Mister MM, a twenty-nine-year-old caucasian homeless man, estranged from his aunt (his only identified social contact) for several months, was brought to the hospital by ambulance after reporting to a medical clinic. Although he presented primarily to apply for Medicaid, the intake clinician noted that he had tried to cut off his right pinky finger with a steak knife, with the intention of eating it. He had made a 1.5-cm laceration around the proximal interphalangeal joint, requiring three sutures and treatment with oral antibiotics. He also sustained a metacarpal shaft fracture but denied pain. He described wanting to eat his raw “tissue” and not his “flesh,” differentiating the two by referring to his skin as “flesh” and the lower layers of subcutaneous tissue and muscle as “tissue.” He reported to the emergency department physician that he wanted to save the bone and mentioned repeatedly that his finger “was not working” and “I do not need it.”
Mister MM consistently denied suicidal ideation in relation to his attempt to self-cannibalize. He was unconcerned and apathetic about his actions and described his behaviour with emotional detachment. In the past, he had cut out a tattoo on his hand and ate the tissue; a scar on the dorsal side of his hand between the thumb and first finger was noted on examination. He further volunteered that “I wanted to be able to say I ate two body parts.”
His additional history of self-harm behaviour consisted of stabbing himself in the neck and chest in 2011 and lacerating his wrist in 2013, requiring five sutures in the emergency department. His aunt also reported that he stabbed himself in the groin about four years before but did not require hospitalization. He did not comment on his motivations for the non-cannibalistic self-harm actions. He explicitly stated that he has no interest in eating the flesh of others.
Mister MM reported that he learned about self-cannibalism from a street gang that practised cannibalism, and he expressed fear of becoming a victim of this gang. He had no direct involvement in this gang and we were unable to find any further information about the gang with the name he provided. He implied that by eating his own tissue, he would appear to be “psychologically superior,” which in turn might deter others from attempting to harm him. He expressed pride in autosarcophagy, described it as his “pursuit,” and felt that self- cannibalism made him unique.
Mister MM was raised by his aunt. Interviewed on the telephone during his hospitalization, she independently reported that he sustained a head injury during infancy. He was labelled as being a “slow learner” in school, which she attributed to his head injury. As a child, he had been diagnosed and treated for attention deficit hyperactivity disorder and learning disabilities but was able to graduate high school. Although he initially denied a history of violence, he later reported participating in gang activity, involvement in fights, and legal charges for trespassing and mischief. To our knowledge, Mister MM had no previous psychiatric admissions or trials of psychiatric medications. There were no acute safety concerns related to his behaviour during his admission.
On admission, Mister MM tested positive for tetrahydrocannabinol but otherwise had a negative blood alcohol level and urine toxicology screen for amphetamines, benzodiazepines, cocaine, methadone, and opiates. He admitted to daily marijuana use and twice weekly consumption of alcohol. He also reported periodic spice (synthetic marijuana) and methamphetamine use several times per year but would not give an approximation of his most recent use, including not reporting whether he had used on the day he attempted to self-cannibalize.
Mister MM’s affect was flat and blunted throughout hospitalization. Although he denied paranoia, delusions, or hallucinations, his thought processes were illogical and disorganized, he displayed paranoid thinking, and at times, he appeared to be responding to internal stimuli. He expressed paranoid ideas about the treatment team, asking questions and taking notes during interviews. He also reported a concern about how the information would be used, and he insisted that notes not be taken. At times, he appeared so overwhelmed or annoyed by our questions that he would abruptly end the interview. Notably, he repetitively touched his nose, an act that he reported was intended to avoid the spread of syphilis (for which he tested negative) and of bed bugs, which he, in fact, had on admission. The nose touching was thought to be part of a delusion that Mister MM did not further explain.
Although initially resistant to our recommendation for starting an antipsychotic medication, he eventually agreed to do so because he felt that accepting medication would expedite his discharge. Olanzapine was initiated and titrated up to 10 mg at bedtime over a period of six days, leading to some improvement in his disorganization but not in his paranoid thinking or flat affect. Despite receiving a great deal of psychoeducation about the potential value of medication, he stated on multiple occasions that he would not take medication as an outpatient because he was concerned about potential interactions with marijuana and alcohol.
