schizophrenia case study

Module 11: Schizophrenia Spectrum and Other Psychotic Disorders

Case studies: schizophrenia spectrum disorders, learning objectives.

• Identify schizophrenia and psychotic disorders in case studies

Case Study: Bryant

Thirty-five-year-old Bryant was admitted to the hospital because of ritualistic behaviors, depression, and distrust. At the time of admission, prominent ritualistic behaviors and depression misled clinicians to diagnose Bryant with obsessive-compulsive disorder (OCD). Shortly after, psychotic symptoms such as disorganized thoughts and delusion of control were noticeable. He told the doctors he has not been receiving any treatment, was not on any substance or medication, and has been experiencing these symptoms for about two weeks. Throughout the course of his treatment, the doctors noticed that he developed a catatonic stupor and a respiratory infection, which was identified by respiratory symptoms, blood tests, and a chest X-ray. To treat the psychotic symptoms, catatonic stupor, and respiratory infection, risperidone, MECT, and ceftriaxone (antibiotic) were administered, and these therapies proved to be dramatically effective. [1]

Case Study: Shanta

Shanta, a 28-year-old female with no prior psychiatric hospitalizations, was sent to the local emergency room after her parents called 911; they were concerned that their daughter had become uncharacteristically irritable and paranoid. The family observed that she had stopped interacting with them and had been spending long periods of time alone in her bedroom. For over a month, she had not attended school at the local community college. Her parents finally made the decision to call the police when she started to threaten them with a knife, and the police took her to the local emergency room for a crisis evaluation.

Following the administration of the medication, she tried to escape from the emergency room, contending that the hospital staff was planning to kill her. She eventually slept and when she awoke, she told the crisis worker that she had been diagnosed with attention-deficit/hyperactive disorder (ADHD) a month ago. At the time of this ADHD diagnosis, she was started on 30 mg of a stimulant to be taken every morning in order to help her focus and become less stressed over the possibility of poor school performance.

After two weeks, the provider increased her dosage to 60 mg every morning and also started her on dextroamphetamine sulfate tablets (10 mg) that she took daily in the afternoon in order to improve her concentration and ability to study. Shanta claimed that she might have taken up to three dextroamphetamine sulfate tablets over the past three days because she was worried about falling asleep and being unable to adequately prepare for an examination.

Prior to the ADHD diagnosis, the patient had no known psychiatric or substance abuse history. The urine toxicology screen taken upon admission to the emergency department was positive only for amphetamines. There was no family history of psychotic or mood disorders, and she didn’t exhibit any depressive, manic, or hypomanic symptoms.

The stimulant medications were discontinued by the hospital upon admission to the emergency department and the patient was treated with an atypical antipsychotic. She tolerated the medications well, started psychotherapy sessions, and was released five days later. On the day of discharge, there were no delusions or hallucinations reported. She was referred to the local mental health center for aftercare follow-up with a psychiatrist. [2]

Another powerful case study example is that of Elyn R. Saks, the associate dean and Orrin B. Evans professor of law, psychology, and psychiatry and the behavioral sciences at the University of Southern California Gould Law School.

Saks began experiencing symptoms of mental illness at eight years old, but she had her first full-blown episode when studying as a Marshall scholar at Oxford University. Another breakdown happened while Saks was a student at Yale Law School, after which she “ended up forcibly restrained and forced to take anti-psychotic medication.” Her scholarly efforts thus include taking a careful look at the destructive impact force and coercion can have on the lives of people with psychiatric illnesses, whether during treatment or perhaps in interactions with police; the Saks Institute, for example, co-hosted a conference examining the urgent problem of how to address excessive use of force in encounters between law enforcement and individuals with mental health challenges.

Saks lives with schizophrenia and has written and spoken about her experiences. She says, “There’s a tremendous need to implode the myths of mental illness, to put a face on it, to show people that a diagnosis does not have to lead to a painful and oblique life.”

