopkins
University Press; 1987.
2. Favazza A, Rosenthal R. Diagnostic issues in self-mutila-
tion. Hosp and Community Psychiatry. 1993;44:134–140.
3. Nakaya M. On background factors of male genital self-mu-
tilation. Psychopathology. 1996;29:242–248.
4. Tapper CM, Bland RC, Danyluk L. Self-inflicted eye inju-
ries and self-inflicted blindness. J Nerv Ment Dis. 1979;167:
5. Clark RA. Self-mutilation accompanying religious delu-
sions: a case report and review. J Clin Psychiatry. 1981;42:
6. Sweeny S, Zamecnik K. Predictors of self-mutilation in
patients with schizophrenia. Am J Psychiatry. 1981;138:
7. Large M, Andrews D, Babidge N, Hume F, Nielssen O. Self-
inflicted eye injuries in first-episode and previously treated
psychosis. Aust N Z J Psychiatry. 2008;42:183–191.
8. Large M, Nielssen O. Evidence for a relationship between
the duration of untreated psychosis and the proportion of
psychotic homicides prior to treatment. Soc Psychiatry Psy-
chiatr Epidemiol. 2008;43:37–44.
9. Nielssen OB, Westmore BD, Large MM, Hayes RA. Homi-
cide during psychotic illness in New South Wales between
1993 and 2002. Med J Aust. 2007;186:301–304.
10. Large M, NielssenO. Treating the firstepisode of schizophre-
nia earlier will save lives. Schizophr Res. 2007;92:276–277.
11. Travers J, Milgram S. An experimental study of the small
world problem. Sociometry. 1969;32:425–443.
12. Tharoor H. A case of genital self-mutilation in an elderly
man. Prim Care Companion J Clin Psychiatry. 2007;9:
13. Agoub M, Battas O. Male genital self-mutilation in patients
with schizophrenia. Can J Psychiatry. 2000;45:670.
14. Ananth J, Kaplan HS, Lin KM. Self-inflicted enucleation of
an eye: two case reports. Can J Psychiatry. 1984;29:145–146.
15. Aung T, Yap EY, Fam HB, Law NM. Oedipism. Aust N Z J
16. Becker M, Hofner K, Lassner F, Pallua N, Berger A. Re-
plantation of the complete external genitals. Plast Reconstr
17. Blacker KH, Wong N. Four cases of autocastration. Arch
Gen Psychiatry. 1963;8:169–176.
18. Borenstein A, Yaffe B, Seidman DS, Kaplan HY, Tsur H.
Successful microvascular replantation of an amputated pe-
nis. Isr J Med Sci. 1991;27:395–398.
19. Buhrich N, Hayman J. Self-inflicted enucleation of both
eyes. Aust N Z J Psychiatry. 1994;28:337–341.
20. Brown BZ. Self-inflicted injuries of the eye. Ann Ophthalmol.
21. Brown BZ. Self-inflicted injuries of the eye. Trans Pac Coast
Otoophthalmol Soc Annu Meet. 1970;51:267–276.
22. Brown R, al-Bachari MA, Kambhampati KK. Self-inflicted
eye injuries. Br J Ophthalmol. 1991;75:496–498.
23. Carson DI, Lewis J. Ocular auto-enucleation while under
the influence of drugs: case report. Adolescence. 1971;6:
24. Conacher GN, Westwood GH. Auto-castration in Ontario
federal penitentiary inmates. Br J Psychiatry. 1987;150:
25. Cooper AJ, Swamy GN. The effect of testosterone on psy-
chopathology and sexual function in a paranoid schizo-
phrenic self-castrate. Can J Psychiatry. 1994;39:436–438.
26. Davidson SI. Auto-enucleation of the eye: a study of self
mutilation. Acta Psychother Psychosom. 1962;10:286–300.
