Cordero R1, Abdul Mohit2 *, Lubin J3, Patel A4, Ganguly A5
1MS4 St. George’s University School of Medicine, New York City, USA.
2Medical Director Adult in Patient Psychiatry Department Kings County Hospital Center, New York City, USA.
3Attending Physician Psychiatrist, Kings County Hospital Center and Associate Residency Program Director SUNY Downstate, NYC, USA.
4PGY-II, Family Medicine, Arrowhead Regional Medical Center, 400 N. Pepper Ave Colton, CA 92324, USA.
5Amvrine Ganguly, 4th Year resident, SUNY Downstate Brooklyn NY, USA.
*Corresponding Author: Abdul Mohit, Medical Director Adult in Patient Psychiatry Department Kings County Hospital Center, NY, USA
Abstract
A 60 y/o male with a past psychiatric history with multiple hospitalizations regarding Schizophrenia associated with Klingsor syndrome, presented to the ED with concern over 5 days prior to the arrival of command auditory hallucinations telling the patient to “cut off his scrotum”. The symptoms started to become so distressing, that the patient reported sleeping less and less over the last 8 days. The patient disclosed a similar history of episodes starting back in 1982 which initially led the patient to be hospitalized after severing his own penis which he almost died from due to blood loss. Pt has had intermittent episodes since, all with the same presentation in the setting of command auditory hallucinations telling the patient specifically to mutilate his genitalia, for which the patient has been treated over the years with various different medication regimens as necessary for breakthrough episodes.
Introduction
This case report serves to illustrate the severity of a rare condition associated with Schizophrenia, Klingsor syndrome, and detail the recurrence of its very specific presentation in a patient over the course of his life and admission in the in-patient psychiatric setting.
Case Presentation
60-year-old African American male with a past psychiatric history with multiple hospitalizations regarding Schizophrenia associated with Klingsor syndrome, presented to the ED with concern over 5 days prior to the arrival of command auditory hallucinations telling the patient to “cut off his scrotum”. The symptoms started to become so distressing, that the patient reported sleeping less and less over the last 8 days. The patient’s insight and cognizance of his condition are very astute, as he knows the voices are not real and is very aware of the danger that they present. Pt detailed his history of illness during the interview, stating that it all began after he dropped out of college in 1982. At that point in time, he was hearing 3 male voices all telling him to mutilate his genitalia specifically. The patient began to drink alcohol daily to suppress the voices which he is currently abstinent from, to suppress the voices which only worked intermittently and was eventually admitted to psychiatric hospitalization to control the hallucinations.
In November of 1985 at the behest of the command auditory hallucinations, the patient severed his own penis, and almost died due to blood loss. The patient was admitted for psychiatric hospitalization at that time, after medical stabilization, and ever since has had additional intermittent breakthrough episodes requiring at times ED visits and or hospitalizations. The patients last episode of auditory hallucinations with the same presentation occurred in 2017-2018 and had been in remission prior to this current episode. During this current episode, the patient is currently hearing 5 male voices despite being compliant on his scheduled medications, Cogentin 1mg PO BID, Risperidone 2mg PO daily and 4mg Nightly, and Haldol Decanoate 200mg IM which he receives monthly. The patient reports additional associated symptoms of depressed mood, anxiety, but denies suicidal ideation, homicidal ideation, visual hallucinations, and exhibits no other forms of delusional or disorganized behavior on examination. The patient disclosed a family history of Schizophrenia in his mother who would also hear voices unrelated to the mutilation of genitalia. The patient’s social history and confirming lab results were negative for any illicit drugs. Over the course of the patient current admission, he initially would consistently hear the voices which repeatedly would command the patient to mutilate his scrotum even with regularly scheduled administration of his medication regimen.
Additional changes were made to his medication regimen at times, such as adding Hydroxyzine 25mg PO BID, decreased Risperidone from 4mg PO nightly to 3mg nightly, and adding Haldol 5mg PO HS and additionally Trazodone 50mg PO HS to assist the patient with sleep which he would still have issues with due to the anxiety and concern surrounding the persistent voices and their commands. This intervention as well didn’t have any effect on the frequency and intensity of the auditory hallucinations, at which point the medication regimen was changed to include Clozaril 25mg PO BID with the discontinuation of Risperidone 3mg PO BID and Trazodone 50mg PO HS. All the appropriate precautions and preliminary lab work were conducted, and risks, benefits, and procedural treatment plans were discussed with the patient to which he agreed.
