Repeated Self-Mutilation and ECT

Mr. A had been given multiple courses of neuroleptics, antidepressants, and mood stabilizers, but he continued to manifest command auditory hallucinations, various religious delusions, and sporadic depressive symptoms. He continued to throw himself down stairs (once requiring plastic surgery for a severe head wound), pulled out his fingernails with his teeth, and attempted to catch a chain saw with his bare hands, severely injuring his right hand. He was then given a year-long trial of clozapine at therapeutic plasma levels—again without success. By then he had accumulated over 2,200 hospital days.

On referral to our hospital, he was given 10 bilateral ECTs at a suprathreshold charge, but on return to his primary hospital, he relapsed into serious self-mutilative behaviors within 1 month. On return, he was again given 10 bilateral ECTs. Haloperidol decanoate, 100 mg/month, was initiated, as well as fluvoxamine, 200 mg at bedtime (both medications had been given previously). Arrangements were then made for him to be transferred to our facility every 2 weeks for maintenance ECT. The interval between the maintenance treatments was gradually lengthened over the next 21 months, during which time he has experienced only one instance of minor self-injurious behavior. He is able to hold a steady job and reside in a board-and-care home with only minimal supervision. In marked contrast to the previous 10 years, he has required no emergency hospitalization.