In recent years, researchers have begun talking about mental health care in the same way addiction specialists speak of recovery—the lifelong journey of self-treatment and discipline that guides substance abuse programs. The idea remains controversial: managing a severe mental illness is more complicated than simply avoiding certain behaviors. Approaches include “medication (usually), therapy (often), a measure of good luck (always)—and, most of all, the inner strength to manage one’s demons, if not banish them. That strength can come from any number of places…love, forgiveness, faith in God, a lifelong friendship.” Saks says, “We who struggle with these disorders can lead full, happy, productive lives, if we have the right resources.”

You can view the transcript for “A tale of mental illness | Elyn Saks” here (opens in new window) .

• Bai, Y., Yang, X., Zeng, Z., & Yang, H. (2018). A case report of schizoaffective disorder with ritualistic behaviors and catatonic stupor: successful treatment by risperidone and modified electroconvulsive therapy. BMC psychiatry , 18(1), 67. https://doi.org/10.1186/s12888-018-1655-5 ↵
• Henning A, Kurtom M, Espiridion E D (February 23, 2019) A Case Study of Acute Stimulant-induced Psychosis. Cureus 11(2): e4126. doi:10.7759/cureus.4126 ↵
• Modification, adaptation, and original content. Authored by : Wallis Back for Lumen Learning. Provided by : Lumen Learning. License : CC BY: Attribution
• A tale of mental illness . Authored by : Elyn Saks. Provided by : TED. Located at : https://www.youtube.com/watch?v=f6CILJA110Y . License : Other . License Terms : Standard YouTube License
• A Case Study of Acute Stimulant-induced Psychosis. Authored by : Ashley Henning, Muhannad Kurtom, Eduardo D. Espiridion. Provided by : Cureus. Located at : https://www.cureus.com/articles/17024-a-case-study-of-acute-stimulant-induced-psychosis#article-disclosures-acknowledgements . License : CC BY: Attribution
• Elyn Saks. Provided by : Wikipedia. Located at : https://en.wikipedia.org/wiki/Elyn_Saks . License : CC BY-SA: Attribution-ShareAlike
• A case report of schizoaffective disorder with ritualistic behaviors and catatonic stupor: successful treatment by risperidone and modified electroconvulsive therapy. Authored by : Yuanhan Bai, Xi Yang, Zhiqiang Zeng, and Haichen Yangcorresponding. Located at : https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5851085/ . License : CC BY: Attribution

This site is intended for healthcare professionals

Schizophrenia case studies: putting theory into practice

This article considers how patients with schizophrenia should be managed when their condition or treatment changes.

DR P. MARAZZI/SCIENCE PHOTO LIBRARY

Treatments for schizophrenia are typically recommended by a mental health specialist; however, it is important that pharmacists recognise their role in the management and monitoring of this condition. In ‘ Schizophrenia: recognition and management ’, advice was provided that would help with identifying symptoms of the condition, and determining and monitoring treatment. In this article, hospital and community pharmacy-based case studies provide further context for the management of patients with schizophrenia who have concurrent conditions or factors that could impact their treatment.

Case study 1: A man who suddenly stops smoking

A man aged 35 years* has been admitted to a ward following a serious injury. He has been taking olanzapine 20mg at night for the past three years to treat his schizophrenia, without any problems, and does not take any other medicines. He smokes 25–30 cigarettes per day, but, because of his injury, he is unable to go outside and has opted to be started on nicotine replacement therapy (NRT) in the form of a patch.

When speaking to him about his medicines, he appears very drowsy and is barely able to speak. After checking his notes, it is found that the nurses are withholding his morphine because he appears over-sedated. The doctor asks the pharmacist if any of the patient’s prescribed therapies could be causing these symptoms.

What could be the cause?

Smoking is known to increase the metabolism of several antipsychotics, including olanzapine, haloperidol and clozapine. This increase is linked to a chemical found in cigarettes, but not nicotine itself. Tobacco smoke contains aromatic hydrocarbons that are inducers of CYP1A2, which are involved in the metabolism of several medicines [1] , [2] , [3] . Therefore, smoking cessation and starting NRT leads to a reduction in clearance of the patient’s olanzapine, leading to increased plasma levels of the antipsychotic olanzapine and potentially more adverse effects — sedation in this case.

