Commentary

In this issue of the Journal of Neurosciences in Rural Practice, a case is presented that is unique in many aspects. Entitled “Self-inflicted penetrating injury to head with complete perseveration of consciousness in a psychotic patient,” the article describes a very unusual psychosis that resulted in a shocking act of self-injury.[1]

Religious delusions have long been a common symptom seen in psychotic individuals, and when psychotic individuals with religious delusions commit acts of self-harm, the most usual body locations targeted are eyes, genitals and hands.[2] Among Christians, this is thought to be due to Biblical New Testament passages, which the delusional mind may take as suggestive of site-specific self-injury. The case reported in this journal issue involves a religious delusion leading to self-inflicted head wound.

There have been previous case reports of non-firearm penetrating head wounds committed by psychotic individuals under the influence of delusions.[6] When the delusions are specifically religious, most self-injuries appear to have a commonality: The patient was punishing himself or herself for a perceived sin.[2] In the new case report, the patient's delusion was that God wanted her to self-injure in order to bring blessings – the motivation thus was self-help, not self-harm. She sought reward rather than punishment.

The case reported in this issue involved an iron rod that the patient “hammered” her head against to cause the injury. There have been several case reports of head wounds with retained intracranial foreign bodies, which reported minimal focal neurological deficits.[3] However, in the reported cases of non-missile penetrating head injuries, the nature of the penetrating agent is usually a nail, knife, screwdriver or needle.[4] Among patients with self-inflicted cranial injuries, the reported methods have been nails, ballpoint pen, power drill, wire and awl.[5] Cranial injuries involving iron rods are rare, and typically accidental – reported cases involving either the patient falling onto the rod[7] or having the rod fall onto the patient,[8] rather than intentional self-injury.

One possible hypothesis for the reported patient's ability to inflict this level of damage upon herself is a high level of pain tolerance. Diminished pain perception (hypoalgesia) has been noted in schizophrenia for many years and its etiology is not well understood.[9] Diminishment or loss of pain sensation may have been present in the new case, as the authors note her lack of a pain report despite penetrating injury to a highly innervated region.

Taken overall, this case allows us to truly marvel at the human brain – from the depths of its dysfunction, as seen in the severely delusional and self-injurious, to its ability to heal from insults, both mental and physical.