Autocastration and Psychosis

To the Editor: The unusual case report in the May issue (1), "Autocastration as a Presenting Sign of Incipient Schizophrenia," was interesting and nicely presented. However, I cannot agree with the authors' conclusion that the self-mutilation was carried out by a person who was not yet overtly psychotic. The case raises the eternally difficult question, What is schizophrenia? Can a person's behavior be as bizarre as this patient's and still be considered nonpsychotic? In my view, the self-destructive act itself is reason enough for a diagnosis of schizophrenia.

However, other factors must be considered. According to information provided by the 29-year-old patient's parents, he was unmarried and had a lifelong history of social isolation. In addition, he had been hospitalized several times for alcoholism and was suffering from liver disease associated with alcohol use. These issues are not explored in the case report. For example, I would be inclined to regard the patient's severe alcoholism as an attempt to self-medicate.

In addition, the patient experienced a surge of religiosity eight months before the self-mutilation. On hospital admission, he feared that his thoughts were being manipulated by the staff via hypnotism. His performance on the Minnesota Multiphasic Personality Inventory was so evasive that the results had to be discarded. The fluctuating clinical course of this patient most likely is a result of changes in life stresses to which he has been exposed. The authors take the family history literally and uncritically and make no attempt to evaluate the informant's reliability.

In short, the case provoked in me many questions—and that may well be its special appeal. I am inclined to believe that its publication will arouse considerable discussion from your readers.

Dr. Linn is clinical professor emeritus of psychiatry at the Mount Sinai School of Medicine of the City University of New York and consultant psychiatrist at Mount Sinai Hospital in New York City.