Mr. S is a 31-year-old, single, unemployed gentleman from a low socioeconomic Tamil-speaking background, who first came to psychiatric hospital in 2003 at the age of 17 years within 10 days of onset of symptoms of psychosis and mania. He was treated with tablet risperidone up to 4 mg/day. He responded well and even went back to school. After 9 months of regular treatment, he stopped medicines. Two months after stopping of medicines he had relapse of psychotic symptoms including Schniderian first rank symptoms without any mood symptoms. His diagnosis was revised to paranoid schizophrenia. He failed trials of tablet risperidone 8 mg/day, tablet olanzepine 25 mg/day, a course of 10 sittings of electroconvulsive therapy, and injection fluphenazine decanoate depot 100 mg intramuscular every month. He did not show significant improvement. He was started on tablet clozapine and the dose was gradually built up to 450 mg/day by 2007. He was on regular follow-up for 9 years during which he had fluctuations in psychiatric symptoms but was managing well without any physical health issues.\nIn 2016, he developed pain in the left lumbar region following trivial trauma (while using a crowbar) and later developed a swelling in the region for which incision and drainage were done at a primary health center. When the ulcer did not heal for about 3 months, he was referred to a surgical department of a teaching hospital for further management. The non-healing ulcer in the incision site of left lumbar gradually had increased in size and was associated with passage of air through the ulcer while defecating or straining. There was no history of abdominal distension, vomiting, obstipation, hematemeis, malena, or fever. Physical examination revealed a soft non-tender abdomen.\nRoentgenogram of abdomen and ultrasonography investigations revealed a foreign body in the abdominal cavity just below the diaphragm without any other features of obstruction or perforation. Contrast-enhanced computer tomography and magnetic resonance imaging revealed a linear foreign body forming a fistula communicating with splenic flexure of the colon [].\nThe patient was posted for elective exploratory laparotomy. On laparotomy, an intact ball point pen of size about 11 cm in length was found to be the foreign body with its tip inside the lumen of splenic flexure and its rear end facing the external ulcer []. The pen was carefully delivered through the external wound and the sealed perforation of size 1 × 1 cm was closed primarily []. Postoperative period was uneventful and the patient was discharged on the 11th postoperative day.\nThe patient recollected that he had swallowed the very same pen in 2004 when he had been very psychotic []. He reported that he had vague abdomen pain on and off, which he did not feel serious enough to report. There was no record of abdomen pain in the patient's case notes over the previous 13 years.\nHe is doing physically well and is on regular follow-up. He is not regularly employed but helps his family in household chores. He is currently on clozapine 450 mg/day, on which he has a serum level was 933 ng/mL.
A 36-year-old single unemployed man who was first diagnosed with schizophrenia by a psychiatrist about 12 years ago is described here.\nHe remained in school until the eighth grade, when his abnormal behaviors at school caused him to stop his education. Also, for the same reason, he was fired from his job 2 years ago. He has been smoking cigarettes since 12years ago, and he started to smoke opium 11 years ago.\nHe did not have any evidence of brain damage or any major medical illnesses. He was the second child in a family of 6 with low socio-economic status. His parents were consanguineous and had no physical or mental abnormalities, although one of his younger brothers suffered from mental retardation. During the 12 years of his disease, he has been treated in both outpatient and inpatient settings. Due to exacerbation of his symptoms, he was admitted to a psychiatric ward on 4 occasions, and the course of his illness shows a fluctuating clinical picture. Since his first disease symptoms, he was diagnosed with personality disorder (borderline type), bipolar disorder, and even factitious disorder. His compliance with taking the prescribed medications and attending follow-ups has been very poor.\nDuring the initial phase of his illness, he had prominent positive features, occasional violent outbursts, and delusions of persecution regarding his family and neighbors. All of his hospital admissions were due to psychotic exacerbations, which initially manifested as violent behavior and aggression towards others and then progressed to delusions of persecution, delusions of reference, and both auditory and visual hallucinations. During this phase of his disease, he was diagnosed with schizophrenia. He had a good appetite, but was suffering from early and terminal insomnia. He also had a history of self-mutilation from about ten years ago, but at the time of visit had no suicidal or homicidal thoughts or plans. His initial treatment plan included Valproic acid 200mg tablets TID (600 mg/day) and an Olanzapine tablet 5mg per day. Two years ago, this regimen was changed by his psychiatrist to Haloperidol 5 mg BID (10 mg/day), Biperiden 2 mg/day, Clonazepam 1 mg/day, Citalopram 20mg BID (40 mg/day), and Propranolol 10mg BID (20 mg/day) prescribed as oral medication. During his hospital admissions, he made steady recoveries, but his follow-ups and compliance were poor. All of his laboratory work-ups and brain computed tomography scans (CT scans) were normal and his electroencephalograms (EEG) showed no abnormalities.\nDuring his fourth and last admission, he was brought to the emergency department because of severe abdominal pain. He had abdominal tenderness in his physical examination and his vital signs were stable. His abdominal X-ray revealed the ingestion of a metallic skewer that was broken apart (). After surgical consultation, endoscopic removal of the objects was suggested, but about an hour later the patient became medically unstable and had a board-like abdomen in his examination. After a second evaluation by a surgical team, the patient was diagnosed with intestinal perforation and an emergency exploratory laparotomy with enterotomy was performed. The surgery was without complications, and metallic items were removed from the patient’s abdomen. He had an uneventful postoperative recovery.\nAfter his recovery, at the subsequent psychiatric follow-up visit, he explained his motive for ingesting the metallic skewer and revealed that a demon that had been living inside his body had been controlling him for the previous three months. He insisted that the demon wouldn’t let him tell the psychiatrists about its existence and wanted to control and use his soul to destroy the world. He believed that he could fight and kill the demon by ingesting the metallic skewer.\nTwo weeks after abdominal surgery, the patient attended our psychiatry outpatient clinic twice. He continued to have delusions of persecution and reference; however, he was convinced that because the surgery involved opening his abdomen, the demon had left his body and there was no need to fight with him anymore. Due to close monitoring by his family members, he did not ingest any further non-food items. Also, this close monitoring helped him have better compliance with his psychiatric visits and therapies.