|Year : 2015 | Volume
| Issue : 3 | Page : 222-224
Van Gogh syndrome: A rare case of bilateral ear mutilation
MK Goutham, Rajeshwari Aroor, Vadish Bhat, Marina Saldanha
Department of ENT and HNS, K S Hegde Medical Academy, Deralakatte, Mangalore, Karnataka, India
|Date of Web Publication||17-Jul-2015|
M K Goutham
Department of ENT and HNS, K S Hegde Medical Academy, Deralakatte, Mangalore, DK, Karnataka
Source of Support: None, Conflict of Interest: None
Self-injury is the intentional and direct injury to self that include bite, burn, ulceration, and head banging. Repetitive self-mutilation is termed the van Gogh syndrome after Vincent van Gogh a renowned Dutch painter of late 19 th century, who during a bout of psychosis deliberately mutilated his ear. Self-mutilation of ears is a rare condition seen usually in patients with mental illness. An unusual case is presented of a psychotic young man who experienced command auditory hallucinations which directed him to amputate his own ears.
Keywords: Command hallucinations, Ear self-mutilation, Schizophrenia, Van Gogh syndrome
|How to cite this article:|
Goutham M K, Aroor R, Bhat V, Saldanha M. Van Gogh syndrome: A rare case of bilateral ear mutilation. Indian J Otol 2015;21:222-4
| Introduction|| |
Perhaps van Gogh is the first name to ring in our minds if we hear about "self-inflicted ear mutilation." Vincent van Gogh a notable post-impressionist painter was famous not only for his art which was rich in rough beauty, emotional honesty and bold colors but also for the self-mutilation of his ear. He had cut the lower half of his left ear with a razor and gave it to a sex worker telling her to take good care of it. He sustained heavy blood loss and was found unconscious in his bed the following morning by the police. 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.
Deliberate self-injury is defined as the intentional, direct injuring of body tissue without suicidal intent.  There are different types of deliberate self-mutilating behaviors like self-cutting, phlebotomy, bites, burns, or ulcerations. Sometimes, especially among psychotic inpatients, eye, tongue, ear or genital self-mutilations have been reported. 
Self-mutilation of various sorts occurs in an appreciable number of individuals with schizophrenia.  Regardless of the act, self-injury is different than a suicide attempt in that death is not the conscious goal. Rather, the goal is often to numb painful feelings or punish oneself in some way. However, in individuals with psychosis, it is typically due to a delusional belief (e.g., the person believes his hand is evil, so he cuts it off) or in response to command auditory hallucinations - voices telling the person to harm him/herself in some specific way. Many patients with schizophrenia develop varying degrees of pain insensitivity and are less susceptible to bodily discomfort than normal individuals. 
| Case Report|| |
Our patient is an 18-year-old male who is a known case of schizophrenia. He had a history of decreased interaction, avoiding family members, suspicious behavior toward mother, and socially withdrawn since 3 years. History of nonadherence to medications and not willing to attend college is also reported. Off late his symptoms were getting worse and was complaining of voices in his head. He had locked himself up since few days. One morning he was found in his bed which was fully stained with blood and with his ears bleeding profusely. He had completely amputated his both ears with a pair of scissors and had flushed it down the drain! He was rushed to the hospital immediately and was given first aid. History revealed that his father was suffering from schizophrenia.
On examination, both his ears were completely amputated leaving a small rim of cartilage in some areas [Figure 1]. Cartilage was exposed all around. Psychiatric evaluation concluded that he was suffering from command hallucinations which ordered him to cut-off his ears. Such was the influence of his hallucinations that he was willing to cut his nose and enucleate his eyes next! He was diagnosed with paranoid schizophrenia and started on antipsychotics and sedatives following which the patient is improving. The wound healed well after putting him on antibiotics and daily dressing [Figure 2] and [Figure 3]. Plastic surgery opinion was taken regarding ear reconstruction.
| Discussion|| |
Self-mutilating behavior has been observed in 10-15% of healthy children, especially between the age of 9 and 18 months. These self-mutilations are considered as pathological after the age of 3 years.  It is common among adolescents, psychiatric patients, and in females.  It is often associated with addictive behavior, suicide attempt, and metabolic syndromes like Lesch-Nyhan and Munchausen's syndrome. Collectively all these self-mutilating behaviors are termed as van Gogh syndrome.
The self-injurious behavior of various sorts occurs in an appreciable number of individuals with major depression, borderline personality disorder, and schizophrenia.  Reports of self-mutilation, the most dramatic example of self-injurious behavior, in patients with schizophrenia include descriptions of unilateral and bilateral eye enucleation,  self-laceration, , self-amputation of various parts of the body, including the hand,  breast,  ear,  penis and testicles, , and, in what is arguably the most extreme case reported to date, virtually the entire face. 
It has been noted that during their acts of self-mutilation these individuals seem to have been in what has been termed a state of "psychotic analgesia."  Studies suggests that this absence of pain may be related to the blunted affect that is characteristic of schizophrenia.  In patients who are felt to be at extremely high risk, careful monitoring, and rapid medication schedules might be effective in preventing such an incident.
| Conclusion|| |
Self-mutilation is one of the rare but a serious complication of Schizophrenia and other mental disorders. It is usually of nonsuicidal intention. It is mostly seen in patients with command hallucinations. Continued investigation of pain insensitivity in schizophrenia and its relationship to other biobehavioral aspects of the disorder is necessary for an increased understanding of the underlying this phenomenon, including affective flattening.
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[Figure 1], [Figure 2], [Figure 3]