Self-Cannibalism in the Absence of Psychosis and Substance Use

1. Erik Monasterio, Senior Clinical Lecturer and Consultant in Forensic Psychiatry erik.monasterio@cdhb.govt.nz 2. Craig Prince, Senior Clinical Psychologist 1. Hillmorton Hospital, Christchurch, New Zealand 1. Correspondence: Dr Erik Monasterio, Forensic Service, Hillmorton Hospital, Private Bag 4733, Christchurch, New Zealand. Email: erik.monasterio@cdhb.govt.nz Next Section

Abstract
Objective: The aim of this paper is to review the literature and describe a case of self-cannibalism. Method: A literature review and a case report of self-cannibalism occurring in a 28-year-old male, in the absence of psychosis and drug and alcohol use, is presented. Results: Seven previous case reports of self-cannibalism were identified in the literature; most cases were associated with severe psychosis. A 28-year-old male amputated and ate a finger, without evidence of impaired reality testing and substance use. Conclusion: Although rare, self-cannibalism can occur in the absence of psychosis and substance use. Future reports may lead to a better understanding of this unusual phenomenon. case report

self-cannibalism

The word cannibalism is derived from the name of the West Indian Carib tribe who were alleged to eat others, although it remains unclear whether they did so. Reports in the scientific literature of human cannibalism in recent times are fairly rare. If one excludes cannibalism during exceptional cases of needing to survive (as occurred with the survivors of an airline catastrophe in the Andes 1), then cases tend to occur in extreme forms of either sexual deviance2 or psychosis.36 Cases of auto- or selfcannibalism (eating part of one's own body) are even rarer. An unusual case of cannibalism and attempted self-cannibalism in 2001 attracted considerable media attention7 and legal debate, after two consenting adults met via an internet advertisement. One of the men was a voluntary victim who attempted to eat his amputated penis before he was killed and partly eaten by the other. The purpose of this report is to review the extant scientific literature on the subject and describe an episode of self-cannibalism occurring in the absence of psychosis. A search of the terms self-cannibalism, auto-cannibalism, and autophagy in AMED (1985 to the current date), EMBASE (1947 to the current date), all EBM reviews, MEDLINE (1945 to the current date), and PsycInfo (1806 to the current date) revealed six pertinent publications 813 dealing with the subject in human populations. These provide seven case reports of self-cannibalism. Two reports (published in a Greek Medical Journal in 1950)8 were unavailable for review. Three reports described self-cannibalism occurring in the context of psychosis and involved the ingestion of two toes, 9 a middle finger10 and large amounts of skin, subcutaneous tissue, and blood from the shoulders. 11 The first of these had the added association of occurring in the context of amphetamine abuse; 9 these reports described severe psychotic symptoms characterized by delusions of persecution, grandiosity, and religiosity10,11 and delusions of influence9 associated with significant behavioral disorganization. 9,11 The last two reports described the phenomenon occurring in the absence of psychosis. The first is not a true case of self-cannibalism as the tetraplegic subject, who had no history of mental disorder, had bitten off flesh from his fingers but expectorated it rather than ingested it.12 The second case occurred in the absence of any mental illness

and in the context of a lifestyle choice that involved extensive body modifications (piercing, tattoos, and tongue splitting) and scarification, including the ingestion of small strips of skin. 13 Previous SectionNext Section

