To the Editor: Major self-mutilation is infrequent and usually occurs in relation with severe mental disorders which often results in permanent and/or totally loss of an organ or its function.¹ In literature, several cases of severe disfigurement or marked self-mutilation in psychotic disorders such as bilateral self-enucleating, penectomy or castration, and penetrating cranio-cerebral injury were reported^1,2 We report an unusual case with torn away of tongue by biting and comorbid oral analgesic use.

A 39-year-old, unemployed man admitted to psychiatry outpatient service with his family because of his self mutilating behaviors. There were lacerations on wings of his nose and a piece of his tongue was deficient. The speech was in pressure but the content was poor. There were no hallucinations or delusions. He had blunted affect. He has bitten a piece of drug per two or three minutes during interview. He had no insight and the judgment was impaired. In history; his initial complaints had been persecution and reference delusions 15 years ago. Then he had begun to rub his eyes as nearly as enucleating them and had traumatized his face. He had struggled with his tooth and gingivas by his tongue thus the family has decided to have his front teeth have been pulled out. There were multiple hospitalizations and multiple treatments trials such as pimozide and clomipramine, flupenthixole decanoate, quetiapine, clonazepam since. He has been biting eight to ten tablets of analgesic drugs in a day for feeling ease for 2 years. He was reported to have ruptured his tongue one year before by rubbing his tongue to his rest of teeth, compulsively (see Figure 1). We initiated olanzapine and titrated up to 20mg/day while we have seen meaningful reductions in his self mutilating behaviors although he has continued to abuse analgesic drug.

Patients with schizophrenia are often suggested to be less sensitive to pain and usually this phenomenon was considered as “psychotic analgesia”.³ Although there was analgesic abuse in the present complaint of our case, at past he could not withstand compulsive behaviors such as: rubbing his hands to his own eyes as nearly enucleating them, or rubbing his hand to his wings of nose, leading to laceration without using any analgesic agent. It was mentioned that the more unusual the self-mutilation done, the higher possibility of the patient to be psychotic.² Hallucinations, Schneider’s symptoms, delusions are well known risk factor for self mutilation in schizophrenia.⁴ Nevertheless, we could not find any relationship between florid positive psychotic symptoms and self-mutilating behaviors. Another interesting feature of this case was analgesic abuse and comorbid rupturing of tongue. However, the patient is still continuing to abuse analgesic agent after rupturation of his own tongue. Thus, analgesic drug abuse and schizophrenia comorbidity seems another explanation. Finally, successful treatment of self mutilation with olanzapine in psychotic disorders was reported in literature.⁵