Nischal Sharma^1*, Tejas Jivan^1*, Andreas Giannakis¹, Abdul Mohit^2#

¹MS4 St.George’s University School of Medcine, Brooklyn, NY, USA

²Medical Director Adult Inpatient Psychiatry Department Kings County Hospital Center, Brooklyn, NY, USA

*Both authors contributed equally"

^#Corresponding Author: Abdul Mohit, Medical Director Adult Inpatient Psychiatry Department Kings County Hospital Center, Brooklyn, NY, USA.

Abstract
This case report describes a rare occurrence of self-mutilation through eye enucleation in a patient with Schizophrenia. A 24-year-old male with a long-term history of Schizophrenia and multiple hospitalizations presented to the emergency department after enucleating his right eye. The patient had been experiencing persecutory delusions and auditory hallucinations, which worsened after non-compliance with antipsychotic medication. The patient exhibited aggressive behavior and attempted self-harm, resulting in severe injuries. Surgical salvage of the enucleated eye was unsuccessful, but the vision was restored in the left eye. Despite various antipsychotic treatments, the patient's symptoms persisted, leading to his transfer to a long-term facility. This case highlights the need for early recognition and management of psychotic symptoms to prevent severe self-harm in patients with Schizophrenia. Constant monitoring, safety measures, strong psychopharmacological management, and collaborative efforts between healthcare professionals and caregivers are crucial for patient well-being and reducing the risk of self-mutilation.

As per Collateral information collected from the patient's mother, the patient had recently been having persecutory delusions with associated auditory hallucinations. These episodes became more frequent and aggressive after the patient became non-compliant with oral Abilify, which had recently been switched from Abilify Maintena. The patient had been previously prescribed Abilify Maintena from a state hospital, where the patient was being seen as an outpatient for a few months. During the initial psychiatric evaluation, the patient stated that the hallucinations provided the experience of being in a movie while chased by monsters behind closed doors in their house. According to the patient's anecdote, he attempted to chase after persecutory voices with a knife when he tried to hit a door, causing severe lacerations on his right hand. At this point, the patient's mother activated EMS. When EMS got to the patient's house, the patient evaded the EMS to run away. While the EMS chased the patient, he enucleated his right eye using his hands. While the patient attempted to do the same for his left eye, he was tased by police officers, which led to his arrest, and later was brought to the emergency department.

Before admission to the psychiatric department, the patient was treated by ophthalmology for surgical salvation of the enucleated eye. Lacerations on the left eye could be repaired, while the right eye could not be salvaged. The patient received inpatient treatment with ophthalmology to restore the vision in his left eye. As per psychiatric management, the patient was restarted on oral abilify in the inpatient psychiatric unit while up-titrating from the minimal effective dose of 5mg. Due to the patient's reluctance to take psychotropic medication, verbal ability could not be optimized. A decision to apply for a medication override was made. After the medication override process, the patient was amenable to using Invega. The patient was trialed with an Invega loading dose (234 mg + 156 mg a week later) followed by a higher-than-normal monthly maintenance dose (234 mg). During individual interviews and group sessions, the patient continued to have persecutory delusions and displayed bizarre behaviors like running head-on into the wall and mindlessly pacing back and forth on the unit. With such limited improvement, a decision was made by the providers to add Haldol PO followed by Haldol decanoate, which was later cross-tapered with Clozaril 12.5 mg PO nightly and slowly titrated to 175 mg. Haldol was then discontinued. Alongside these dual antipsychotics, the patients received Cogentin 1 mg PO twice daily for prophylaxis against extrapyramidal symptoms. The patient continued to receive inpatient treatment in the psychiatric unit and was eventually transferred to a long-term state facility for further treatment.

Discussion
This case report displays a rare self-mutilating behavior through enucleation triggered by an acute psychotic break. Typical symptoms of Schizophrenia include positive features such as paranoia, delusions, hallucinations, and impaired behavior that may put a patient at risk for self-harm to an unknown degree. Additionally, it studies specific paranoid behavior, which, when coupled with a lack of medication adherence, can lead to rapid cognitive decline, ultimately leading to a patient's self-mutilation. Per the patient's report, the behavior was driven by an intense need to control one's paranoia and the utmost need to assert control over auditory hallucinations and persecutory delusions. The report further claims the importance of various healthcare professionals' awareness of the potential for self-harm in someone with Schizophrenia. A low threshold for bizarre behavior should be held by people around patients to reach out for appropriate authority when such behaviors are displayed.

Conclusion
Eye enucleation, although uncommon, has been seen in patients with psychiatric illnesses such as Schizophrenia. [1] Acutely psychotic features such as persecutory delusions, positive symptoms, and auditory hallucinations may warrant extensive clinical workup to determine the risk of self-harm in patients. Physicians and other providers should work interactively with families and caregivers to establish a low threshold for bizarre behavior in patients with established Schizophrenia. Constant monitoring, environmental safety measures like restricting access to weapons, drugs, and other hazards, and the ability to have urgent access to medical and psychiatric care should be prioritized by caregivers at all levels.

References

1. Chechko N, Stormanns E, Podoll K, Stickel S, Neuner I (2020) Self-enucleation of the right eye by a 38-year-old woman diagnosed with schizoaffective disorder: a case report. BMC Psychiatry. 20(1): 563.
2. McCutcheon RA, Keefe RSE, McGuire PK (2023) Cognitive impairment in schizophrenia: aetiology, pathophysiology, and treatment. Mol Psychiatry.