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BritishJournalofPsychiatry(1984),145,193—194
SelfShootingofaPhantomHead
DAVIDAMES
Medicaljournalsareenlivenedbycasereportsof
bizarreandunusualsyndromes.Althoughsomatic
delusionsarerelativelycommoninschizophrenia,reportsofhallucinationsanddelusionsofbicephalyare
rare.Forapatienttoattempttoremoveaperceivedsecondheadbyshootingandtosurvivetheexperienceformorethantwoyearsmaywellbeunique,and
meritspresentation.
ThepatientinquestioncametotheRoyalMel
bourneHospitalinOctober1980,whenaged39.There
wasahistoryofprevioustreatmentatvariouspsychia
trichospitalsoverthelastsixyears.Itwassignificant
thathiswifehaddiedinacaraccidenttwoyears
previously,andthathewasthedriverinthataccident.
Thepatientcametohospitalearlyoneafternoonwithaself-inflictedgunshotwound.A.22bullethadenteredthehardpalateontheleft-handsideandemergedinthemidlineatthetopoftheforehead.At
presentation,hewasdrowsyandrespondedslowlyto
verbalcommands;adivergentsquintandleftproptosiswerenotedtobepresent.Skullx-raysrevealed
multiplebulletfragmentswithintheleftfrontallobe
andsubcutaneously.Hisgeneralconditionwas
stabilisedandatoperation,twodayslater,anumberofsub-cutaneousbulletfragmentswereremoved,acraniotomyperformed,anintracerebralclotevacuated,andallwoundsclosed.Overthenextfewdays,hisconsciousstateimproved,anditwaspossibletointerviewhim.Hedescribedasecondheadonhisshoulder.Hebelievedthattheheadbelongedtohiswife'sgynaecologist,anddescribedpreviouslyhavingfeltthathiswifewashavinganaffairwiththisgynaecologist,priortoherdeath.Hedescribedbeingabletoseethesecondheadwhenhewenttobedatnight,andstatedthatithadbeentryingtodominatehisnormalhead.Healsostatedthathewashearingvoices,includingthevoiceofhiswife'sgynaecologist
fromthesecondhead,aswellasthevoicesofJesusandAbrahamaroundhim,conversingwitheachother.All
thevoiceswereconfirmingthathehadtwoheads;thevoicefromthesecondheadhadbeentellinghimthatitwasthe‘¿kingin',andwouldalsosaytohimthatitwasgoingtotakehiswifeaway.Hedidnotdescribeanyotherhallucinatoryordelusionalexperiences.
“¿Thetherheadkepttryingtodominatemynormalhead,andIwouldnotletit.ItkepttryingtosaytomeIwouldlose,andIsaidbull-shit.―“¿mthekingpinhere―itsaidanditkeptgoingonlikethatforaboutthreeweeksandfinallyIgotjackofit,andIdecidedtoshootmyotherheadoff.―Hestatedthathefiredsixshots,thefirstatthe
secondhead,whichhethendecidedwashangingbya
thread,andthenanotheronethroughtheroofofhismouth.Hethenfiredfourmoreshots,oneofwhich
appearedtohavegonethroughtheroofofhismouth
andthreeofwhichmissed.Hesaidthathefeltgoodatthatstage,andthattheotherheadwasnotfeltanymore.Thenhepassedout.Priortoshootinghimself,hehadconsideredusinganaxetoremovethephantomhead.Adiagnosisofschizophreniawasmade,andhewastreatedwithchlorpromazineinaninitialdoseof200mg,q.i.d.Theexperienceofthesecondheadfadedoverthreetofourweeks,andhewouldnolonger
discussit.Towardstheendofhistwomonths'admission,hedecidedthathiswifehad,afterall,not
beenunfaithfultohim,andstatedthathenolongerexperiencedthefeelingofthesecondheadoranyauditoryhallucinations.Hewasdischargedtothecareofhisparentsonchlorpromazine,200mg,q.i.d.andsodiumphenytoin,100mg,q.i.d.ThefollowingJanuary,hewasreadmittedforaroutineduralrepair,aftersymptomsofCSFrhinorrhoeahadbeennoted.Mildmaturity-onsetdiabeteswasalsonoted.Aroutineduralrepairwasperformed,andthediabetestreatedwithsmalldosesofmetforminandglibenclamide.Hewasseenregularlyinpsychiatricout-patientsfollowingthisoperationandbyMarch,statedthatthesecondheadwasdead,thathewastakinghischlorpromazineregularly,andthathehadnoworries.Atthisstage,itwasnotedthathewasdrinkingheavilyandwhenseenamonthlater,headmittedtodrinkingsixpintsofbeerdailyanddrivinghomeafterwards.Hecontinuedtodrinkthroughouttheyear,andononeoccasionceasedhismedication,butwasrestartedatthefollowingoutpatientsvisit,whenhewasquestionedagainaboutthe
twoheads:
0.Couldyouseetheotherhead?A.Yes.
0.Youfeltit,oryoucouldseeit?193
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