Patients who want to stop, or who inadvertently stop, smoking while taking antipsychotics should be monitored for signs of increased adverse effects (e.g. extrapyramidal side effects, weight gain or confusion). Patients who take clozapine and who wish to stop smoking should be referred to their mental health team for review as clozapine levels can increase significantly when smoking is stopped [3] , [4] .

For this patient, olanzapine is reduced to 15mg at night; consequently, he seems much brighter and more responsive. After a period on the ward, he has successfully been treated for his injury and is ready to go home. The doctor has asked for him to be supplied with olanzapine 15mg for discharge along with his NRT.

What should be considered prior to discharge?

It is important to discuss with the patient why his dose was changed during his stay in hospital and to ask whether he intends to start smoking again or to continue with his NRT. Explain to him that if he wants to begin, or is at risk of, smoking again, his olanzapine levels may be impacted and he may be at risk of becoming unwell. It is necessary to warn him of the risk to his current therapy and to speak to his pharmacist or mental health team if he does decide to start smoking again. In addition, this should be used as an opportunity to reinforce the general risks of smoking to the patient and to encourage him to remain smoke-free.

It is also important to speak to the patient’s community team (e.g. doctors, nurses), who specialise in caring for patients with mental health disorders, about why the olanzapine dose was reduced during his stay, so that they can then monitor him in case he does begin smoking again.

Case 2: A woman with constipation

A woman aged 40 years* presents at the pharmacy. The pharmacist recognises her as she often comes in to collect medicine for her family. They are aware that she has a history of schizophrenia and that she was started on clozapine three months ago. She receives this from her mental health team on a weekly basis.

She has visited the pharmacy to discuss constipation that she is experiencing. She has noticed that since she was started on clozapine, her bowel movements have become less frequent. She is concerned as she is currently only able to go to the toilet about once per week. She explains that she feels uncomfortable and sick, and although she has been trying to change her diet to include more fibre, it does not seem to be helping. The patient asks for advice on a suitable laxative.

What needs to be considered?

Constipation is a very common side effect of clozapine . However, it has the potential to become serious and, in rare cases, even fatal [5] , [6] , [7] , [8] . While minor constipation can be managed using over-the-counter medicines (e.g. stimulant laxatives, such as senna, are normally recommended first-line with stool softeners, such as docusate, or osmotic laxatives, such as lactulose, as an alternative choice), severe constipation should be checked by a doctor to ensure there is no serious bowel obstruction as this can lead to paralytic ileus, which can be fatal [9] . Symptoms indicative of severe constipation include: no improvement or bowel movement following laxative use, fever, stomach pain, vomiting, loss of appetite and/or diarrhoea, which can be a sign of faecal impaction overflow.

As the patient has been experiencing this for some time and is only opening her bowels once per week, as well as having other symptoms (i.e. feeling uncomfortable and sick), she should be advised to see her GP as soon as possible.

The patient returns to the pharmacy again a few weeks later to collect a prescription for a member of their family and thanks the pharmacist for their advice. The patient was prescribed a laxative that has led to resolution of symptoms and she explains that she is feeling much better. Although she has a repeat prescription for lactulose 15ml twice per day, she says she is not sure whether she needs to continue to take it as she feels better.

What advice should be provided?

As she has already had an episode of constipation, despite dietary changes, it would be best for the patient to continue with the lactulose at the same dose (i.e. 15ml twice daily), to prevent the problem occurring again. Explain to the patient that as constipation is a common side effect of clozapine, it is reasonable for her to take laxatives before she gets constipation to prevent complications.

Pharmacists should encourage any patient who has previously had constipation to continue taking prescribed laxatives and explain why this is important. Pharmacists should also continue to ask patients about their bowel habits to help pick up any constipation that may be returning. Where pharmacists identify patients who have had problems with constipation prior to starting clozapine, they can recommend the use of a prophylactic laxative such as lactulose.

Case 3: A mother is concerned for her son who is talking to someone who is not there

A woman has been visiting the pharmacy for the past 3 months to collect a prescription for her son, aged 17 years*. In the past, the patient has collected his own medicine. Today the patient has presented with his mother; he looks dishevelled, preoccupied and does not speak to anyone in the pharmacy.

His mother beckons you to the side and expresses her concern for her son, explaining that she often hears him talking to someone who is not there. She adds that he is spending a lot of time in his room by himself and has accused her of tampering with his things. She is not sure what she should do and asks for advice.

