On-line version ISSN 2078-5135
SAMJ, S. Afr. med. j. vol.99 n.4 Cape Town Apr. 2009
The quest for a groundless surgical procedure
MB ChB. Department of Psychiatry, University of Limpopo, Ga-Rankuwa
To the Editor: A 20-year-old male student first presented to the surgical outpatient department of a tertiary hospital at the age of 16 in 2003, when he complained of constipation, pain on defecation and flatulence, which he said had started when he was 12 years old. Findings on examination were normal and he was treated with stool softeners, reassured and discharged. From 2003 to 2006, he presented to the surgical department on numerous occasions. The working diagnoses included haemorrhoids, fissure in ano, constipation and incontinence of gas, but his anus was always found to be normal. Treatment included analgesics, stool softeners, antiseptics, antibiotics, dietary advice and reassurance. Despite his demands, no surgical procedures were performed.
It took 6 years for the patient to be referred to the psychiatry department. Apart from his visits to surgical outpatients, he had consulted his school teachers, an educational psychologist, a social worker and a clinical psychologist.
A psychiatric history revealed that the patient's symptoms went back to 2000, when he had consulted his priest about anger, a short temper and a bad smell that constantly surrounded him. Since then, according to his mother, he had behaved strangely. When people visited the family, he locked himself in his room and did not allow anybody near him. When watching TV, he complained of a smell that only he was aware of, and he insisted on sitting on paper to avoid the smell rising from underneath him. He stated that all the dogs in the neighbourhood constantly barked at him because he smelt of faeces, and that everybody looked at him and closed their nostrils when he was present. He felt guilty that people were breathing polluted air from his dysfunctional anus. Because of this, he had demanded a surgical procedure to reduce the size of his anus. During the first interview, he wore his uncle's trousers because all his own trousers were dirty. He had to wash his trousers one pair at a time because washing more than one would cause dogs in the neighborhood to bark. He was upset by his family, who complained that he was wasting washing powder. He felt depressed most of the time and had thought of committing suicide by jumping in front of a car or stabbing or shooting himself. He defecated on alternate days and felt very anxious after defecating. This anxiety was relieved by wiping his anus 10 times and washing after defecating. He took water to the toilet, and washed his entire body after defecating.
The patient had started school at age 7, had never failed, was usually top of his class and had passed grade 12 with an exemption and a distinction in physical science.
He was diagnosed as schizophrenic with depressive, obsessive and compulsive symptoms. The symptoms were remarkably reduced with antipsychotic therapy.
Obsessive-compulsive symptoms are frequent in schizophrenia.1-3 Evidence of obsessive-compulsive disorder (OCD) was found in 14% of 50 consecutive patients with first-episode schizophrenia; the mean age at onset of the obsessive-compulsive symptoms was 16.6 years.1 In 4 patients, the obsessive-compulsive symptoms were evident before occurrence of the schizophrenic symptoms. Other reports found OCD in 13 - 46% of patients with chronic schizophrenia.2,3
Although it is unclear whether it is possible to decrease the incidence of schizophrenia, treating prodromal symptoms early and sustained pharmacological interventions can improve its long-term course.4
An early diagnosis would have saved the patient and his family considerable suffering. A high degree of suspicion of psychiatric disease should be borne in mind when faced with unexplained recurrent complaints in the absence of physical abnormalities.
I acknowledge with thanks the support in various forms that I received from Professor S T Rataemane, Professor Ralph Kirsch, Dr A A Motojesi, the Dr George Mukhari Hospital and Limpopo University, Ga-Rankuwa.
1. Poyurovsky M, Fuchs C, Weizman A. Obsessive-compulsive disorder in patients with first episode schizophrenia. Am J Psychiatry 1999; 156: 1998-2000. [ Links ]
2. Fenton WS, McGlashan TH. The prognostic significance of obsessive-compulsive symptoms in schizophrenia. Am J Psychiatry 1986; 143: 437-441. [ Links ]
3. Berman I, Merson A, Viegner B, Losonczy MF, Pappas D, Green AJ. Obsessions and compulsions as a distinct cluster of symptoms in schizophrenia: a neuropsychological study. J Nerv Ment Dis 1998; 186: 150-156. [ Links ]
4. Wyatt R. Early intervention for schizophrenia: Can the course of the illness be altered? Biol Psychiatry 1995; 38: 1-3. [ Links ]
Accepted 26 September 2008.
Corresponding author: A Lawrence (firstname.lastname@example.org)