Case of bilateral self-enucleation in Korea

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SELF-ENUCLEATION IS RARE in clinical psychiatry. As most cases have occurred in European Christian culture, it has been viewed as caused by a literal interpretation of Matthew's admonition: ‘And if thy right eye offends thee, pluck it out, and cast it from thee: for it is profitable for thee that one of thy members should perish, and not that thy whole body should be cast into hell’ (Matthew 5:29).1 We present a case of a bilaterally self-enucleated Korean man uninfluenced by Christian beliefs or underpinnings. The patient and his family gave informed consent for publication.

A 34-year-old Korean man with a 12-year history of schizophrenia gouged out both his eyeballs with his fingers. The loss of both eyeballs was definitely established by a computed tomography (CT) scan. No neurological complications had arisen. After the patient was admitted to the ophthalmology care unit, he underwent silicone sphere implantation, eyelid reconstruction, and tarsorrhaphy in both eyes.

Psychiatric consultation-liaison revealed the following information. In a preliminary interview the patient denied that his parents, other family members or he himself had any religious background. An examination of his mental state revealed persecutory and grandiose delusions with contents of ‘evil eyes’, which had been elaborated by auditory hallucinations. He said: ‘I could not pluck out my own eyes, which had been transmuted into grotesque machinery under the curse of an evil robot. By telepathy I received the message that my eyes should be removed. I am a transcendental being beyond the mundane world, because I have overcome all pleasure of the flesh by self-enucleation’. A review of the patient's psychiatric history revealed destructive behaviors due to dis-egoification of aggression. At the age of 22, he had plucked out the eyes of a number of goldfish that, with the onset of schizophrenia, were perceived to be evil robots. At the age of 30, he was prosecuted on a charge of physically assaulting his mother.

As he was medicated daily with risperidone 4 mg and chlorpromazine 200 mg during his stay in the ophthalmology care unit, his aggressiveness was markedly reduced. However, his delusions of persecution and grandeur persisted. Although he should have been transferred to the psychiatric care unit for further care, he was discharged against medical advice.

A few cases involving self-enucleation have been reported in Asians, although most cases have been reported in the Christian West.1 This case, and all other Asian cases, support the view that self-enucleation is not culturally restricted, and is an attempt to exploit universal symbols to relieve the inner turmoil of a disordered self-boundary. In other words, the cause of self-enucleation is not a literal interpretation of any biblical passage but rather a paranoid delusion related to the eye(s).1,2 In summary, this case of a Korean man suggests that self-enucleation is not a culture-specific phenomenon and should be regarded as an extreme form of deliberate self-harm designed to reduce psychotic suffering.

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