What action can the pharmacist take?

It is important to reassure the mother that there is help available to review her son and identify if there are any problems that he is experiencing, but explain it is difficult to say at this point what he may be experiencing. Schizophrenia is a psychotic illness which has several symptoms that are classified as positive (e.g. hallucinations and delusions), negative (e.g. social withdrawal, self-neglect) and cognitive (e.g. poor memory and attention).

Many patients who go on to be diagnosed with schizophrenia will experience a prodromal period before schizophrenia is diagnosed. This may be a period where negative symptoms dominate and patients may become isolated and withdrawn. These symptoms can be confused with depression, particularly in younger people, though depression and anxiety disorders themselves may be prominent and treatment for these may also be needed. In this case, the patient’s mother is describing potential psychotic symptoms and it would be best for her son to be assessed. She should be encouraged to take her son to the GP for an assessment; however, if she is unable to do so, she can talk to the GP herself. It is usually the role of the doctor to refer patients for an assessment and to ensure that any other medical problems are assessed. 

Three months later, the patient comes into the pharmacy and seems to be much more like his usual self, having been started on an antipsychotic. He collects his prescription for risperidone and mentions that he is very worried about his weight, which has increased since he started taking the newly prescribed tablets. Although he does not keep track of his weight, he has noticed a physical change and that some of his clothes no longer fit him.

What advice can the pharmacist provide?

Weight gain is common with many antipsychotics [10] . Risperidone is usually associated with a moderate chance of weight gain, which can occur early on in treatment [6] , [11] , [12] . As such, the National Institute for Health and Care Excellence recommends weekly monitoring of weight initially [13] . As well as weight gain, risperidone can be associated with an increased risk of diabetes and dyslipidaemia, which must also be monitored [6] , [11] , [12] . For example, the lipid profile and glucose should be assessed at 12 weeks, 6 months and then annually [12] .

The pharmacist should encourage the patient to attend any appointments for monitoring, which may be provided by his GP or mental health team, and to speak to his mental health team about his weight gain. If he agrees, the pharmacist could inform the patient’s mental health team of his weight gain and concerns on his behalf. It is important to tackle weight gain early on in treatment, as weight loss can be difficult to achieve, even if the medicine is changed.

The pharmacist should provide the patient with advice on healthy eating (e.g. eating a balanced diet with at least five fruit and vegetables per day) and exercising regularly (e.g. doing at least 150 minutes of moderate-intensity activity or 75 minutes of vigorous-intensity activity per week), and direct him to locally available services. The pharmacist can record the adverse effect on the patient’s medical record, which will help flag this in the future and thus help other pharmacists to intervene should he be prescribed risperidone again.

*All case studies are fictional.

Useful resources

• Mind — Schizophrenia
• Rethink Mental Illness — Schizophrenia
• Mental Health Foundation — Schizophrenia
• Royal College of Psychiatrists — Schizophrenia
• NICE guidance [CG178] — Psychosis and schizophrenia in adults: prevention and management
• NICE guidance [CG155] — Psychosis and schizophrenia in children and young people: recognition and management
• British Association for Psychopharmacology — Evidence-based guidelines for the pharmacological treatment of schizophrenia: updated recommendations from the British Association for Psychopharmacology

About the author

Nicola Greenhalgh is lead pharmacist, Mental Health Services, North East London NHS Foundation Trust

[1] Chiu CC, Lu ML, Huang MC & Chen KP. Heavy smoking, reduced olanzapine levels, and treatment effects: a case report. Ther Drug Monit 2004;26(5):579–581. doi: 10.1097/00007691-200410000-00018

[2] de Leon J. Psychopharmacology: atypical antipsychotic dosing: the effect of smoking and caffeine. Psychiatr Serv 2004;55(5):491–493. doi: 10.1176/appi.ps.55.5.491

[3] Mayerova M, Ustohal L, Jarkovsky J et al . Influence of dose, gender, and cigarette smoking on clozapine plasma concentrations. Neuropsychiatr Dis Treat 2018;14:1535–1543. doi: 10.2147/NDT.S163839

