Mr. C, aged 32, poured molten lead into his right eye during a period of great emotional distress and during a time when pharmacological treatment for his depression was not producing any beneficial effect. We call such an action incomplete oedipism since the patient did not enucleate the eye, but merely damaged it. After the injury, he was hospitalized for a long period and, after much medical treatment, had an almost normal eye. Destroying the eye was, according to his words, a way of blackmailing his parents. One evening, he had quarreled with his parents who had denied him permission to buy a motorbike. As a result, he decided to punish them by damaging his own eye. This action took place after a long history of psychiatric treatment, including prescription of a wide variety of psychotropic drugs, ranging from neuroleptics to antidepressants, as well as atypical antipsychotics.
He had experienced at least three previous depressive episodes but no hypomania. His first depressive episode was at the age of twenty. At time of our evaluation a DSM-IV diagnosis of major depression was made comorbid with DSM-IV-TR delusion disorder (persecutory type). One of his main symptoms was a paranoid delusion that other people, and in particular people living in his neighborhood, stared at him all the time and laughed at him. This belief made the patient angry and depressed since, as a result, he felt unable to leave his home and, in addition, he experienced great anxiety.
He grew up in a very disturbed family. His sister had a serious obsessive-compulsive disorder. His elderly parents lacked empathy and showed hysterical and obsessive behaviors. His relationship with his mother was very disappointing for him as she was emotionally distant. She would blackmail his father by pretending to faint and by lying on the floor as if dead. The father rejected his son, fearing that he could get infected by the patient. The father said that he had not wanted him, and he ignored the son.
The patient had experienced a homosexual relationship during his teens and showed some perversions involving women. He used to meet prostitutes in the street, but only to ask them if they offered the kind of sex for which he was looking. He became excited thinking of sexual relationships with very old ladies or performing bizarre sexual acts, but he experienced guilt over these thoughts and desires.
During our first meeting with the patient, he was anxious, depressed and very insecure. He could not engage in any social interaction and was afraid of other people's judgment. He confessed that he engaged in deliberate self-harm almost daily (such as cutting or inserting needles under his skin) in order to reduce his deep anxiety, anger and dysphoria. A central feature of this patient was his suicidal intent as he always felt hopeless and depressed, unable to have friends, a girlfriend or sustained social interactions. He had never attempted suicide, but he had a detailed plan for killing himself. He intended to jump from a window if he experienced another serious depressive episode. He had guilt delusions based on the large amount of money spent for his eye treatments. He also had hypochondriac delusions apparently based on mild ailments which were later identified as side-effects of the medications that he was taking.
Another feature of his personality was somatic anxiety. His disorder distressed him in two totally different areas. On one hand, he felt excited by his desires and thoughts; on the other one hand he felt guilt over them and condemned them. This guilt led to anxiety and anger, resulting in deliberate self-harm and suicidality.
One of the authors (MP) treated him with regular sessions of psychotherapy. At the beginning the patient was reluctant to talk. He focused on his everyday difficulties, especially his belief of being stared by other people. After a few months of psychotherapy, the patient revealed important facts of his childhood life, especially related to his parents' behavior. His mother was described as cold and lacking feelings. The patient had experienced very strong hatred for his parents for which he felt guilty. This severe guilt led him to the eye injury. Contrary to expectations, the eye self-injury in our patient was not related to any religious belief. Psychotherapy also addressed his negative transference feelings which were always covered with politeness and compliance with the therapy.
At the time that he applied for a psychiatric consultation, he felt hopeless and helpless but highly motivated to start a new treatment. We prescribed quetiapine 800 mg a day, lamotrigine 200 mg a day and lithium carbonate 600 mg a day. We also gave him the chance to start psychodynamic psychotherapy with one or two sessions per week depending on factors such as his occasional request to meet therapist twice a week, suicidal crises or serious episodes of hopelessness.
After eighteen months, the patient had dramatically improved. Not only did he feel less depressed and more positive about the future, but he was able to talk about the eye injury without feeling guilty, recalling the stressful period during which he had injured his eye. He was also less suicidal, reporting thoughts of suicide only from time to time.