This is a case presentation of a 44-year-old male with a significant past psychiatric history from 10 + years that included various diagnoses including schizotypal personality disorder, dependent personality disorder, schizoaffective disorder, schizophrenia, anxiety disorder and skin picking disorder. He was referred to consultation-liaison psychiatry when admitted to the intensive care unit following a self-inflicted wound through the central frontal bone and dura. The wound was inflicted via self picking and eventually with the use of a “butter knife” over the course of 2 years.

Prior to this presentation, he had been followed by a community team with minimal clinical effective treatment, likely due at least in part to unclear diagnoses. Initial admission psychotropic medications included Clomipramine, Quetiapine, Clonazepam, Paroxetine, Risperidone, Pregabalin, and Valproic acid (for a seizure disorder). As patient was intubated on initial assessment, we reviewed his history from clinical notes and gathered collateral (including from family doctor who had continuous contact with patient and family) to help with diagnostic clarity. There was no clear evidence that the patient had any severe persistent mental illness such as schizophrenia or schizoaffective disorder. There was no reported psychosis (hallucinations or delusions), no disorganized behaviour otherwise, and no disorganized speech. Rather, he had a constellation of symptoms that included components of general anxiety and personality disorders. In addition, he had overvalued ideas (i.e. bizarre beliefs related to the need of skin picking), but when further investigated this was more in keeping with longstanding beliefs of his rather than true delusions.

As per DSM-5 criteria, there was recurrent picking of skin leading to skin lesions, repeated attempts to decrease or stop skin picking (patient had reported awareness that this was a problem) and it was associated with significant distress and functional impairment. His skin picking also appeared to be in the context of long-standing anxiety, potentially low intellectual disability (as noted by family doctor and family) and potentially even exacerbated by sub-optimal management of his psychiatric medications over the years. There was unfortunately no formal IQ testing done prior this presentation as these services were not available or accessible to the family.

The patient was initially admitted by the neurosurgery team as he had eroded a large portion of his scalp, the underlying frontal bone as well as the dura in close proximity to the sagittal sinus, resulting in an epidural abscess and leakage of cerebrospinal fluid (Fig. 1). His initial prognosis was poor – with risks of infection, bleeding and even death due to the risk of exsanguination or thrombosis of his sagittal sinus. In addition to the initial neuro-surgical stabilization, and from a literature review on skin picking disorder, we made the following medication changes on admission: discontinued Quetiapine, Clomipramine, Risperidone, Trazodone, Pregabalin, with a slower taper of Paroxetine over 3–4 weeks. We also initiated Fluoxetine which was titrated to 60 mg, Olanzapine 15 mg and NAC 600 mg qAM and 1200 mg qHS. SSRI, antipsychotic augmentation and NAC all have evidence in treating skin picking disorder [3] as previously discussed.

Imaging on initial presentation: A: Coronal CT demonstrating left parasagittal intracranial air as a sign of a dural defect; B: Axial CT (bone window) demonstrating the bone defect, a bone splinter and the depth of the skin defect; C: Sagittal CT again showing the bone splinter entering the frontal lobe as well as the sagittal extent of the scalp and bone defect; D: Coronal MRI showing gadolinium enhancement underneath the defect as a sign of encephalitis; E: Sagittal MRI demonstrating the extent of brain involvement

After stabilizing the patient in the intensive care unit, a neurosurgical procedure was performed in conjunction with plastic surgery debriding devitalized bone within the adjacent brain and covering the dural defect. Over time, and with the new treatment described, he significantly reduced his skin picking which allowed some healing of the bone. He concurrently had significant improvement in his mental status exam. He became alert, oriented and engaged in his care. He was cooperative and had no disorganized behaviour. His speech was normal. He had no evidence of psychosis, including no delusions and no hallucinations. He denied any beliefs of self-harm. He had insight that his self-inflicted wound was problematic but described an ongoing need to do so. He continued his new medication treatment regimen and started psychotherapy for habit reversal techniques during the admission. He also remained on IV antibiotics for 6 weeks, after which he received an initial skin graft. The skin healed with full epithelialization (Fig. 2). A second plastic reconstructive surgery was scheduled for 6 months. His mental status exam continued to improve during the admission, with no evidence of psychosis and ongoing insight into his skin picking disorder.

3 months post initial reconstructive surgery showing skin epithelization