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LETTER TO EDITOR
Year : 2019  |  Volume : 3  |  Issue : 2  |  Page : 180-181

The mental health attributes of recurrent metallic foreign body insertion to scalp in a young woman


1 Department of Psychiatry, King George's Medical University, Lucknow, Uttar Pradesh, India
2 Department of Neuro-Surgery, King George's Medical University, Lucknow, Uttar Pradesh, India

Date of Submission29-May-2019
Date of Decision16-Jul-2019
Date of Acceptance03-Sep-2019
Date of Web Publication18-Dec-2019

Correspondence Address:
Dr. Sujita Kumar Kar
Department of Psychiatry, King George's Medical University, Lucknow, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aip.aip_35_19

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How to cite this article:
Singh J, Kar SK, Srivastava C. The mental health attributes of recurrent metallic foreign body insertion to scalp in a young woman. Ann Indian Psychiatry 2019;3:180-1

How to cite this URL:
Singh J, Kar SK, Srivastava C. The mental health attributes of recurrent metallic foreign body insertion to scalp in a young woman. Ann Indian Psychiatry [serial online] 2019 [cited 2020 Jan 22];3:180-1. Available from: http://www.anip.co.in/text.asp?2019/3/2/180/273377



Sir,

Self-injurious behavior is common among patients with dissociative disorder.[1],[2] Dissociative amnesia is a variant of dissociative disorder, in which patients often present with episodic memory loss of traumatic or distressing events and often have difficulty in recalling personal information during the episodes. Hence self-inflicted injuries occurring during the episodes of dissociative amnesia often remain enigmatic.[3] Evidence suggests that patients with dissociative amnesia have increased risk of self-harm; however, it is underestimated.[4] We present here the case of a woman who inserted foreign bodies to her scalp during the episodes of dissociative amnesia.

A 32-year-old female with adequate premorbid functioning was suffering from migraine since 1½ years with obsessive–compulsive disorder characterized by recurrent thoughts of contamination and pathological doubts accompanied with compulsive cleaning and checking behavior occurring over 1 year and associated depressive episode for the past 8 months. During the past 6 months, she had nonstereotyped, twisting body movements lasting for several minutes, followed by state of stupor lasting for 30 min to 1 h. Often, these episodes followed bouts of headache. These episodes were never associated with tongue bite and incontinence and never occurred during sleep. Such episodes used to occur daily. She reported amnesia about the events happening immediately before the episodes of stupor. She reported pain and foreign body sensation on her scalp after several such episodes. There were no features suggestive of depersonalization or derealization. Her headache was episodic, pulsatile, and severe in nature, which was initially resolved with over-the-counter analgesic use and often triggered by disturbances in her daily routine. She denied to any obvious psychosocial stressor. However, she expressed her worries related to her mental illness and headache. Electroencephalogram and neuroimaging of the head did not reveal any abnormality; however, multiple sharp foreign bodies [Figure 1]a, [Figure 1]b, [Figure 1]c, [Figure 1]d were found on the scalp on neuroimaging. Four metallic needles were removed surgically from her scalp, which she inserted during the episode of amnesia.
Figure 1: (a-d) Computed tomography of the head (three-dimensional, a and b; three-dimensional, c and d) showing sharp metallic foreign bodies on the scalp

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She had undergone surgery again for removal of needles, after a month. The patient had not received specific treatment for migraine or for her psychiatric illnesses, until she reported foreign bodies (needles) in her scalp. A diagnosis of obsessive–compulsive disorder with moderate depressive episode with dissociative amnesia and migraine was kept as per the ICD 10 and International Headache Society Criteria, respectively. Her psychiatric illness was treated with fluoxetine up to 80 mg/day, and migraine was treated with amitriptyline 25 mg/day. She had responded well to this treatment, with reduction in frequency of headache, dissociative episodes, and improvement in the symptoms of depression over 6-month follow-up period.

In this patient, the dissociative episodes seemed to be triggered by headache, which was ignored by family members, leading to inadequate treatment. She could not remember completely about insertion of needles during these episodes due to amnesia, as awareness regarding self-inflicted trauma would have been more embarrassing for her. Earlier evidence suggests about similar pattern of self-inflicted nonfatal injuries during periods of dissociative amnesia.[5] Such peculiar clinical phenomenology may present during dissociative amnesia. Untreated headache can be a triggering factor for dissociative disorders. Patients presenting with headache often consult general physicians, and their mental health issues often remain unexplored. Identification of the triggering factors for dissociative episodes and addressing them adequately may be helpful in reduction of such self-injurious behavior. Similarly, untreated psychiatric illness (obsessive–compulsive disorder) and headache, in turn, produce distress, which might further worsen the headache and precipitate dissociative symptoms. Our patient had shown improvement in her symptoms of obsessive–compulsive disorder and headache after specific treatments, which resulted in reduction of subjective distress and resolution of the dissociative disorder.

Hence, there is a need for collaborative, multidisciplinary approach for addressing the mental health issues of such patients. Evidence supports the association of pain with dissociative disorders.[6] This case conveys that headache can be a precipitant of dissociative episodes, and during dissociative amnesia, patients may have self-injurious behavior. Adequate management of headache might be helpful in reducing the dissociative phenomenon.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Noma S. Dissociative disorder and self-injury. Seishin Shinkeigaku Zasshi 2011;113:912–7.  Back to cited text no. 1
    
2.
Saxe GN, Chawla N, Kolk BV der. Self-destructive behavior in patients with dissociative disorders. Suicide and Life-Threatening Behavior 2002;32:313–20.  Back to cited text no. 2
    
3.
van der Hart O, Nijenhuis E. Generalized dissociative amnesia: episodic, semantic and procedural memories lost and found. Aust N Z J Psychiatry 2001;35:589–600.  Back to cited text no. 3
    
4.
Staniloiu A, Markowitsch HJ. Dissociative amnesia. The Lancet Psychiatry 2014;1:226–41.  Back to cited text no. 4
    
5.
Singh P, Jain A, Kar SK. Dermatitis artefacta: A consequence of self-injurious behavior during dissociative amnesia. Med J Dr DY Patil Univ 2017;10:217.  Back to cited text no. 5
    
6.
Fishbain DA, Cutler RB, Rosomoff HL, Rosomoff RS. Pain-determined dissociation episodes. Pain Med 2001;2:216–24.  Back to cited text no. 6
    


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