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An eye for an I! A beginner’s guide to auto-enucleation

I have to say that I have no idea what it must be like to lose an eye (i.e., enucleation) but one thing I can’t possibly begin to imagine is what it must like is to remove my own eye (i.e., auto-enucleation). However, there are many clinical and medical reports of people that self-mutilate by stabbing or removing their eye(s). Arguably the most infamous auto-enucleator was Oedipus (in Sophocles’ play) who removed both his eyes after he realized he had unwittingly slept with his own mother and killed his own father.

The psychiatrist Dr. Armando Favazza defines self-mutilation as “the deliberate, direct, non-suicidal destruction or alteration of one’s body tissue”. Dr. Niraj Ahuja and Dr. Adrian Lloyd writing in the Australian and New Zealand Journal of Psychiatry also add that self-mutilation relates to bodily self-damage without wishing to die. Dr. Favazza also believes there are three fundamentally different types of self-mutilation. Enucleation is included in the first type (major self-mutilation) and is the least common. Other forms of self-mutilation in this category include self-castration, penectomy (cutting off one’s own penis) and self-limb amputation.

The second type includes “monotonously repetitive and sometimes rhythmic acts such as head-banging, hitting, and self-biting” (which according to Dr Favazza occur mostly in “moderate to severely mentally retarded persons as well as in cases of autism and Tourette’s syndrome”). The final and most common forms of bodily self-mutilation are moderately superficial and include a compulsive sub-type (e.g., hair-pulling, skin scratching and nail-biting), as well as an episodic/repetitive sub-type (e.g., skin-cutting, skin carving, burning, needle sticking, bone breaking, and wound picking). Many of these self-harming behaviours are a symptom and/or an associated feature in a number of mental personality disorders (e.g., anti-social, borderline, and histrionic personality disorders).

Reports of auto-enucleation in the medical literature were first described in the 1840s. By the early 1900s, the act of removing one’s own eye was actually termed ‘Oedipism’ by Blonel. Auto-enucleation is (of course) exceedingly rare although a couple of studies in the American Journal of Ophthalmology (in 1984) and an analysis of 1,146 enucleations between 1980 and 1990 in the British Journal of Ophthalmology (in 1994) estimated there were 2.8 to 4.3 per 100,000 in the population. However, some papers (such as those by Dr. Favazza) on major self-mutilation have put the incidence as low as one in 4 million.

Enucleators are also known to be at increased risk of further self-harming, and (predictably) are more likely to be living in psychiatric institutions when the auto-enucleation event occurs. They are also at increased risk of removing the second eye at a later date if they didn’t pull out both eyes to start with. A review by Dr. H.R. Krauss and colleagues in a 1984 issue of the Survey of Opthalmology examined 50 cases of self-enucleation and reported that 19 of them had bilateral auto-enucleation (i.e., had removed both of their eyes). A 2007 paper by Dr. Alireza Ghaffari-Nejad and colleagues in the Archives of Iranian Medicine examined the many theories behind self-harming behaviour. They briefly overviewed theories ranging from Fruedian psychoanalytic theory to biologically-based theories. They wrote:

Psychoanalytically self-injurious behaviour has been linked to castration and explained as a process of failure to resolve oedipal complex, repressed impulses, self punishment, focal suicide and aggression turned inwards especially in cases of depression. [Other authors] have postulated interpersonal loss preceding self-injurious behaviour and linked it to rejection sensitivity…Biologically serotonergic depletion preceding self-mutilation has been linked to aggression and depression…Some authors have claimed strong moral, religious and delusional component”

A recent literature review by Dr. Alexander Fan in the journal Psychiatry reported that the vast majority of auto-enucleation cases suffer from psychotic illness (particularly schizophrenia) although other medical and/or psychiatric conditions associated with auto-enucleation include obsessive-compulsive neuroses, severe depression, post-traumatic stress disorders, drug-induced psychoses, bipolar mania. There are also case studies where auto-enucleation has been linked with structural brain lesions, Down Syndrome, epilepsy, neurosyphilis, and Lesch-Nyhan syndrome (juvenile gout). These are similar to other forms of extreme self-mutilation. For instance, self-mutilation in schizophrenia in response to auditory hallucinations has often been described as Van Gogh Syndrome (in reference to the painter’s self-excision of his own left ear)

Other reviews of the psychiatric literature have reported that those who remove their own eyes commonly have delusions (typically sexual and/or religious) and that when asked about motivations for self-harming include reasons such as guilt, atonement, sin, evil, etc. Although some authors have noted that enucleators with religious beliefs are often Christian, other case studies have made reference to other religious faiths (e.g., Muslims). Finally, another paper by Favazza in Hospital and Community Psychiatry concluded that:

“Males in a first episode of a schizophrenic illness that is characterized by delusions associated with a body part or religious delusions are at the greatest risk for MSM [major self-mutilation]. However, MSM of this severity is so rare that it cannot be predicted accurately unless there has been a previous attempt at self-injury or the patient has spoken about wanting to remove or injure an organ. Threatened ocular mutilation deserves special mention because it may occur in a hospital setting, and the case histories suggest that one-to-one nursing is not always be sufficient to prevent enucleation”.

Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Berguaa, A., Sperling, W. & Kuchlea M. (2002). Self-enucleation in drug-related psychosis. Ophthalmologica, 216, 269-271.

Eric, J.C., Nevitt, M.P., Hodge, D. &  Ballard, D.J. (1984). Incidence of enucleation in a defined population. American Journal of Ophthalmology, 113, 138-44.

Fan, A.H. (2007). Autoenucleation: A case report and literature review. Psychiatry, October, 60-62.

Favazza, Armando (1998) ‘Introduction’, in Marilee Strong A Bright Red Scream: Self-mutilation and the Language of Pain. New York: Viking.

Favazza, A. & Rosenthal R. (1993). Diagnostic issues in self-mutilation. Hospital and Community Psychiatry, 44, 134-140.

Field, H. & Waldfogel, S. (1995). Severe ocular self-injury. General Hospital Psychiatry, 17, 224-227.

Gamulescu, M.A., Serguhn, S., Aigner, J.M., Lohmann, C.P., & Roider J. (2001). Enucleation as a form of self-aggression, two case reports and review of the literature. Klin Monatsbl Augenheilkd, 218, 451-454.

Ghaffari-Nejad, A., Kerdegari, M., & Reihani-Kermani, H. (2007) Self-mutilation of the nose in a schizophrenic patient with Cotard Syndrome. Archives of Iranian Medicine, 10, 540-542.

Gottrau, P., Holbach, L.M. & Nauman, G.O. (1994). Clinicopathological review of 1,146 enucleations (1980-90). British Journal of Ophthalmology, 78, 260-5.

Jeffreys, S. (2000). ‘Body art’ and social status: Cutting, tattooing and piercing from a feminist perspective Feminism and Psychology, 10, 409-429.

Krauss, H., Yee, R. & Foos, R. (1994). Autoenucleation. Survey of Ophthalmology, 29, 179-87.

MacLean, C. & Robertson, B.M. (1976). Self enucleation and psychosis. Archives of General Psychiatry, 33, 242-249.

Patil, B. & James, N. (2004). Bilateral self-enucleation of eyes. Eye, 18, 431-432.

Patton N. (2004). Self-inflicted eye injuries: A review. Eye, 18, 867-872.

Rao, K.N. & Begum, S. (1996) Self enucleation in depression; A case report. Indian Journal of Psychiatry, 38, 267-70

Witherspoon, D., Feist, F., Morris, R. & Feist, R. (1989). Ocular self-mutilation. Annals of Ophthalmology, 21, 255-259.

Aural wrecks: A brief look at self-mutilation of the ear

If I was playing a word association game and said the words ‘self-inflicted ear mutilation’, I would hazard an educated guess that the first thing that popped into most people’s minds would be the Dutch artist Vincent Van Gogh. On the evening of December 23, 1888, in Aries (France) Van Gogh (in a state of deep depression) cut off the lower part his own right ear with a razor (and later immortalized in his famous painting Self Portrait With Bandaged Ear). Earlier in the day he had threatened his long-time friend and artist Paul Gaugin with a razor and was not in a good state of mind (both that day and in life more generally). Van Gogh had become a heavy smoker and heavy drinker and had taken a liking to the alcoholic drink absinthe. After cutting off his ear, he took it over to a local brothel and gave it to a prostitute called Rachel (telling her to take good care of it). He would have died of blood loss but the local police took him to the hospital.

This incident has given rise to what has been called the Van Gogh Syndrome which has now become a catch-all term for self-mutilation, particularly in relation to amputation of a bodily extremity (such as the cutting off of one’s own penis, or the removal of one’s own eye). Such actions may be due to a wide range of conditions including psychoses, mood disorders (e.g., clinical depression), body dysmorphic disorder, or as a component of Lesch-Nyhan syndrome (a genetic disorder that affects how the human body builds and breaks down purines).

