Psychopathological conditions and somatic consequences of a suicide attempt with a corrosive substance in a patient suffering from long-lasting paranoid schizophrenia - a case study


 
 Background: Schizophrenia is a chronic mental illness that affects 20 million people worldwide. Patients diagnosed with paranoid schizophrenia are characterized by cognitive deficits and the so-called negative symptoms, which significantly lower their quality of life and have implications for their independence and ability to fulfill various social roles.
 
 Aim: This study aims to present the case of a 49-year-old woman who has been suffering from schizophrenia for a long time and, due to a psychotic exacerbation with delusions and auditory hallucinations in the form of ordering voices, attempted suicide by ingesting a highly corrosive chemical agent used for unblocking pipes (the so-called “mole”).
 
 Case report: The patient was admitted to the 1st Department of Psychiatry, Psychotherapy and Early Intervention of SPSK 1 in Lublin for psychiatric treatment, after being transferred from the SPSK 1 Surgery Clinic, where she was initially admitted after the suicide attempt.
 
 Discussion: The psychotic exacerbation in the patient could have resulted from sensory deprivation due to her feeling of loneliness and deep social isolation.


Introduction
Schizophrenia is a chronic mental illness that affects 20 million people worldwide [1]. Compared to the general population, people with this condition are 2-3 times more likely to suffer premature death [2]. It has been reported that the number of individuals who attempt suicide but do not succeed is about 10-15 times greater than the number of people who die as a result of suicide [3]. Recent studies have also shown that women are more likely to attempt suicide than men [4,5].
In patients diagnosed with paranoid schizophrenia, symptoms such as impaired communication skills, difficulties in acquiring competences, and less satisfactory interpersonal relationships are observed, which significantly lower their quality of life and have implications for their independence and ability to perform various activities [6]. As a result of the increased burden associated with a long-term psychological problem, social isolation often worsens. This situation can be caused by the symptoms themselves but also through stigmatization by others, including relatives [7,8]. A potential consequence of social isolation, especially in a combination with a lack of social support, may be an increasing limitation of stimuli and information influx from outside, which is defined as sensory deprivation [9]. Short-term sensory deprivation can be a relaxing state; however, long-term exposure can lead to increased anxiety or even hallucinatory experiences. Such situation is particularly important for patients with long-term disease originated from endogenous psychosis, development or worsening the anxiety or the so-called productive psychopathology, along with hallucinations, delusions and disorganization [10].
Generally, in people diagnosed with schizophrenia, the factors that increase the risk of suicidal behavior include the presence of persecutory delusions, tendency of aggressive or impulsive behavior, previous suicide attempts, and the use of psychoactive substances [11]. Furthermore, studies have demonstrated that a majority of the patients with schizophrenia who commit suicide had productive symptoms (e.g. hallucinations), and prior to the attempt, experienced depressed mood, the severity of which often met the criteria of moderate and severe depressive episode [12]. In addition, nearly half of the patients with schizophrenia who attempted suicide had auditory hallucinations in the form of ordering voices, which, together with depressive symptoms, increase the risk of suicidal behavior [13].

Objective
In this paper, we present the case of a 49-year-old woman who has been suffering from schizophrenia for a long time and attempted suicide by ingesting a highly corrosive chemical agent during a psychotic exacerbation marked by delusions and auditory hallucinations in the form of commanding voices. We also discuss the somatic consequences of this suicide attempt, including damage to parts of the digestive and respiratory systems, which, along with the coexisting psychotic psychopathology, had a significant impact on the further psychiatric and somatic treatment.