27. Dilly JS, Imes RK. Autoenucleation of a blind eye. J Neuro-
28. Duggal HS, Jagadheesan K, Nizamie SH. Acute onset of
schizophrenia following autocastration. Can J Psychiatry.
29. Eisenhauer GL. Self-inflicted ocular removal by two psychi-
atric inpatients. Hosp Community Psychiatry. 1985;36:
30. Erdur B, Turkcuer I, Herken H. An unusual form of self-
mutilation: tongue amputation with local anesthesia. Am
J Emerg Med. 2006;24:625–628.
31. Evins SC, Whittle T, Rous SN. Self-emasculation: review of
the literature, report of a case and outline of the objectives of
management. J Urol. 1977;118:775–776.
32. Feldshuh B, Zasloff M, Frosch WA. ‘‘If thy right eye offend
thee.’’ A case of bilateral self-enucleation. Isr Ann Psychiatr
Relat Discip. 1977;15:145–155.
33. Fisch RZ. Genital self-mutilation in males: psychodynamic
anatomy of a psychosis. Am J Psychother. 1987;41:453–458.
34. Goldstein JL, Gerdis JE, Whitman LJ, Novins DK. A case
of genital self-amputation in which reconstruction was pro-
posed. Gen Hosp Psychiatry. 1990;12:401–402.
35. Goldenberg E, Sata L. Religious delusions and self mutila-
tion. Curr Concepts Psychiatry. 1978;4:2–5.
36. Goldwyn RM, Cahill JL, Grunebaum HU. Self-inflicted in-
jury to the wrist. Plast Reconstr Surg. 1967;39:583–589.
37. Gorin M. Self-inflicted bilateral enucleation. Arch Ophthal-
38. Greilsheimer H, Groves JE. Male genital self-mutilation.
Arch Gen Psychiatry. 1979;36:441–446.
39. Hall DC, Lawson BZ, Wilson LG. Command hallucinations
and self-amputation of the penis and hand during a first psy-
chotic break. J Clin Psychiatry. 1981;42:322–324.
40. Halo HH, Jordan TA, Stewart RM, Apshaga SE. Self-
enucleation: pathology and treatment. R I Med J. 1990;73:
41. Hingorani M, Singh A, Williams H. Oedipism and ocular
self mutilation. Ir J Psychol Med. 1995;12:144–146.
42. Ishida O, Ikuta Y, Shirane T, Nakahara M. Penile replanta-
tion after self-inflicted complete amputation: case report.
J Reconstr Microsurg. 1996;12:23–26.
43. Jimenez-Cruz JF, Garcia-Reboll L, Alonso M, Broseta E,
Sanz S. Microsurgical penis replantation after self-mutila-
tion. Eur Urol. 1995;27:246–248.
44. Jones NP. Self-enucleation and psychosis. Br J Ophthalmol.
45. Kalin NH. Genital and abdominal self-surgery. A case re-
port. JAMA. 1979;241:2188–2189.
46. Kobayashi T, Osawa T, Kato S. Upper-extremity self-
amputation in a case with schizophrenia. Eur Psychiatry.
47. Koh KG, Lyeo BK. Self-enucleation in a young schizo-
phrenic patient-a case report. Singapore Med J. 2002;43:
48. Krauss HR, Yee RD, Foos RY. Autoenucleation. Surv Oph-
49. Kumar AV, Geist CE. A case report of bilateral autoenu-
cleation and its prevention. Orbit. 2007;26:309–313.
50. Kushner AW. Two cases of auto-castration due to religious
delusions. Br J Med Psychol. 1967;40:293–298.
51. Landstrom JT, Schuyler RW, Macris GP. Microsurgical
penile replantation facilitated by postoperative HBO treat-
ment. Microsurgery. 2004;24:49–55.
52. Lazarou EE, Catalano G, Catalano MC, Leon YC, Gorman
JM. The psychological effects of leech therapy after penile
auto-amputation. J Psychiatr Pract. 2006;12:119–123.
