Why..
https://jamanetwork.com/journals/jama/article-abstract/364889
A 22-year-old man came to the emergency room stating that during the previous eight hours he had been operating on himself, attempting to denervate his adrenal glands. After handing the intern a detailed sheet of self-written instructions for "deep abdominal wound repair," he explained that he had been unable to complete the procedure. He had become extremely tired and was experiencing more pain than anticipated in retracting his liver; therefore, he came to the emergency room for wound closure and postoperative care. On examination his vital signs were stable, and he appeared in no acute distress. A 14-cm incision, from his xiphoid process to and around his umbilicus and extending through the peritoneum into the abdominal cavity, was apparent after removal of his abdominal bandages.
The patient was taken to the operating room, where exploration of his abdominal cavity was performed. There was minimal bleeding from the wound's edges, and the peritoneal cavity was found to be clean and packed with gauze bandages. Thread ligatures were tied around major vessels, and his abdominal viscera were free of injury. His wound was cleansed and irrigated with an antibiotic solution; appropriate closure was performed.
On the third postoperative day, during psychiatric evaluation, he explained both why and how he performed the surgery. He stated that the peripheral catecholamines circulating in his system caused him to be unduly nervous and were responsible for his "mental illness." He had spent several months preparing for the procedure and acquiring the necessary surgical instruments and medications. He had also spent many hours a day in the medical library studying surgical texts and learning the most recent research on the adrenal gland and peripheral catecholamines.
The Laporatomy.—At four o'clock on the morning of his surgery, he disinfected his dormitory room with spray disinfectant and alcohol and draped an area with sheets that he had previously sterilized. For anesthesia, he took oral barbiturates. He also took hydrocortisone and prepared a canister of vaporized adrenalin, readying himself for a possible shock syndrome. He performed the procedure wearing sterile gloves and a surgical mask.
Lying supine and looking into strategically placed mirrors to obtain an optimum view, he began by cleansing his abdomen with alcohol. The incision was made with a scalpel, exposure obtained by retractors, and the dissection carried out with surgical instruments. Lidocaine hydrochloride was injected into each successive tissue layer during the opening. He controlled hemostasis with locally applied gelatin powder, while sterilized cotton thread ligatures were used for the larger vessels. After eight hours he had had minimal blood loss but was unable to obtain
adequate exposure to enter the retroperitoneal space because of the unexpected pain in retracting his liver. Exhausted, he bandaged his wound, cleaned up his room, and called the police for transport to the hospital because of a "rupture."
Past History.—The patient denied any
family history of schizophrenia or affective or seizure disorder. He recalled an isolated and lonely childhood and felt that he was ridiculed for being "weird" in elementary school. As an adolescent, masturbating gave him temporary relief from anxieties and tensions. Soon he was
masturbating three times a day and believed that it was involuntary and out of his control. He said he feared that "it was destroying my body and nervous system."
By age 21 years he had had coitus three times and found it bothersome. One month after his last "sexual session" he went to a urology clinic seeking a bilateral orchiectomy to save him from his "hyperaggressiveness." The woman he had intercourse with "told me I was a bad lover; I kissed her too hard, I hugged and banged into her too hard." He stated: "I'm no homosexual
or transsexual. I still want a hugging and
kissing relationship with a woman."
After being rejected for the orchiectomy, the patient began self-medication with a progestational agent, norethindrone acetate, 4 mg daily; conjugated estrogens, 1.5 mg daily; and hydrocortisone, 10 mg daily. He continued this regimen during the next seven months with the purpose of "decreasing the secretion of
[luteinizing hormone] LH, [follicle-stimulating hormone] PSH, and [adrenocorticotrophic hormone] ACTH from my pituitary gland." He experienced these months as a "time of well-being," relatively free from the turmoil that had previously overwhelmed him. In addition, he noted a decrease in his sexual thoughts and fantasies and his ability for erection.
At this point, he decided to immunize himself against his own luteinizing hormone-releasing hormone (LH-RH) by attempting to induce an autoimmune response. He reasoned that this should decrease the pituitary gland's secretion of
FSH and LH with a consequent decrease
in his testosterone level, thus permanently
maintaining his sense of "well-being."
He prepared a mixture of bovine serum
albumin, conjugated LH-RH, and Freund's
adjuvant and administered it both intradermally and subcutaneously at eight sites in his anterior lower legs. Within two weeks, this led to abscess formation, which required hospitalization in another city for treatment. At that time his serum
testosterone level was 30 ng/dL (normal male, 350 to 1,200 ng/dL). Because he had also continued taking the female hormones, it was impossible to tell if his lowered testosterone level was due to the self-immunization procedure. He was later transferred to the psychiatric ward, and
the diagnoses of schizophrenia, possible temporal lobe epilepsy, and gender identity problems were made.
At that time his mental status was
described as follows: "There were no loose
associations. The patient was circumstantial and tangential at times; his belief that his difficulties arose from too much libido, which would be solved by becoming asexual, reached delusional proportions. There was no evidence of hallucinations. Affect was occasionally labile, but usually appropriate."