CASE REPORT
In 2009, a 28-year-old man intentionally cut off his little finger with a jigsaw, cooked it, and ate the flesh thereof. After an admission to a psychiatric hospital and careful evaluation, he was noted not to be psychotic and not to have consumed drugs or alcohol. Mr X is a physically large Caucasian man who was teased and picked on as a child because of his size. He was also reprimanded after inadvertently hurting other children while playing with them. He felt that he received no support and was left feeling angry, alone, inadequate, and lacking autonomy. He experienced periods of depression and lacked the skills to effectively regulate his emotions, especially during times of personal crisis. At odds with his meek nature, he began fantasising about harming/killing his tormentors, thereby providing temporary relief for his anger. At the age of 22 years, he came into contact with mental health services and was diagnosed with major depressive disorder (DSM-IV-TR14). He was successfully treated with an antidepressant and received supportive psychotherapy. However, 2 years later, while experiencing deterioration in his mood, he was also physically assaulted by two men. He felt extreme anger and for the first time fantasised about not only killing his assailants, but of eating them too. He believed that by doing so, he would rob them of everything. His fantasies appear to have been perpetuated by an interest in (violent) movies and taboo subjects, were ego-syntonic, and were experienced during both settled and unsettled periods, but heightened during the latter. Over the years that followed, he sustained periods of relatively settled mental state interspersed by a number of episodes of deterioration in mood (sometimes with suicidal ideation). These were often brought on by times of crisis such as work failure, social isolation, or feeling abandoned by his treating team. He developed an unusual psychological mechanism, which he called a gauge, by which he and mental health staff would know that he had crossed the line of no return, and that significant harm to himself or others was imminent. The gauge was to cut off three of his fingers and eat them. Not surprisingly, he had a number of inpatient admissions after he voiced thoughts of killing others or cutting off his fingers and eating them. However, his diagnosis remained unchanged and outpatient follow-up periods were brief. At the end of 2008, following another personal crisis, and while not being fully compliant with his medication, he spiralled into another episode of depression. He experienced significant insomnia and suicidal ideation, and ruminated for days about cutting off his fingers. In an effort to seek reprieve from these thoughts, he tied a shoelace around his finger to act as a tourniquet and cut the finger off with a jigsaw. He then cooked it in a pan with some vegetables and ate its flesh. His plan was to amputate another two fingers the following day. Mr X reported initial excitement (non-sexual) and a sense of relief from his ruminations. Given the instantaneous benefit, he felt that there was no point in cutting off any more fingers. He was subsequently admitted to the acute psychiatric inpatient unit where he presented with moderate symptoms of depression. He was assessed as not being under the influence of substances, not psychotic, and with no features of OCD or mania. He denied a history of violence (and had no convictions for violent behaviours). In hindsight, he stated that he regretted his actions because of its debilitating effect. After being assessed by the authors, it was felt that Mr X had a vulnerable personality structure with difficulty in regulating emotions during times of personal crisis. He experienced thoughts of harming himself or others, depending on where he perceived the fault to lie. His violent thoughts provided him with relief from intense emotional distress and some sense of control over a world where he generally felt he had little control. Furthermore, there was secondary gain from informing mental health staff of his thoughts and subsequently receiving mental health attention. It may be that the act of actually cutting off his finger (and eating its flesh) made staff take him more seriously and provide the care and understanding that he longed for. Previous SectionNext Section

DISCUSSION

Two significant behaviours are at play in a number of the above cases: deliberate self-harm/self-injury and self-cannibalism. In terms of the former, when not the result of psychotic thinking, it occurs in those with depression and borderline personality disorder, among others. Linehan 15 explains such actions as being behavioral solutions to intolerably painful emotions. Many patients report a relief or reduction in intensity of aversive emotions following such acts. The resulting positive effect reinforces such behaviours and increases their likelihood of being resorted to during periods of distress in the future. While Mr X reported a sense of relief from the thoughts of self-injury following the act of cutting off his finger, he did not appear to find relief from his overall predicament. He had never resorted to self-harm in the past and his first such act was extreme in nature. He also did not stop at this point, continuing with more extreme actions. Pffflin16 states that, Apart from acts of cannibalism arising from situations of extreme necessity the cannibalistic deeds of individuals are always an expression of severe psychopathology. As noted above, self-cannibalism is a very rare occurrence and in the scientific literature has generally been documented in frankly delusional patients. Apart from the case study presented above, only one other episode of nonpsychotic self-cannibalism is reported. In that case,13 the woman in question was followed up over a number of months, with her actions centering on extreme body modification as a lifestyle trend. It is questioned to what extent peer pressure was present and whether she derived shock value from pushing practices to the extreme (which included ingesting small amounts of skin). In the present case, the concern generated by threatening to eat part of oneself or other people usually got the patient help during times of personal crisis. It is possible that his lack of violence and any offending behaviour, as well as his lack of psychosis, made clinicians somewhat complacent about his threats and that more drastic action was finally required by him. It may also be that a long history of violent fantasies finally came to fruition during a period of personal crisis and depression, whereby he succumbed to his overvalued idea. The present case report highlights an occurrence of self-cannibalism not only in the absence of psychosis and psychoactive substance use, but also in an individual who had experienced longstanding egosyntonic fantasies and impulses of this nature. Taking into consideration a widely publicized media report of consented cannibalism and self-cannibalism,7 it would seem likely to the authors that while this phenomenon is rare, it is by no means unique. It is hoped that this report alerts clinicians to its presence and over time may lead to a better understanding of it. Previous SectionNext Section

Acknowledgments
We would like to thank Dr Helen Austin for her assistance in the preparation of this manuscript. DISCLOSURE The authors report no conflict of interest. The authors alone are responsible for the content and writing of this paper