[4] Ashir M & Petterson L. Smoking bans and clozapine levels. Adv Psychiatr Treat 2008;14(5):398–399. doi: 10.1192/apt.14.5.398b

[5] Young CR, Bowers MB & Mazure CM. Management of the adverse effects of clozapine. Schizophr Bull 1998;24(3):381–390. doi: 10.1093/oxfordjournals.schbul.a033333

[6] Taylor D, Barnes TRE & Young AH. The Maudsley Prescribing Guidelines in Psychiatry . 13th edn. London: Wiley Blackwell; 2018

[7] Oke V, Schmidt F, Bhattarai B et al . Unrecognized clozapine-related constipation leading to fatal intra-abdominal sepsis — a case report. Int Med Case Rep J 2015;8:189–192. doi: 10.2147/IMCRJ.S86716

[8] Hibbard KR, Propst A, Frank DE & Wyse J. Fatalities associated with clozapine-related constipation and bowel obstruction: a literature review and two case reports. Psychosomatics 2009;50(4):416–419. doi: 10.1176/appi.psy.50.4.416

[9] Medicines and Healthcare products Regulatory Agency. Clozapine: reminder of potentially fatal risk of intestinal obstruction, faecal impaction, and paralytic ileus. 2020. Available from: https://www.gov.uk/drug-safety-update/clozapine-reminder-of-potentially-fatal-risk-of-intestinal-obstruction-faecal-impaction-and-paralytic-ileus (accessed April 2020)

[10] Leucht S, Cipriani A, Spineli L et al. Comparative efficacy and tolerability of 15 antipsychotic drugs in schizophrenia: a multiple-treatments meta-analysis. Lancet 2013;382(9896):951–962. doi: 10.1016/S0140-6736(13)60733-3

[11] Bazire S. Psychotropic Drug Directory . Norwich: Lloyd-Reinhold Communications LLP; 2018

[12] Cooper SJ & Reynolds GP. BAP guidelines on the management of weight gain, metabolic disturbances and cardiovascular risk associated with psychosis and antipsychotic drug treatment. J Psychopharmacol 2016;30(8):717–748. doi: 10.1177/0269881116645254

[13] National Institute for Health and Care Excellence. Psychosis and schizophrenia in adults: prevention and management. Clinical guideline [CG178]. 2014. Available from: https://www.nice.org.uk/guidance/cg178 (accessed April 2020)

You might also be interested in…

Schizophrenia: symptoms, diagnosis and treatment

Nearly half of long-term antidepressant users could safely taper off medication using helpline

Boots UK shuts online mental health service to new patients

An official website of the United States government

Official websites use .gov A .gov website belongs to an official government organization in the United States.

Secure .gov websites use HTTPS A lock ( Lock Locked padlock icon ) or https:// means you've safely connected to the .gov website. Share sensitive information only on official, secure websites.

• Publications
• Account settings
• Advanced Search
• Journal List

Case study: A patient with severe delusions who self-mutilates

Lesiba t lebelo, gerhard p grobler.

• Author information
• Article notes
• Copyright and License information

Corresponding author: Gerhard Grobler, [email protected]

Corresponding author.

Received 2019 Apr 17; Accepted 2020 Mar 5; Collection date 2020.

Licensee: AOSIS. This work is licensed under the Creative Commons Attribution License.

Background and introduction

Although some overlapping features exist between self-injury and intention to die, there is growing recognition that non-suicidal self-injury (NSSI), including major self-mutilation (MSM), and suicidal behaviour are distinct entities as evidenced by their significance in terms of aetiology, psychiatric impairment, psychological function, method of self-harm and course or outcome between the two phenomena. 1

We present a case of self-harm in a mental healthcare user diagnosed with schizophrenia to highlight the distinction made above.

Case presentation

Mr X is a 38-year-old, unemployed, single male with no children and with an elementary level of education. This was his index presentation with a 4-year history characterised by ongoing persecutory delusions, as well as auditory hallucinations. He was brought to the Emergency Department by ambulance because he was found to be bleeding profusely from his scrotum in the toilet of a petrol filling station. He alleged that he had cut open his scrotum to remove his testicles before his ‘tormentors’ could do so. He stated clearly that he did not want to die because he valued his life. This was therefore not an attempt at suicide.

