Needles in Legs: A Response to Command Hallucinations

To the Editor: Command hallucinations are those that direct a person to perform certain acts. These may compel a patient to perform actions that can put the safety of the patient and others at risk. In fact command hallucinations have been regarded as ‘potentially the most dangerous symptoms of schizophrenia’.¹ There have been instances wherein patients have been subjected to significant injuries as a consequence of such behaviors. However, at times the acts in response to these hallucinations might get unnoticed despite of them being detrimental to the safety and health of the patient. We hereby present a case where a patient was inserting pins and needles in her body in response to command hallucinations. The act of the patient went unnoticed for two years.

Mrs S.B, a 42-year-old married female presented in the psychiatry OPD of the institute accompanied by son and husband. According to the informants, she had been suffering from a continuous illness which started after around a week of her marriage in 1986. The husband had noted that the patient complained of hearing voices which were not heard by him. She would report the voices to be coming from outside the house. She had been afraid because these voices which were intimidating and appeared distressed throughout. She would also be fearful of people wanting to cause her harm and hence stopped going outside the house. Her demeanor had changed and would not be reassured by the husband that no one was out to harm her. She was suspicious and withdrawn. She would at times be very irritable and at times threw household articles for no apparent reason. Sometimes she would repeat words incessantly for no apparent reason and at times she would utter things not understandable by the family members. Her sleep had been decreased and appetite was poor. Her social interaction had decreased and herself care was markedly impaired. She was not able to take care of the household and the husband took over the major responsibilities.

Around 2 years back, she disclosed that she had been hearing the voice of her sister-in-law all this time, at home though she was not seen. She was asked by the voice to insert needles in her right calf, hip and hands or grave consequences would befall her family. Afraid, she complied with the commands and kept on inserting sewing needles into her body, not telling the family members. As a result she would have pain in the calf. She was given X ray imaging of body limbs, chest and abdomen was carried out. X-ray of the hip joints (Antero-posterior view) (Figure 1) and knee joints (lateral view) (Figure 2) revealed multiple radiopaque shadows fitting the description of needles.

Examination revealed no sensory or motor neurological deficits, and no inflammation or sinus at the sites. The needles were not visible on the exterior. However, some of the needles had been pulled out by her at different occasions previously when they had become palpable. During the interview, she spoke in a low volume and was preoccupied with the needles and requested medications to dissolve them. Otherwise she was largely uncooperative.

She had been treated by different psychiatrists for the past 20 years with antipsychotics with a diagnosis of schizophrenia. There had been reluctance to take medications initially and her symptoms fluc-tuated over the time period. Presently has been maintained on Risperidone (4 mg per day) with clinical improvement and had been manageable at home, and had decrement in the voices that plagued her. Due to the needles in the calf and hip, orthopedics and surgery consultation was taken. Since there was no inflammation or neural or vascular impairment, active intervention for the needles was not deemed imperative.