53. Leslie J, Taff ML, Patel I, Sternberg A, Fernando MM. Self-
inflicted ocular injuries. A rare form of self-mutilation. Am J
Forensic Med Pathol. 1984;5:83–88.
54. Lidman D, Danielsson P, Abdiu A, Fahraeus B. The func-
tional result two years after a microsurgical penile replanta-
tion. Case report. Scand J Plast Reconstr Surg Hand Surg.
55. MacLean G, Robertson BM. Self-enucleation and psycho-
sis. Report of two cases and discussion. Arch Gen Psychia-
56. Martin T, Gattaz WF. Psychiatric aspects of male genital
self-mutilation. Psychopathology. 1991;24:170–178.
57. Mendez R, Kiely WF, Morrow JW. Self-emasculation.
J Urol. 1972;107:981–985.
58. Money J, De Priest M. Three cases of genital self-surgery
and their relationship to transexualism. J Sex Res.
59. Mora W, Drach GW. Self-emasculation and self-castration:
immediate surgical management and ultimate psychological
adjustment. J Urol. 1980;124:208–209.
60. Moskovitz RA, Byrd T. Rescuing the angel within: PCP-
related self-enucleation. Psychosomatics. 1983;24:402–406.
61. Murphy M, Nathan M, Lee E, Parsons B, Gunasekera L.
Oedipism: auto-enucleation in a schizophrenic patient. Ir
J Psychol Med. 2006;23:159–160.
62. Myers WC, Nguyen M. Autocastration as a presenting
sign of incipient schizophrenia. Psychiatr Serv. 2001;52:
63. Novak-Grubic V, Tavcar R. Autocastration and schizophre-
nia. Psychiatr Serv. 2002;53:485–486.
64. Pantuck AJ, Lobis MR, Ciocca R, Weiss RE. Penile replan-
tationusing the leech
65. Riffle MD. ‘‘Lower extremity’’ amputation: conclusion. Air
Med J. 2007;26:202–204.
66. Riffle MD, Ross DW, Wichman C, MacKinnon M. ‘‘Lower
extremity’’ amputation. Air Med J. 2007;26:164.
67. Rogers T. Self-inflicted eye-injuries. Br J Psychiatry. 1987;
68. Romilly CS, Isaac MT. Male genital self-mutilation. Br
J Hosp Med. 1996;55:427–431.
69. Rosen DH, Hoffman AM. Focal suicide: self-enucleation by
two young psychotic individuals. Am J Psychiatry. 1972;128:
M. Large et al.
70. Schlozman SC. Upper-extremity self-amputation and re- Download full-text
plantation: 2 case reports and a review of the literature.
J Clin Psychiatry. 1998;59:681–686.
71. Schweitzer I. Genital self-amputation and the Klingsor syn-
drome. Aust N Z J Psychiatry. 1990;24:566–569.
72. Schweitzer I, Rosenbaum MB, Sharzer LA, Strauch B. Liai-
son consultation psychiatry with patients who have replan-
tation surgery to the upper limb. Aust N Z J Psychiatry.
73. Sharpe JR, Belsole RJ, Keesal RW, Sadlowski RW, Finney
RP. A preplanned approach to the amputated penis. South
Med J. 1979;72:1634.
74. Shirodkar SS, Hammad FT, Qureshi NA. Male genital self-
amputation in the Middle East. A simple repair by anterior
urethrostomy. Saudi Med J. 2007;28(5):791–793.
75. Shiwach RS. Autoenucleation—a culture-specific phenome-
non: a case series and review. Compr Psychiatry. 1998;39:
76. Shore D, Anderson DJ, Cutler NR. Prediction of self-muti-
lation in hospitalized schizophrenics. Am J Psychiatry. 1978;
77. Stunell H, Power RE, Floyd M Jr, Quinlan DM. Genital
self-mutilation. Int J Urol. 2006;13:1358–1360.