He was initially admitted to the urology ward and then referred to psychiatry. The multi-disciplinary team diagnosed him with and treated him for schizophrenia. He responded well to haloperidol 2.5 mg orally in the morning and 5 mg orally at night. A long-acting injectable antipsychotic, flupenthixol decanoate 20 mg intramuscular was also prescribed. No adverse effects were reported. Lorazepam was titrated downwards from 1 mg orally twice daily to 1 mg orally at night, and then stopped before he was discharged. Lansoprazole 30 mg daily orally, tramadol 50 mg three times daily orally and paracetamol 1 g orally were also prescribed as needed.

Upon discharge, on day 44 of the admission, the patient was symptom free with no psychotic or anxiety features.

The patient did not manifest any depressive symptoms throughout his hospitalisation, nor on his 4-week follow-up visit subsequent to discharge. He also demonstrated full and complete understanding that the voices, the self-conviction and his belief that people were coming to harm him were all part of his illness called schizophrenia. He also demonstrated full understanding that the belief of being harmed and people conspiring against him were also part of his schizophrenic illness that had been untreated for at least the past 4 years. With no negative emotion, he demonstrated intellectual understanding with unconditional acceptance of his illness. We emphasised to him that he must be consistent with medical check-ups at his local clinic as some other medical conditions can cause his illness to resurface. It was further emphasised to him that for as long as he took his treatment regularly and as prescribed the schizophrenia would be managed and controlled well. He agreed to stay away from all psychoactive substances. This user was amenable to following up with a clinical psychologist, an occupational therapist and a social worker.

He was followed up 1 month later and then referred to his local clinic for continuation of the prescribed treatment, appointments for continuation of psycho-education, counselling and relevant psycho-therapies. This patient responded well and remitted only on antipsychotic agents.

Literature review and discussion

In a study of measurable variables, paranoia and auditory hallucinations, psychotic-like experience (PLE) and stressful life events all contributed to the patient causing self-harm. Compared to those without PLEs, the prevalence of NSSI was higher than those with PLEs. 1

Psychotic-like experiences are highly prevalent in the general population, with figures of 20% or above being reported in some studies. 1 Major self-mutilation (or NSSI) is a rare but potentially catastrophic complication of severe mental illness. Most people who inflict NSSI have a psychotic disorder, usually a schizophrenia spectrum psychosis. It is not known when in the course of psychotic illness, NSSI is most likely to occur. 2 In general, schizophrenia is associated with worse social functional outcomes compared with other psychotic disorders, but the few studies that directly tested this assumption by comparing the longitudinal courses of social functioning in affective and non-affective psychoses have yielded conflicting findings. 3

Cases of genital self-mutilation reported in the literature have been in patients with psychosis, including schizophrenia. 4 Our own literature review found only a few case reports, published in 1974 (a female patient with schizophrenia and erotomania), 1986 (autocastration with biblical delusions) and in 1995. Greilsheimer writes that: ‘Men who intentionally mutilate or remove their own genitals are likely to be psychotic…’. 5

The reason for presenting the case is that there was no similar case recorded in our country, using Google Scholar search engine database of at least the past 5 years, nor elsewhere when we searched using the following keywords: ‘Self-castration, non-suicidal self-injury and psychosis, self-castration due to psychosis’.

In the South African context, the promulgation of the Traditional Health Practitioners Act no. 35 of 2004 has become an important precipitant for the local review of the place of culture and religion/spirituality in secular areas such as health, mental health and spirituality. 6 Our patient did not display delusions with religious or spiritual content. This particular patient was not practising any religion although he claims to believe in God. He emphasised that he was convinced by his delusions and hallucinations that some people known to him were conspiring to cut his scrotum and extract his testicles for some ritualistic practices. Their psychosis can eventually weaken their faith as they may think that they have been successfully bewitched and cursed even if they have been mentally stabilised.