This case shares both similarities and differences with previous reports regarding self-cannibalism. Mister MM presented with features of psychosis, a recent history of isolation, history of self-mutilation, paranoid beliefs, and alexithymia, all of which have been noted as risk factors for self-cannibalism (Ahuja and Lloyd, 2007). As previously hypothesized, patients may obtain relief from painful emotions following autosarcophagy (Monastario and Prince, 2011). However, because of alexithymia, as in this case, they may be unable to report any subjective awareness of causal connections. In any event, it is clear that as a psychopathological phenomenon, auto-cannibalism goes considerably beyond typical self-harm.
Given Mister MM’’s history of marijuana, alcohol, spice, and methamphetamine use, substance-induced self-cannibalism was part of the differential diagnosis. Methamphetamine use was an important factor in a previous related case report (de Moore and Clement, 2006), and self-mutilation and self-injurious behaviour have been associated with amphetamine psychosis (Kratofil et al., 1996). Mister MM was hospitalized and observed for fifteen days, with minimal change in his presentation, which made it less likely that his presentation was substance induced. However, because of his (seemingly intentionally) vague report regarding substance use, it is impossible to know for sure. Of course, persistent psychosis after discontinuation of methamphetamine use is well known (Kratofil et al., 1996; Mikellides, 1950).
Unlike other drug-induced cases of self-cannibalism where self-injurious behaviour was linked to expressions of regret (Kratofil et al., 1996), Mister MM did not express regret and was emotionally detached when describing his actions. We postulate that this phenomenon may be related to Mister MM’s lack of insight, which is exemplified by his chief complaint at the time of presentation revolving around his desire to apply for Medicaid. His persistent concern wishing to impress the cannibalistic street gang might have also contributed to his ongoing lack of regret regarding self-cannibalism.
In their article, Ahuja and Lloyd (2007) raise the interesting point that alterations or reductions in pain perception noted to occur in individuals with schizophrenia might result in decreased pain during self-injurious behaviour. This same phenomenon of pain inhibition has also been associated with methamphetamine intoxication (Yamamotova and Slamberova, 2012). Mister MM’s subjective description of not experiencing pain, and not requiring treatment for pain, supports this hypothesis and may render him more vulnerable to the future risk of self-harm. Although schizophrenia was included in our differential diagnosis, we diagnosed Mister MM with “Other Specified Schizophrenia Spectrum Disorder according to Diagnostic and Statistical Manual of Mental Disorders”, 5th Edition, diagnostic criteria, owing to insufficient collateral information regarding his symptoms and timeline of social deterioration.
Mister MM’s decision to remain homeless, his resistance to medications, and his lack of insight into his illness make future similar attempts more likely. One similar case report described a man with methamphetamine use and medication noncompliance who cut off and ate his toes while in a psychotic state but who was able to have periods of functionality during which he was able to work full-time and live independently after receiving treatment with depot antipsychotic medications (de Moore and Clement, 2006). Mandated outpatient medication administration would likely have been useful in further stabilizing Mister MM’s psychosis and achieving better functionality.
The limitations of the present case study (together with the familiar shortcomings of case reports overall) include our inability to acquire sufficient collateral information, the lack of important information due to the patient’s limited self-reflection and unwillingness to share information, and our inability to follow-up and monitor the patient’s progress after discharge from the hospital.
Although seemingly an obscure topic, self-cannibalism has gained attention beyond the scientific literature; Dr Mark D. Griffiths (2012), who writes a blog about extreme behaviour, posted an entry on autosarcophagy in 2012 offering examples from literature and film. He indicates there are cases where no associated psychopathology was uncovered.
In conclusion, Mister MM’s case highlights the importance of investigating underlying causes for acts of self-cannibalism such as substances, psychosis, alternate motivating factors, and relevant cultural or spiritual beliefs, all of which might interact concurrently in a complex fashion. Given how rarely self-cannibalism is reported in the psychiatric literature, further study is essential to help elucidate its true prevalence and the connections between self-cannibalism and psychiatric illness.