Missing the point: self-inflicted traumatic brain injury in psychosis

• Published in: BMJ case reports 2016-12, Vol.2016, p.bcr2016216767
• Main Authors: Maruca-Sullivan, Phelan E, Goldenberg, Matthew N, Cone, David C, Ciarleglio, Justine
• Format: Article
• Language: English
• Subjects: Acute Disease; Adult; Attention Deficit Hyperactivity Disorder; Bipolar disorder; Brain - diagnostic imaging; Brain Injuries, Traumatic - diagnostic imaging; Brain Injuries, Traumatic - psychology; Cerebral Hemorrhage - diagnostic imaging; Cerebral Hemorrhage - psychology; Cerebral Hemorrhage, Traumatic - diagnostic imaging; Cerebral Hemorrhage, Traumatic - psychology; Delayed Diagnosis; Emergency medical care; Foreign Bodies - diagnostic imaging; Foreign Bodies - psychology; Headache Disorders - psychology; Humans; Male; Patients; Psychosis; Psychotic Disorders - complications; Reminder of Important Clinical Lesson; Schizophrenia; Self-Injurious Behavior - diagnostic imaging; Self-Injurious Behavior - psychology; Skull Fractures - diagnostic imaging; Skull Fractures - psychology; Stabbings; Temporal Bone - injuries; Tomography, X-Ray Computed; USA/Canada; White; Wounds, Penetrating - diagnostic imaging; Wounds, Penetrating - psychology
• ISSN: 1757-790X; 1757-790X
• DOI: 10.1136/bcr-2016-216767

A 36-year-old man was brought to the emergency department by emergency medical services after being found acting unusually at a gas station with blood on his head and clothing. He presented acutely psychotic and reported that he had a pen in his head. Medical evaluation was notable for a superficial puncture wound to the right temple, and he was medically cleared for psychiatric evaluation. After he developed nausea and headache later that evening, the CT scan revealed a temporal bone fracture, pneumocephalus, intraparenchymal haemorrhage and the presence of a metal pen tip lodged in the brain parenchyma. The full nature of the injury went undiscovered in the emergency department for 16 hours due to the superficial appearance of the injury and his acute psychosis with prominent delusional thought content and disorganisation. He underwent craniotomy with removal of the pen and subsequent hospitalisation for intravenous antibiotics, followed by a prolonged psychiatric hospitalisation for psychosis.