A 31-year-old male presented with features of remaining aloof, sad, having prominent guilt ideas and entertaining thoughts of causing self-harm. The symptoms had developed insidiously when his wife learnt about his extramarital affair with a known relative. After his wife left him, the feelings of low mood became more intense and he started to entertain suicidal thoughts. While driving his motorcycle in the night, he met with an accident and started to bleed profusely. He tasted his own blood and liked the smell and taste of it. Thus, the frequent incidences of wrist cutting started so that he could suck his own blood. The act would be preceded by a mounting tension and arousal and subsequent relief would be noted later. He would break bottles and, with the glass pieces, would slash his palm, wrist and feet to see and feel the blood. He would also chew the glass pieces and the hurt caused by the glass pieces to his cheek and lips would actually be enjoyed by the individual. He even resorted to head banging so that the injuries caused to the scalp would produce more blood. As his unusual behavior was noted, he was admitted to the psychiatric center. While he was admitted to the hospital, he remained symptomatic. He was noted to remain quiet and aloof only to be shattered with episodic outbursts of intense anger and aggression. He assaulted other inpatients and derived pleasure from this fact. The episode lasted from 15 to 30 min and subsided on its own. The individual would remember the incident, but would give no reasonable explanation for his acts of violence.
He even consumed dettol solution with the intent to taste it after there was insurmountable anxiety before the act. He denied history of seizures, head injury or amnesia. There was no history suggestive of psychoses. He denied having any guilt ideas for his acts of aggression and denied a past history of similar episodes. He accepted consuming alcohol on several occasions but denied the relation of carrying out his episodic outbursts of violence to alcohol intake. Detailed premorbid history revealed him to be a rebellious student who had made violent protests during student election campaigning and even stabbed an opponent leader. He was also rusticated from school for several months. He had one broken love affair in college.[ ]
A detailed medical evaluation and central nervous system evaluation were not significant. All hematological and biochemical parameters were within normal limits. Computed tomography (CT) scan and electroencephalogram (EEG) were normal. Mental state e xamination revealed him to be a depressed individual who had passive suicidal ideations with deranged biodrives. No thought disorder or perceptual anomalies were noted. Psychometric tests were carried out, which revealed the following:
Rorschach test revealed impulsivity, poor ego strength, no paranoid traits but low productivity.
Personality inventory showed him to be irritable, with impulsive traits, and a cyclothymic mood.
Bender Gestalt test : Organizational disturbances and poor visuomotor sequencing were noted.
BDRS score of 16, which showed mild to moderate depression.
He was managed with behavioral therapy, individual therapy, selective serotonin reuptake inhibitors that included Cap. Fluoxetine 20 mg OD and mood stabilizers that included Tab. Divalproex 1 g BD and Tab. Lamotrigine 50 mg BD. A typical antipsychotic that included Tab. Largectil 1800 mg/day was added along with Tab. Propanolol 40 mg BD. Gradually, his spouse also agreed and was initiated in the therapy, which proved beneficial. After 6 months of follow-up, the individual remained asymptomatic and there were no incidents of episodic outbursts or undirected aggression. There was no evidence of prominent depressive cognitions.