As per the 'New Orange Plan' published by Ministry of Health, Labor and Welfare in 2016 states that elderly people suffering from dementia, will be about 700 million people by 2025 in Japan. By the increase in elderly ratio, not only dementia increases but also schizophrenia, delusional disorders, depression, mania, and insomnia in elderly are also expected to increase.
Suicide rate in Japan is also high. The suicide cases were above 30,000 in 1998, which increased to 34,427 in 2003. Then it gradually decreased to 21,897 in 2016 but the suicide rate at the age of more than 60 years is the highest, accounting for about 40%. Morbidity of depression is said as a risk factor of suicide by elderly people.
In this case, we have discussed about a 77 year old man, who was in depressed mood. His wife was also unaware with his depression; he often had quarrels and at last committed suicidal genital self-mutilation.
Elderly, Impulsivity, Suicide, Genital, Penile self-mutilation, Depression
A 77-years-old man was transported by an ambulance because of genital self-mutilation on his left flank and penis by using branch-cutting scissors at home.
Spinal stenosis neurogenic bladder was reported. Originally, patient gets angry with a short temper.
He came from the country area, he was born as the eldest son among four. His parents were strict, he studied at University while self-supporting with arbeit. He met his wife at the home where he was working as a teacher of her younger sister and married as soon as after graduated from university. At the time of marriage, he was so much interested in her and his commitment was so strong that he was saying "I will die if I cannot get married you". He got a good job at a major bank. He has worked hard until late at night, leaving a single son with his wife, often having a drinking party and golfing. He had been prescribed to psychiatry clinic after retirement at 75-years-old because of insomnia. He also visited urology clinic with neurogenic bladder. On the other hand, he was active, regularly got together with his colleague, golfing, drinking party, he published books on history.
2 years ago, his spinal stenosis was getting worse, last year he got a surgery and a rehabilitation, he was able to walk, but his back pain still remained and further worse merged the causal bladder. He was on certified nursing care and started self-urination.
He began to complain often and once while at walking with his wife he had a quarrel with her and he tried to jump off the balustrade with his legs hanging off. He cut his cervical part with a knife, and he went out saying "I'll die" and was protected by the police.
He got a fight with his wife from saying "You stole 300 thousand yen". His wife was upset and left home until late at night. Early in the next morning his wife got a phone call from him, she went to his bed and found him falling on the bed with a lot of blood, she called an ambulance.
He told a psychiatrist at ER, "I've forgotten what happened, and I can not live, I want to die". The incised wounds of the left flank and the penis were not functionally damaged, underwent disinfection and suturing, after he was admitted.
Oral administration of ramelteon 8 mg + tiapride 25 mg was started. On day 3, he appeared delerium state, he said, "Please help" "My children is kidnapped", "I have numbness in my lower body, my feet got cold" "I feel the body floating", "Is my physical connected?"
On day 11, he shouted with a loud voice when asking for treatment, and immediately after that he apologized as he showed easy excitement and impulsiveness.
After that, "I do not feel like feeling depressed, it's not good, 20 points", "I thought I didn't want to die, but could not live by myself".
From day 13 we judged him depressed and started DUL 20 mg. Although self-mutilation part recovered smoothly, he explained about self-mutilation, "I don't remember" with angry.
On day 23, he got a smile, depressive mood and appetite improved, "I do not feel like to die NOW" up to DUL 40 mg.
On day 30 up to DUL 60 mg, "I feel well and there is no pain", in addition to depressed mood, pain disappeared. He became active, began to read books and to talk with everyone.
Regarding the feelings before hospitalization, he looked back at the fact that he was concerned about health but denied he really wanted to die. Also, he denied about drinking on a daily basis, dependence on sleeping pills, and over using before self-mutilation.
Blood, electrocardiogram, brain wave was all normal. Cognitive examinations such as Hasegawa dementia scale (HDS-R)29/30 (2-2-1), MMSE 27/30, FAB 17/18, STM - COMET Immediately memory 8/15 Delayed memory 9/15 are all normal. In Cranial MRI ischemic changes were pointed and in Cranial SPECT nothing particular was pointed in blood flow.
He was originally healthy, sociable and successful, further even after retirement, he published his own books and regularly held a collection of hobbies, such as golf, and was meaningful. Characteristic aspects were short-tempered and nervous since young, and they used sleeping pills because of insomnia.
After he suffered from spinal stenosis, he could not go out for hobbies and relationships with friends, daily life help in daily life has become necessary, he became feeling "numbness", "cold", then poor appetite and willing. Embarrassment increased, and repeated attempts to suicide, his wife and son understood because of physical disorder and the original short temper personality. So after his self-mutilation, his wife offered to divorce, however, his depression improved, she willing to agree his discharge to home.
His cognitive functions were normal. We diagnosed him as depression from suicidal attempt, appetite loss, depressive feeling and "coldness", "numbness", disappeared due to DUL.
Health problems are the most frequent cause of suicide among elderly people, and it is said that the relation with depression is the most common among them [1,2], he is also postoperative of spinal stenosis, depression with major symptoms such as anxiety, depression, decreased motivation and so on.
In the suicide attempts of the elderly, major methods are neck hanging, jumping, and drawing [2,3]. The method of injures on the left breast and cut his penis by using a branch-cutting scissors, was a rare method.
Dating with women in his youth inspite of married, we don't know the relationship between his appropriate relationship and the method of suicide attempt. He has performed self-urination because of concomitant neuropathic bladder after operation of spinal stenosis. Neurogenic bladder improved after improvement of depression and self-urination was no longer necessary, so difficulty of urination was more related.
Urologists reported the penile self-mutilation cases. Many of them were due to psychotic disorders such as schizophrenia, depression and so on. Non-psychotic penile Self-mutilation were due to desire for to change sex or religious beliefs [4,5].
Hindley and Gordon  said the personality characteristics before dementia and the aggressive behavior such as homicide are not related, and the other side Cohen  said there is a risk of aggressive behavior in the history of assault, alcohol abuse, psychiatric symptoms such as paranoia, endogenous depression, vascular dementia, catastrophic behavior, low resistance of frustration, career of soldiers, police officers, firefighters, etc..
He is not in dementia and he is originally short temper, he was famous for yelling at work not only at home, but also in the workplace. Also, he daily drunk before self-mutilation. They seem to be factors to increase impulsivity.
He had insomnia, alcohol and sleeping pills using, he might used more sleeping pills after having quarreled with his wife, he stayed home alone, ran into self-mutilation. Delirium appeared after hospitalization, and he lost memory of self-mutilation after improved. It is suspected that he was in a delirium state retroactively at the time of self-mutilation. Although he denied the possibility but remained that he is overdosed with sleeping pills and fell into a delirium state at the time of self-mutilation.
We experienced a case of depression caused by restricted activity due to orthopedic diseases, made self-mutilation after an argument with his wife. In addition to depression, he had high risk factors of elderly suicide attempt, such as repetition of suicide attempt, impatience character, drinking, sleeping pill.