Repeated Self-Mutilation and ECT
To the Editor: In their Clinical Case Conference, Cheryl A. Green, M.D., et al. (1) described a homeless patient with bipolar disorder who had committed two very serious acts of self-mutilation: a near-amputation of his right arm and, 15 years later, an attempted self-enucleation of his right eye. In the intervening years, he had been hospitalized multiple times; several admissions had lasted longer than 10 months; his average length of stay had been approximately 4 months. His medications included one or more mood stabilizers, a neuroleptic, and a benzodiazepine. It appears that this patient, despite his very severe illness and prolonged hospitalizations, was never given ECT.
Readers may be interested in my recent case report (2) regarding a 35-year-old veteran with a 10-year history of repeated self-mutilation and 27 hospitalizations who was successfully treated with maintenance ECT. The patient bears some similarities to the man described by Dr. Green et al.
Mr. A had been given multiple courses of neuroleptics, antidepressants, and mood stabilizers, but he continued to manifest command auditory hallucinations, various religious delusions, and sporadic depressive symptoms. He continued to throw himself down stairs (once requiring plastic surgery for a severe head wound), pulled out his fingernails with his teeth, and attempted to catch a chain saw with his bare hands, severely injuring his right hand. He was then given a year-long trial of clozapine at therapeutic plasma levels—again without success. By then he had accumulated over 2,200 hospital days.
On referral to our hospital, he was given 10 bilateral ECTs at a suprathreshold charge, but on return to his primary hospital, he relapsed into serious self-mutilative behaviors within 1 month. On return, he was again given 10 bilateral ECTs. Haloperidol decanoate, 100 mg/month, was initiated, as well as fluvoxamine, 200 mg at bedtime (both medications had been given previously). Arrangements were then made for him to be transferred to our facility every 2 weeks for maintenance ECT. The interval between the maintenance treatments was gradually lengthened over the next 21 months, during which time he has experienced only one instance of minor self-injurious behavior. He is able to hold a steady job and reside in a board-and-care home with only minimal supervision. In marked contrast to the previous 10 years, he has required no emergency hospitalization.
The role of maintenance ECT in the management of such patients requires further study, but in this case it appears to be both life saving and highly economical.
1. Green CA, Knysz W III, Tsuang MT: A homeless person with bipolar disorder and a history of serious self-mutilation. Am J Psychiatry 2000; 157:1392-1397Google Scholar
2. Dean CE: Severe self-injurious behavior associated with treatment-resistant schizophrenia: treatment with maintenance electroconvulsive therapy. J ECT 2000; 16:302-308Crossref, Medline, Google Scholar