Van Gogh would have been classed as a ‘psychotic self-mutilator’ in psychiatrist Karl Menninger’s self-mutilation typology developed in the 1930s. He proposed that self-mutilators fall into one of six categories:

  • Neurotic self-mutilators: These individuals comprise nail biters and pickers, extreme hair removal and those seeking unnecessary cosmetic surgery.
  • Religious self-mutilators: These individuals comprise self-flagellators and/or genital self-mutilators.
  • Puberty rite self-mutilators: These individuals comprise those who engage in hymen removal, circumcision or clitoral alteration.
  • Psychotic self-mutilators: These individuals engage in eye or ear removal, genital self-mutilation and extreme amputation.
  • Organic disease self-mutilators: These individuals comprise those who engage in repetitive head banging or hand biting, intentionally fracturing fingers and eye removal, due to diseases such as encephalitis or disorders such as severe mental retardation.
  • Conventional self-mutilators: These individuals comprise normal people that engage in customary or conventional forms of self-mutilation (that most would argue is not self-mutilation at all, e.g., nail clipping, hair trimming, and beard shaving).

More recent typologies tend to talk about self-harm rather than self-mutilation and class such behaviour into one of three types (i.e., psychotic, organic or typical). Again, Van Gogh would be classed as a psychotic self-harmer:

  • Psychotic self-harmers: These individuals comprise those who remove or amputate body parts (e.g., eyes, limbs, ears, genitals, digits). In these cases, body part removal is carried out in response to hallucinations bought on by psychosis. Unsurprisingly, this is the most severe type of self-harming.
  • Organic self-harmers: These individuals comprise those who self-harm in the form of behaviours such as head-banging and lip-biting because of conditions such as Autistic Spectrum Disorders, developmental disabilities, and other similar disorders. Here the self-harm is a consequence of physical or chemical issues in the body.
  • Typical self-harmers: These individuals comprise those who self-harm in the form of self-cutting, burning, hair-pulling (trichotillomania), skin-picking (dermotillomania), biting, hitting, interference with wound healing, scratching or bone-breaking. Here, the self-harm is initiated by emotional or psychological trauma that is unrelated to psychotic or organic conditions. This is the most common type of self-harming.

In a 2006 issue of the Journal of Deaf Studies and Deaf Education, Dr. David Veale reported that major self-injurious behaviours tend to “be very isolated events and consists of severe or life-threatening tissue damage, such as self-castration, eye nucleation, or less commonly self-amputation of a limb or ear. They mainly occur in young psychotic men or older males with psychotic depression usually in the context of command auditory hallucinations or delusions of guilt”.

Despite the fact that self-inflicted ear mutilation is well documented, there are surprisingly few published case studies. In 1989, Dr. J. Silver and colleagues published a case study of self-inflicted ear mutilation (as part of wider self-mutilation) in the journal Psychosomatics. Their case was a 35-year old male paranoid schizophrenic who presented for treatment following dermatological self-mutilation following severe lacerations (including the ear, arms, and face). They concluded that the self-mutilation behaviour appeared to be associated with his psychotic symptoms, and that the self-mutilation was exacerbated by failure to take his neuroleptic medication.

Dr. Christopher Alroe and Dr. Venkat Gunda reported some cases of self-inflicted ear mutilations in a 1995 issue of the Australian and New Zealand Journal of Psychiatry. They presented three cases of self-amputation of the ear by three white right-handed men. All three men had psychiatric problems (one having schizophrenia and two having personality disorders. They compared their cases with that of van Gogh. The authors also surveyed all Australian and New Zealand prisons to determine the frequency of self-mutilation of the ears within the last five years. They found only one other case. Based on the cases, they argued that connections exist between the self-amputees and supports the notion that self-mutilation is “contagious”.

It is also worth noting that there are cases of people who have cut off their ears but would not be classed as psychotic because they have done it for a very specific reason. The most recent case was that of British prisoner Michael O’Donnell who (on May 2, 2010) cut off his ear so that he could escape from an ambulance while he was being transported to hospital for treatment. In the end, it was all in vain as he was caught and re-arrested three weeks later.

Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Alroe, C.J., & Gunda, V. (1995). Self-Amputation of the Ear: Three Men Amputate Four Ears within Five Months. Australian and New Zealand Journal of Psychiatry, 29, 508-512.

Edwards, G. (1998). A brief history of ear mutilation. Deluxe. Located at: http://rulefortytwo.com/articles-essays/gallimaufry/ear-mutilation/

Menninger, K. (1935). A psychoanalytic study of the significance of self-mutilation. Psychoanalytic Quarterly, 4, 408-466.

Menninger, K. (1938). Man Against Himself. New York: Jovanovich.

Silva, J.A., Leong, G.B. & Weinstock, R. (1989). A case of skin and ear self-mutilation. Psychosomatics, 30, 228-230.

Press Association (2010). Prisoner who cut off ear to escape is recaptured. The Guardian, May 28. Located at: http://www.guardian.co.uk/uk/2010/may/28/prisoner-cut-off-ear-recaptured

Veale, D. (2006). A compelling desire for deafness. Journal of Deaf Studies and Deaf Education, 11, 369-372.