In Reply: We appreciate Dr. Linn's thoughtful comments on our case report. The issues he has raised are certainly clinically relevant and were part of our thinking about this case. We would like to take the opportunity to address his main points.
First, at the time of the autocastration, the patient endorsed none of the "classic" signs or symptoms associated with schizophrenia. DSM-IV criteria set guidelines for how we arrive at official psychiatric diagnoses, and our evaluation did not uncover clear evidence of delusions, hallucinations, disorganization of thought or behaviors, or prominent negative symptoms. Thus we felt that we could not justify a diagnosis of schizophrenia. Granted, one can argue that autocastration is a disorganized behavior. But is this true in all cases? There are case reports indicating that some persons castrate themselves on the basis of deep religious convictions alone. Moreover, contemporary cultures in various parts of the world support what can be considered acts of self-mutilation related to religious or spiritual beliefs and rites.
We should add that the same issues generated several stimulating and passionate discussions among members of the patient's treatment team, including psychiatric residents, medical students, nurses, and attending physicians. It was fascinating to see the strength of the different professionals' opinions on this case, which likely indicated strong countertransference feelings about such an emotionally laden action.
We were uncertain about the validity of the patient's history and therefore the diagnosis. His reluctance to divulge his inner feelings and thought processes remained an obstacle during his hospitalization. In addition, we did not assume that the history provided by his family members was accurate. We contacted family members after obtaining the patient's permission in hopes of better understanding his condition and determining whether or not his act was indeed related to psychosis. As it turned out, the family was not aware of any psychotic symptoms. Thus, in terms of a diagnosis of schizophrenia, we were left with a lot of "smoke" but no definite "fire."
The patient's results on the Minnesota Multiphasic Personality Inventory were not valid; however, invalid results are not uncommon for patients with nonpsychotic disorders, such as personality disorders. Finally, the patient's history of alcohol abuse also complicated the diagnosis. We agree with Dr. Linn that the patient's drinking may have represented an attempt to self-medicate.
In conclusion, the question posed by Dr. Linn, "Can a person's behavior be as bizarre as this patient's and still be considered nonpsychotic?" raises both scientific and philosophical issues. In this specific case, time provided the correct answer. As the old saying goes, "Hindsight is 20/20."