Patients living with schizophrenia and who suffer persistently high levels of psychotic symptoms as well as poorer (psychosocial) functioning and lower self-esteem have higher severity of suicide behaviour. 7 Even in first episode psychosis, one in 10 people engages in self-harm. 8

It is important to take note of this case as it is the first of its kind and adds to existing knowledge in mental health that untreated and long-standing psychosis can result in the patient harming himself irreversibly such that they lose the capacity to reproduce.

Despite the vulnerable position of the testicles, testicular trauma is relatively uncommon. The mobility of the scrotum may be one reason, severe injury is rare. Given the importance of preserving fertility, traumatic injuries of the testicles deserve careful attention. Testicular injuries can be divided into three broad categories based on the mechanism of injury: (1) blunt trauma, (2) penetrating trauma and (3) degloving trauma. Such injuries are typically seen in males aged 15–40 years.

Our patient was psychotic with auditory hallucinations, persecutory delusions and bizarre delusions which did not include religious delusions when he harmed himself. He was convinced that his ‘tormentors’ were listening to his thoughts and he consequently planned to cut open his scrotum to remove his testicles before they could do that to him. The main reason our patient injured himself was not to die but to relieve himself of the constant and increasing threats of being robbed of his testicles. It is important in the South African context to treat a psychiatric patient by using the multi-disciplinary team approach which is also holistic in nature and covers all aspects of mental healthcare service provision, including spirituality, as most citizens (92%) of South Africa expressed religious affiliation. 9

Not all patients who harm themselves, even severely, are suicidal. Some just want to rid themselves of tormenting psychosis as in this case.

Acknowledgements

The authors wishes to acknowledge their colleagues who supported this project and their patients from whom they learnt much.

Competing interests

The authors have declared that no competing interest exists.

Authors’ contributions

Both authors contributed equally to this work.

Ethical consideration

This article followed all ethical standards for research without direct contact with human or animal subjects.

Funding information

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Data availability statement

Data sharing is not applicable to this article as no new data were created or analysed in this study.this study.

The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors.

How to cite this article: Lebelo LT, Grobler GP. Case study: A patient with severe delusions who self-mutilates. S Afr J Psychiat. 2020;26(0), a1403. https://doi.org/10.4102/sajpsychiatry.v26i0.1403

• 1. Koyanagi A, Stickley A, Haro JM. Psychotic-like experiences and nonsuidical self-injury in England: Results from a National Survey. PLoS One. 2015;10(12):e0145533 10.1371/journal.pone.0145533 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ]
• 2. Large M, Babidge N, Andrews D, Storey P, Nielssen O. Major self-mutilation in the first episode of psychosis. Schizophr Bull. 2009;35(5):1012–1021. 10.1093/schbul/sbn040 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ]
• 3. Velthorst E, Fett AK, Reichenberg A, et al. . The 20-year longitudinal trajectories of social functioning in individuals with psychotic disorders. Am J Psychiatry. 2016;174(11):1075–1085. 10.1176/appi.ajp.2016.15111419 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ]
• 4. Clark RA. Self-mutilation accompanying religious delusions: A case report and review. J Clin Psychiatry. 1981;42(6):243–245. [ PubMed ] [ Google Scholar ]
• 5. Greilsheimer H, Grover JE. Male genital self-mutilation. Arch Gen Psychiatry. 1979;36(4):441–446. 10.1001/archpsyc.1979.01780040083009 [ DOI ] [ PubMed ] [ Google Scholar ]
• 6. Van Rensburg J, Bernard-Repsold A. The role of spirituality in South African specialist psychiatric practice and training [PhD thesis] University of the Witwatersrand; 2010. [cited 2012 Nov 10]. Available from: http://wiredspace.wits.ac.za/handle/10539/11211 [ Google Scholar ]
• 7. Tarrier N, Haddock G, Lewis S, Drake R, Gregg L, The SOCRATES Trial Group . Suicide behaviour over 18 months in recent onset schizophrenic patients: The effects of CBT. Schizophr Res. 2006;83(1):15–27. 10.1016/j.schres.2005.12.846 [ DOI ] [ PubMed ] [ Google Scholar ]
• 8. Nordentoft M, Jeppesen P, Abel M, et al. . OPUS study: Suicide behaviour, suicidal ideation and hopelessness among patients with first-episode psychosis: One-year follow-up of a randomised controlled trial. Br J Psychiatry. 2002;181(suppl. 43):s98–s106. 10.1192/bjp.181.43.s98 [ DOI ] [ PubMed ] [ Google Scholar ]
• 9. Schoeman WJ. South African religious demography: The 2013 general household survey. HTS. 2017;73(2):a3837 10.4102/hts.v73i2.3837 [ DOI ] [ Google Scholar ]

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

• View on publisher site
• PDF (453.8 KB)
• Collections

Similar articles

Cited by other articles, links to ncbi databases.