78. Strain JJ, DeMuth GW. Care of the psychotic self-amputee
undergoing replantation. Ann Surg. 1983;197:210–214.
79. Tang WN. The first case of autocastration from east Asia.
Can J Psychiatry. 1996;41:607–608.
80. Tapper CM, Bland RC, Danyluk L. Self-inflicted eye inju-
ries and self-inflicted blindness. J Nerv Ment Dis. 1979;167:
81. Tavcar R, Dernovsek MZ, Zvan V. Self-amputation of left
hand: a case report. J Clin Psychiatry. 1999;60:793–794.
82. Thomas RB, Fuller DH. Self-inflicted ocular injury associ-
ated with drug use. J S C Med Assoc. 1972;68:202–203.
83. Thompson JN, Abraham TK. Male genital self mutilation
after paternal death. Br Med J. 1983;287:727–728.
84. Volkmer BG, Maier S. Successful penile replantation follow-
85. Walter PJ, Krauss DJ, Nsouli IS. Repeat male genital self-
mutilation precipitated by urinary complications of prior re-
pair. J Urol. 1993;149:1551–1552.
86. Waugh AC. Autocastration and biblical delusions in schizo-
phrenia. Br J Psychiatry. 1986;149:656–658.
87. Wei FC, McKee NH, Huerta FJ, Robinette MA. Microsur-
gical replantation of a completely amputated penis. Ann
Plast Surg. 1983;10:317–321.
88. Yang JG, Bullard MJ. Failed suicide or successful male gen-
ital self-amputation? Am J Psychiatry. 1993;150:350–351.
89. Young LD, Feinsilver DL. Male genital self-mutilation com-
90. Yucel B, Ozkan S. A rare case of self-mutilation: self-enucle-
ation of both eyes. Gen Hosp Psychiatry. 1995;17:310–311.
91. Master V, Santucci R. An American hijra: a report of a case
of genital self-mutilation to become India’s ‘‘third sex’’.
92. Bhatia MS, Arora S. Penile self-mutilation. Br J Psychiatry.
93. Shimizu A, Mizuta I. Male genital self-mutilation: a case re-
port. Br J Med Psychol. 1995;68:187–189.
94. Gleeson MJ, Connolly J, Grainger R. Self-castration as
treatment for alopecia. Br J Urol. 1993;71:614–615.
95. Brenner I. Upper-extremity self-amputation in a case of
dissociative identity disorder. J Clin Psychiatry. 1999;60:
96. Saha S, Chant D, McGrath J. Meta-analyses of the incidence
and prevalence of schizophrenia: conceptual and methodolog-
ical issues. Int J Methods Psychiatr Res. 2008;17:55–61.
97. First MB. Desire for amputation of a limb: paraphilia, psy-
chosis, or a new type of identity disorder. Psychol Med.
98. Johnson TW, Brett MA, Roberts LF, Wassersug RJ.
Eunuchs in contemporary society: characterizing men who
are voluntarily castrated (part I). J Sex Med. 2007;(4 Pt 1):
99. Hill AB. The environment and disease: association or causa-
tion? Proc R Soc Med. 1965;58:295–300.
100. Siddle R, Haddock G, Tarrier N, Faragher EB. Religious
delusions in patients admitted to hospital with schizophre-
nia. Soc Psychiatry Psychiatr Epidemiol. 2002;37:130–138.
101. Link BG, Stueve A, Phelan J. Psychotic symptoms and vio-
lent behaviors: probing the components of ‘‘threat/control-
override’’ symptoms. Soc Psychiatry Psychiatr Epidemiol.
102. Ward A, Ishak K, Proskorovsky I, Caro J. Compliance with
refilling prescriptions for atypical antipsychotic agents and
its association with the risks for hospitalization, suicide,
and death in patients with schizophrenia in Quebec and
Saskatchewan: a retrospective database study. Clin Ther.