A 22-year-old man came to the emergency room stating that during the previous eight hours he had been operating on himself, attempting to denervate his adrenal glands. After handing the intern a detailed sheet of self-written instructions for "deep abdominal wound repair," he explained that he had been unable to complete the procedure. He had become extremely tired and was experiencing more pain than anticipated in retracting his liver; therefore, he came to the emergency room for wound closure and postoperative care. On examination his vital signs were stable, and he appeared in no acute distress. A 14-cm incision, from his xiphoid process to and around his umbilicus and extending through the peritoneum into the abdominal cavity, was apparent after removal of his abdominal bandages.
The patient was taken to the operating room, where exploration of his abdominal cavity was performed. There was minimal bleeding from the wound's edges, and the peritoneal cavity was found to be clean and packed with gauze bandages. Thread ligatures were tied around major vessels, and his abdominal viscera were free of injury. His wound was cleansed and irrigated with an antibiotic solution; appropriate closure was performed.
On the third postoperative day, during psychiatric evaluation, he explained both why and how he performed the surgery. He stated that the peripheral catecholamines circulating in his system caused him to be unduly nervous and were responsible for his "mental illness." He had spent several months preparing for the procedure and acquiring the necessary surgical instruments and medications. He had also spent many hours a day in the medical library studying surgical texts and learning the most recent research on the adrenal gland and peripheral catecholamines.
The Laporatomy.—At four o'clock on the morning of his surgery, he disinfected his dormitory room with spray disinfectant and alcohol and draped an area with sheets that he had previously sterilized. For anesthesia, he took oral barbiturates. He also took hydrocortisone and prepared a canister of vaporized adrenalin, readying himself for a possible shock syndrome. He performed the procedure wearing sterile gloves and a surgical mask.
Lying supine and looking into strategically placed mirrors to obtain an optimum view, he began by cleansing his abdomen with alcohol. The incision was made with a scalpel, exposure obtained by retractors, and the dissection carried out with surgical instruments. Lidocaine hydrochloride was injected into each successive tissue layer during the opening. He controlled hemostasis with locally applied gelatin powder, while sterilized cotton thread ligatures were used for the larger vessels. After eight hours he had had minimal blood loss but was unable to obtain
adequate exposure to enter the retroperitoneal space because of the unexpected pain in retracting his liver. Exhausted, he bandaged his wound, cleaned up his room, and called the police for transport to the hospital because of a "rupture."
Past History.—The patient denied any
family history of schizophrenia or affective or seizure disorder. He recalled an isolated and lonely childhood and felt that he was ridiculed for being "weird" in elementary school. As an adolescent, masturbating gave him temporary relief from anxieties and tensions. Soon he was
masturbating three times a day and believed that it was involuntary and out of his control. He said he feared that "it was destroying my body and nervous system."
By age 21 years he had had coitus three times and found it bothersome. One month after his last "sexual session" he went to a urology clinic seeking a bilateral orchiectomy to save him from his "hyperaggressiveness." The woman he had intercourse with "told me I was a bad lover; I kissed her too hard, I hugged and banged into her too hard." He stated: "I'm no homosexual
or transsexual. I still want a hugging and
kissing relationship with a woman."
After being rejected for the orchiectomy, the patient began self-medication with a progestational agent, norethindrone acetate, 4 mg daily; conjugated estrogens, 1.5 mg daily; and hydrocortisone, 10 mg daily. He continued this regimen during the next seven months with the purpose of "decreasing the secretion of
[luteinizing hormone] LH, [follicle-stimulating hormone] PSH, and [adrenocorticotrophic hormone] ACTH from my pituitary gland." He experienced these months as a "time of well-being," relatively free from the turmoil that had previously overwhelmed him. In addition, he noted a decrease in his sexual thoughts and fantasies and his ability for erection.
At this point, he decided to immunize himself against his own luteinizing hormone-releasing hormone (LH-RH) by attempting to induce an autoimmune response. He reasoned that this should decrease the pituitary gland's secretion of
FSH and LH with a consequent decrease
in his testosterone level, thus permanently
maintaining his sense of "well-being."
He prepared a mixture of bovine serum
albumin, conjugated LH-RH, and Freund's
adjuvant and administered it both intradermally and subcutaneously at eight sites in his anterior lower legs. Within two weeks, this led to abscess formation, which required hospitalization in another city for treatment. At that time his serum
testosterone level was 30 ng/dL (normal male, 350 to 1,200 ng/dL). Because he had also continued taking the female hormones, it was impossible to tell if his lowered testosterone level was due to the self-immunization procedure. He was later transferred to the psychiatric ward, and
the diagnoses of schizophrenia, possible temporal lobe epilepsy, and gender identity problems were made.
At that time his mental status was
described as follows: "There were no loose
associations. The patient was circumstantial and tangential at times; his belief that his difficulties arose from too much libido, which would be solved by becoming asexual, reached delusional proportions. There was no evidence of hallucinations. Affect was occasionally labile, but usually appropriate."