CASE: A ‘purification’
Mr. B, age 61, is in the ICU after shooting himself in the abdomen. The trauma team asks our psychiatry consultation/liaison service to determine if he needs special observation to prevent further self-harm.
Two days ago, Mr. B stood in the parking lot of a nearby hospital, aimed his rifle toward the left upper part of his abdomen, and fired. Bleeding profusely, he dragged himself to the hospital’s emergency room. ER staff stabilized him hemodynamically, then transferred him to our hospital’s regional trauma center, where surgeons performed an emergency laparotomy and found 2 sigmoid colon perforations, with feces floating outside the bowel.
After a partial colectomy and colostomy, Mr. B received broad-spectrum antibiotics, narcotic pain medication, and bowel rest in the ICU. When the trauma team called us, the patient’s condition was stable and he had awakened enough to communicate, although he still needed frequent monitoring.
We visit Mr. B in the ICU and ask him why he shot himself. He denies he was attempting suicide but adds that for months he has been feeling depressed, stressed, and guilty about “all the bad things I’ve done in my life.” Shooting himself helped him forget these negative thoughts.
A devout Roman Catholic, Mr. B has been researching flagellation and other forms of physical penance and considers the shooting a purification. He says he shot himself in the abdomen 2 previous times and felt better for months or years after each shooting.
Four years ago, Mr. B donated his left kidney to an unknown recipient. He does not equate the kidney donation with the shootings but says he felt happy while recuperating. He was later disappointed, however, because the procedure did not help him attract the “attention” he had hoped for.
Mr. B says he had been considering the latest shooting for at least 8 months and had carefully planned it. After studying anatomy textbooks, he figured he could fire into the left upper portion of his abdomen without striking a vital organ.
For several evenings, Mr. B aimed his rifle toward his abdomen but could not bring himself to pull the trigger. On the night of the shooting, he said, he “accidentally” fired at a more damaging angle than he had planned.
Cognitive examination results are mostly normal, although Mr. B has trouble interpreting similarities and proverbs. He appears pale but well-nourished, well-groomed, and serene. He speaks softly, often closing his eyes or staring into the distance. He says he feels “relieved” and “happy” after the shooting but did not anticipate such a severe injury. He denies suicidal thoughts and—because of his current euphoric mood—he hopes he never “needs” to shoot himself again.
The authors’ observations
We first considered delusional disorder and major depressive disorder with psychotic features. Mr. B’s belief that shooting himself would solve his problems seemed delusional, although he did not appear psychotic otherwise. Confusingly, Mr. B’s pre-admission symptoms seemed to suggest major depressive disorder, but he was happy in the ICU.
We explored other diagnoses, such as an odd form of OCD and a personality disorder (especially cluster A, given his strange beliefs), though at this point we had too little information for either diagnosis.
The authors’ observations
Mr. B was recovering from major abdominal surgery, was taking nothing orally, and claimed to feel fine psychologically. Because he was not grossly psychotic and did not endorse anxiety or depression, we decided against medication but recommended a chaplain consult and planned to visit Mr. B daily to gather more history.
We considered Mr. B a low suicide risk—especially while hospitalized—after he said his “need” to shoot himself had dissipated. He also endorsed no suicidal thoughts or other depressive symptoms, and the nursing staff viewed him as pleasant and compliant. We noted this evidence in the chart and continued to reassess him daily.
HISTORY: Dreams, nightmares
Over the next week, Mr. B shares his life story. He says his parents divorced when he was age 5, and around that time he spent approximately 2 weeks in the hospital after being hit by a truck. He considers those 2 weeks a bright spot in an otherwise turbulent childhood because his parents did not fight and he was showered with gifts and attention.