• Download .nbib .nbib
• Format: AMA APA MLA NLM

Add to Collections

Very Early-Onset Schizophrenia in a Six-Year-Old Boy

Information & authors, metrics & citations, view options, key points/clinical pearls, acknowledgments, information, published in.

Export Citations

If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Simply select your manager software from the list below and click Download. For more information or tips please see 'Downloading to a citation manager' in the Help menu .

View options

Login options.

Already a subscriber? Access your subscription through your login credentials or your institution for full access to this article.

Not a subscriber?

Subscribe Now / Learn More

PsychiatryOnline subscription options offer access to the DSM-5-TR ® library, books, journals, CME, and patient resources. This all-in-one virtual library provides psychiatrists and mental health professionals with key resources for diagnosis, treatment, research, and professional development.

Need more help? PsychiatryOnline Customer Service may be reached by emailing [email protected] or by calling 800-368-5777 (in the U.S.) or 703-907-7322 (outside the U.S.).

Share article link

Copying failed.

PREVIOUS ARTICLE

Next article, request username.

Can't sign in? Forgot your username? Enter your email address below and we will send you your username

If the address matches an existing account you will receive an email with instructions to retrieve your username

Create a new account

Change password, password changed successfully.

Your password has been changed

Reset password

Can't sign in? Forgot your password?

Enter your email address below and we will send you the reset instructions

If the address matches an existing account you will receive an email with instructions to reset your password.

Your Phone has been verified

As described within the American Psychiatric Association (APA)'s Privacy Policy and Terms of Use , this website utilizes cookies, including for the purpose of offering an optimal online experience and services tailored to your preferences. Please read the entire Privacy Policy and Terms of Use. By closing this message, browsing this website, continuing the navigation, or otherwise continuing to use the APA's websites, you confirm that you understand and accept the terms of the Privacy Policy and Terms of Use, including the utilization of cookies.

Case Reports in Schizophrenia and Psychotic Disorders

Loading... Editorial 13 September 2023 Editorial: Case reports in schizophrenia and psychotic disorders Massimo Tusconi , Gabriele Nibbio , Rishab Gupta  and  Erika Carr 906 views 0 citations

Case Report 19 July 2023 Case report: Psychosis and catatonia in an adolescent patient with adipsic hypernatremia and autoantibodies against the subfornical organ Matthias Liebrand ,  11 more  and  Jochen Kindler 1,699 views 2 citations

Case Report 06 April 2023 A rare case of schizophrenia coexistence with antiphospholipid syndrome, β-thalassemia, and monoclonal gammopathy of undetermined significance Yingming Jin ,  2 more  and  Jianfen Xu 1,422 views 1 citations

Loading... Case Report 20 February 2023 Delta-8-THC association with psychosis: A case report with literature review Chelsea R. Miller ,  2 more  and  Badari Birur 5,118 views 6 citations

Case Report 18 November 2022 Case report: Recovery of hallucinations and cognitive impairment after administration of donepezil in a patient with schizophrenia and carbon monoxide poisoning Seon-Hwa Baek ,  4 more  and  Jae-Min Kim 2,304 views 0 citations

Case Report 02 June 2022 Case Report: Anti-N-Methyl-D-Aspartate Receptor Encephalitis Manifesting With an Isolated Psychiatric Episode and Normal Ancillary Tests Denis Pavǎl ,  4 more  and  Ioana Valentina Micluţia 3,516 views 1 citations

Case Report 31 May 2022 Psychotic Symptoms and Malignant Neuroleptic Syndrome in Williams Syndrome: A Case Report Boris Karpov ,  1 more  and  Tuula Kieseppä 2,092 views 3 citations