Klingsor Syndrome – A rare case report from Andaman and Nicobar Islands
Year: 2024
Type: article
Study design: Case Report
Abstract: Klingsor syndrome or genital self-mutation (GSM) is a rare clinical entity,[1] seen in psychiatric disorders such as depression, under command hallucinations, religious preoccupations, and substance abuse.[2] Self-injury behavior as a mode of suicide goes unreported, and 6% of adults have self-injurious behavior and 0.5 to 1.8% die by suicide.[3] Most episodes of GSM tend to occur in the context of psychosis or delusional coercion.[4] Phallicide is GSM with motive to die in depression or bipolarity.[5] This case report describes Klingsor syndrome associated with commanding hallucinations in a 45-year-old male at a tertiary care hospital in Andaman. He was brought to the emergency after partially amputating his penis, reporting he acted in response to commanding hallucinations. There was 6-month history of low mood, anhedonia, delusional guilt, and auditory hallucinations but did not seek treatment. He consumed alcohol daily to mute hallucinations and was abstinent 1 week before admission, with poor social or occupational functioning for 6 months. On examination, he was alert but uncooperative, with poor eye contact and decreased speech. Initially guarded and psychotic, he became more cooperative after 24 hours. His speech was relevant and coherent, with dull affect, delusions of guilt, and self-harming hallucinations. Cognitive functions were satisfactory, with no alcohol withdrawal signs. Admitted in a surgery ward, he underwent suprapubic catheterization. Due to persistent suicidal ideations, he was transferred to a psychiatry ward for comprehensive management. Columbia-suicide severity rating Scale (C-SSRS) assessed the severity of suicidal thoughts, and high risk was present as he still had commanding AH, which were distressful (Ideation intensity score 23). History revealed poor psychosocial support and a year-long marital separation with psychiatric admissions for alcohol use disorder 4 years ago, without complicated withdrawal, and past suicidal gestures under intoxication, though details were unavailable, and no treatment sought. Premorbid assessment was not possible due to the absence of reliable attendant and no relevant family history. Based on the Diagnostic and Statistical Manual for Mental Disorders - 5th edition (DSM-5), the diagnosis of Major Depressive Disorder-Severe Depression with Psychotic symptoms with Alcohol Use Disorder-Severe was made. Acute suicide risk was noted, and a high-risk protocol was followed in the ward setting. ECT was suggested, but family members denied. He underwent comprehensive physical and neurological workup, which was normal. Pharmacotherapy with Mirtazapine 45 mg and Olanzapine 20 mg with clonazepam for sleep disturbance yielded significant improvement reflected in Hamilton Rating Scale for Depression score as 32 (at admission); 12 (at discharge) and Brief psychiatric rating scale score as 48 (at admission); 22 (at discharge). Admitted for one and half months, he showed good improvement and underwent supportive counseling. His mood and psychotic symptoms improved, and reassessment on C-SSRS revealed no active ideas. Written informed consent was obtained from the patient and caregiver. He was referred to higher centers for urologist intervention. GSM is the highest in the schizophrenia spectrum (49.0%) and substance users (18.5%) and less common in depression (8.9%) and bipolar disorder (1.3%).[3] Case reports of suicide by GSM under depression are present; however, we could not find any such lethal act secondary to commanding hallucinations. It is one the first reports from Andaman and Nicobar Islands. Suicide rates are the highest in Andaman in India.[6] The literature on GSM is sparse, needing more studies to identify social characteristics and risk factors. This rare case report from the Andaman Island highlights GSM in a psychiatric patient with commanding hallucinations. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
Source: Indian Journal of Psychiatry
Authors: Pooja Govind, Anand Lingeswaran
Language: English
Subfield: Clinical Psychology
Field: Psychology
Domain: Social Sciences
Open Access status: diamond
OpenAlex ID: W4401690554