Case report
Our case represents a 49-year-old female who had no children, had been trained as a farmer technician, and living alone for 2 years on a pension. Psychiatrically hospitalized seven times. During the long-term treatment, the patient was diagnosed with several types of psychiatric diseases including bipolar disorder and recurrent depressive disorders. She has been taking Risperidon 3 mg, Mianserin 10 mg, and Sodium Valproate 300 mg. Figure 1 presents the time course of the patient's subsequent hospitalizations and the treatment given.
The patient was admitted to the 1st Department of Psychiatry, Psychotherapy and Early Intervention of SPSK 1 in Lublin for psychiatric treatment, after being transferred from the Department of Surgery of SPSK 1 after a suicide attempt by drinking a corrosive agent used to unblock the pipes (the so-called "mole"). According to her account, she "felt fine" for six months and was in a stable mental state. The patient stated that her mental health deteriorated with the feeling of loneliness that intensified before Easter and that she experienced auditory hallucinations in the form of male voices, ordering her to commit suicide with the wording: "take a 'mole' and drink it." The patient was initially inactive in the ward, spending most of her time in bed and in a depressed mood. She reported increased feelings of guilt and sin and also complained of prolonged sleep latency. Although the patient declaratively denied productive symptoms during her stay in the Department of Psychiatry, her behaviors suggested that she was experiencing auditory hallucinations. She also denied suicidal tendencies when speaking with doctors, but spontaneously revealed resignation and suicidal thoughts in some instances. After 2 weeks of hospitalization, the patient admitted that she felt guilty and "sinful" about the attempted suicide. She was completely unaware of the morbid motivation of the suicide attempt. In addition to the above symptoms, her clinical picture revealed negative symptomatology as well as formal and content-related thinking disorders.
At the end of the second week of hospitalization, the patient reported increased difficulties in consuming food and fluids and was therefore administered intravenous fluid therapy. A surgical consultation was performed, during which esophagoscopy was performed. After a few days, the patient was transferred to the General Surgery Clinic for further diagnosis and treatment as she complained of discomfort with oral feeding.
An esophagoscopy revealed a severe inflammatory reaction throughout the pharynx, epiglottis, and esophagus mucosa. The esophagus was not obstructed by the apparatus at a height of about 30 cm. Therefore, a balloon expansion was performed, but transitions below were not achieved. The patient was transferred back to the Department of Psychiatry.
The results of imaging and laboratory tests carried out during psychiatric and surgical hospitalization are presented in Table 1. The findings were consulted with an internal diseases specialist who diagnosed that the patient had subclinical hyperthyroidism and tachycardia.
During hospitalization, Olanzapine 10 mg and Mirtazapinum 30 mg (per peg) were administered to the patient for gastrostomy. However, her mental state did not significantly improve after pharmacotherapy and other forms of therapeutic interactions. The level of criticism over the suicide attempt itself increased, while the underlying disease was not fully understood. Due to her psychological and somatic conditions, which included, inter alia, the inability to eat normally and constant risk of dehydration, the patient was referred to a Care and Treatment Institution.

Discussion
The described case of a patient diagnosed with schizophrenia, who attempted suicide under the influence of psychotic symptoms, illustrates the complications that can arise from both psychiatric interactions and treatment of the somatic consequences of the attempt. We believe that the psychotic exacerbation in the patient could have, at least partially, resulted from sensory deprivation due to her feeling of loneliness and deep social isolation.
In a person diagnosed with a mental illness, treatment of serious, physiological consequences of a suicide attempt encounters formal and legal difficulties. This is due to the fact that specialists other than psychiatrists may consider that such a person is fundamentally incapable of giving informed consent to perform certain medical procedures, including surgical interventions, which may prevent them from providing adequate medical care.
One of the greatest challenges of psychiatric treatment is the continuous development of community care organizations, the lack of which will significantly limit the provision of proper support to people with schizophrenia outside of hospital settings. The presented case demonstrates the potential consequences of the lack of community support in a long-term mentally ill people. An increased social isolation, which through many mechanisms, including interpersonal and sensory deprivation, may lead to the deterioration of mental health. Moreover, insufficient development of community

Abdominal ultrasound
A large number of reflections from bowel loops complicating complete evaluation; enlarged liver, homogeneous, hyperechoic features of steatosis; areas of lower echo corresponding to less fatty flesh at the gallbladder bed; extra-and intrahepatic bile ducts not dilated; gallbladder invisible; pancreatic area not available for examination; spleen not enlarged, homogeneous, normochogenic; kidneys are of typical size, with normal corticospinal structure, and no signs of urinary stagnation or reflections characteristic of textured deposits; a cyst with a left kidney septum, 23 mm in size; urinary bladder with smooth wall outlines; homogeneous uterus; abdominal aorta, perioral area visible fragmentarily, to the extent sufficient for examination without visible pathological changes; no evidence of free abdominal fluid

Chest X-ray
Increased bronchial and peribronchial drawing of the lower lung fields, right capacity; pulmonary fields with preserved aeration; vascular lung cavities, slightly thickened; silhouette of the heart is not enlarged; diaphragm on tie contours, with the left dome set high; a large gas bubble in the fundus projection

Laboratory tests
Glucose-125 mg/dl gamma-glutamyltransferase-78 IU/l Nt-proBNP-533 pg/ml D-dimer-2038 ng/ml CRP-292 mg/l TSH-0.0043 fT4-21.25 fT3-3.38 care also makes it impossible to effectively monitor the patient's mental state, including suicidal risk, as well as to continue somatic and psychiatric treatment, which would allow at least partial recovery after a suicide attempt.

Conclusions
To monitor suicidal risk in patients with paranoid schizophrenia, appropriate standards for dealing with a suicidal crisis should be proposed. There is a constant need for the development of community psychiatric care. Suicidal behaviors may have serious consequences for the somatic health of patients with long-term mental illness. Therefore, it is necessary to further develop the principles for organizing interdisciplinary medical care for this population.