Even with this change in his medication regimen, the patient continued to hear the same specific auditory hallucinations which led to an episode during which the patient took a strip of cloth from the inner part of his hospital pajamas, and tied it around his scrotum which was only discovered when the patient began to complain of pain in his genital region and when prompted to expose the affected area, revealed the strangulated scrotum at which point the cloth was removed by the nursing staff and patient was placed on one-to-one observation. Clozaril was then increased to 50mg PO BID with the additional discontinuation of Haldol 5mg PO HS. With continued persistence of the command auditory hallucinations, patient Clozaril was eventually increased to 150mg PO BID due to continued persistence of the voices after which the patient gradually began to hear the voices less and less. Ultimately after this adjustment of his medication regimen, the patient stopped hearing the voices, and after an appropriate period, the patient exhibited enough stability and comfort that he could trust himself to be discharged from admission safely.
Discussion
Genital self-mutilation is an act that has been performed by individuals of all races, religions, and cultures, having roots that trace back to Greek and Roman mythology [1,2]. GSM may involve injuring, or even partial or total removal of the external genitalia. Although having been seen throughout history, the practice remains extremely rare. Most episodes of GSM tend to occur in the context of psychosis, whether through command hallucinations, or delusional coercion [3]. When it comes to rates among different genders, females tend to exhibit this behavior with associated personality disorders such as borderline personality disorder. Males on the other hand tend to exhibit this behavior during episodes of psychosis [4]. It is estimated that of the patients recorded to carry out this behavior, 65% had psychotic illnesses and of that population, 31 % of them made repeated attempts [5]. There tend to be three general subtypes of patients to exhibit this behavior: Acutely psychotic individuals, those with significant personality disorders, and individuals influenced by sociocultural factors and religious beliefs [6].
Risk factors for committing GSM include religious delusions, themes of guilt and sexual conflict, a history of depression with past suicide attempts, and having been abused in childhood [2,7]. When this behavior is induced by psychosis, especially in those who were coerced by command hallucinations, it is known as Klingsor Syndrome. The name “Klingsor” was based on a fictitious character in Wagner’s opera “Parsifal” where Klingsor was a magician who castrated himself in an unsuccessful attempt to gain acceptance from the Knights of the Grail. Although this phenomenon is rare, it is a very severe threat to a patient’s life. As in any acutely psychotic patient, or patient with the risk factors mentioned above, a thorough and complete psychiatric evaluation must include a detailed description of what a patient is experiencing or being coerced to do during episodes of stress or acute psychosis. It is often hard to predict or illicit from a psychotic patient what they could be coerced to do in the future at any given time. Information of past behavior, and aggressive initial psychiatric treatment is of the utmost importance. These factors can give patients the insight into their condition that they need to understand when to seek help when breakthrough psychosis occurs, as well as the importance of medication adherence such as seen in this case.
Conclusion
Schizophrenia associated with Klingsor syndrome is a very rare and as illustrated in this case report, very debilitating condition. Its recurrence and specificity make it unique but also life-threatening. It is very important to understand the specificity surrounding the hallucinations patients with Schizophrenia, or any other psychiatric disorder may experience to tailor treatment appropriately as well as identify and prevent patients from harming themselves in the most severe and in this case bizarre of manners.
References
- Alao AO, Yolles JC, Huslander W (1999) Female genital self- mutilation. Psychiatric Services (Washington DC.). 50(7): 971.
- Schweitzer I (1990) Genital self-amputation and the Klingsor syndrome. AustNZ J Psychiatry. 24(4): 566-569.
- Stunnel H, Power RE, Floyd JNR M, Quinlan DM (2006) Genital Self-Mutilation. International Journal of Urology, 13(10): 1358- 1360.
- Eke N (2000) Genital self-mutilation: there is no method in this madness. BJU Int. 85(3): 295-298.
- Aboseif S, Gomez R, McAninch JW (1993) Genital self- mutilation. J Urol. 150(4): 1143-1146.
- Greilsheimer H, Groves JE (1979) Male Genital Self-mutilation. Arch Gen Psychiatry. 36(4): 441–446.
- Nerli RB, Ravish IR, Amarkhed SS, Manoranjan UD, Prabha V, et al. (2008) Genital self-mutilation in nonpsychotic heterosexual males: Case report of two cases. Indian Journal of Psychiatry.