Sir: Although suicidal behavior has been known to occur in patients with known schizophrenia and other psychotic disorders,1 the occurrence and frequency of underlying acute psychosis in victims of suicide attempts have not been well described.
I report the case of a trauma victim who had been hit by a car in an incident that initially appeared to be accidental; he was later revealed to have acute psychosis that had led to a suicide attempt.
Case report. Mr. A, a 36-year-old man, was brought to the emergency room (ER) in August 2007 after being hit by a car in traffic. He had some lacerations on his head and a broken femur. While being treated in the trauma unit, he was found to be talking to himself.
Neurology was consulted but was unable to find any neuroanatomical cause for the patient to be talking to himself. Psychiatry was consulted, and a detailed history was obtained. Mr. A then revealed that the accident was, in fact, a suicide attempt. He had been hearing the voices of his friends and family talking outside the wall. He was sad that they were saying bad things about him and hated him but were not willing to come in. He felt that his life was worthless.
Interestingly, the patient was seen in the ER of another institution for suicidal ideation only 1 night prior to this event. Unfortunately, he managed to escape from the ER that day after he suddenly became very suspicious of the ER staff. He felt deceived and disheartened. This heightened his feelings of worthlessness, and he ran into moving traffic to kill himself.
Apparently, Mr. A had been having troubles for the past few years. He had been divorced twice and was staying with his mother. He believed that his mother poisoned his food. Every time his mother said, “I love you, son,” he heard a small voice that followed immediately and said, “You know it is not true.”
He was admitted to an inpatient psychiatric unit and started on risperidone treatment.
This case illustrates an example of the high risk of suicidality associated with first presentation of frank psychosis. One Irish study2 showed that about 10% of patients present with suicide attempt as their first presentation of psychosis, and about 18% of patients will have a suicide attempt within 4 years of their diagnosis, of which 3% die from suicide. Suicide attempt, in fact, seems to be one of the common presentations of psychotic disorder. It is prudent to investigate any situation that may actually represent a suicide attempt and obtain a detailed history to look for any clues of psychosis.
Rashmi Ojha, M.D.
Creighton/Nebraska Psychiatry Residency Program, Omaha, Nebraska
Footnotes
Dr. Ojha reports no financial or other relationship relevant to the subject of this letter.
REFERENCES
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