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CASE REPORT
Year : 2015  |  Volume : 24  |  Issue : 1  |  Page : 76-78  Table of Contents     

Cavum septum pellucidum in a case of schizophrenia presenting with self-mutilating behavior


1 Department of Psychiatry, Central Institute of Psychiatry, Ranchi, India
2 Training Co-ordinator, Project HIFAZAT, Central Institute of Psychiatry, Ranchi, India
3 Department of Psychiatry, ICARE Institute of Medical Sciences and Research, Haldia, West Bengal, India

Date of Web Publication16-Jul-2015

Correspondence Address:
Shreekantiah Umesh
Central Institute of Psychiatry, Kanke, Ranchi - 834 006, Jharkhand
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-6748.160940

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   Abstract 

Cavum septum pellucidum (CSP) is a neurodevelopmental anomaly, which is commonly reported in schizophrenia patients. Various symptoms of schizophrenia, including thought disturbances have been associated with CSP. We present a rare case of undifferentiated schizophrenia with CSP who presented with self-mutilating behaviors.

Keywords: Cavum septum pellucidum, schizophrenia, self-mutilating behavior


How to cite this article:
Umesh S, Bose S, Khanra S, Das B, Nizamie S H. Cavum septum pellucidum in a case of schizophrenia presenting with self-mutilating behavior. Ind Psychiatry J 2015;24:76-8

How to cite this URL:
Umesh S, Bose S, Khanra S, Das B, Nizamie S H. Cavum septum pellucidum in a case of schizophrenia presenting with self-mutilating behavior. Ind Psychiatry J [serial online] 2015 [cited 2020 Sep 18];24:76-8. Available from: http://www.industrialpsychiatry.org/text.asp?2015/24/1/76/160940

Cavum septum pellucidum (CSP) is a neurodevelopmental anomaly characterized by the presence of a thin plate of two laminae, which forms the medial wall of the lateral ventricles that fails to fuse forming a fluid filled cavity. [1] The enlarged CSP, which persists postnatally is considered to be a putative marker of disturbances in early brain development. [2] Previous studies have also shown an association of CSP with severe thought disturbances, more negative symptoms, higher suicide rates and greater cognitive deficits in schizophrenia. [3] We present a case of undifferentiated schizophrenia, who presented with self-mutilating behavior, was found to be having CSP.


   Case report Top


A 28-year-old unmarried male from low socioeconomic status came to the hospital for consultation of psychiatric problems along with his caregivers. There was no past psychiatric or medical history or family history of mental illness. The presenting complaints were unprovoked aggressive outbursts, poor self-care, disorganized behavior and self-mutilating behaviors for last 4 years. Physical examination revealed old burnt scar over the forehead, fused ear lobules bilaterally and polydactyly in right upper limb and crush injury of left thumb and index finger. On mental status examination, patient was unkempt, disheveled with poor eye contact. He was irritable and guarded. No thought and the perceptual abnormality were elicited at the time of admission. He was diagnosed as "undifferentiated schizophrenia" according to International Classification of Disease-10 th version. [4]

Patient was advised to take in-patient psychiatric care on the same day of consultation. He remained aggressive, disorganized and on two occasions, he tried to crush his left index finger and thumb by hammering it with a stone. He was started on electro convulsive therapy (ECT) sessions considering aggressive outburst and self-mutilating behavior. During pre-ECT evaluation "computed tomography" scan of the head revealed "Grade II CSP" [Refer [Figure 1]. Along with ECT, patient also received oral chlorpromazine 600 mg/day, which was hiked gradually over 2 weeks.
Figure 1: Plain computed tomography image of the patient and arrow head pointing towards cavum septum pellucidum

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Patient started showing improvement in aggressive and self-mutilating behavior. On mental status examination, he reported that he became angry for no apparent reason, following which he would start hammering his fingers with stones. He also reported delusion of persecution against parents. He received nine sessions of ECT with minimal cognitive impairment and was continued on oral chlorpromazine 600 mg/day without any side effects. There was improvement in self-mutilating behavior, disorganized behavior and poor self-care, but occasional aggressive outbursts persisted. He was discharged on chlorpromazine 600 mg/day.


   Discussion Top


Anatomically, the septum pellucidum consists of two laminae of tissue composed of white matter surrounded by gray matter. The septum is known to be a part of the limbic system and is connected via the medial forebrain bundle to the hypothalamus and via the fornix to the hippocampus and amygdala. [5] CSP is present in 100% of fetuses and premature infants, but the posterior half of the leaves normally fuse by 3-6 months of age. [6] The presence of a CSP later in life reflects neurodevelopmental abnormalities of structures bordering the septum pellucidum, such as the corpus callosum and hippocampus and may be considered as a marker of limbic system dysgenesis. [7]

Despite being a normal variant, CSP has been seen in various psychiatric disorders, most commonly in schizophrenia. [3] In a recent meta-analysis, Trzesniak et al. [3] have mentioned that incidence of CSP ranges between 1.1% and 89.7% in healthy volunteers, and from 10.0% to 89.5% in patients with schizophrenia spectrum disorder. They have also suggested that the clinical significance of CSP may depend more on its size rather than presence or absence in schizophrenia. [3] Nevertheless, one recent longitudinal study has also found that CSP may not be linked to the neurobiology of emerging psychotic disorders and may be related to the progression of the disorder per se. [8]

The exact function of the septum is not yet completely understood; however it may appear to moderate behaviors such as rage and arousal. [9] Interestingly, CSP is associated with aggressive features of antisocial personality disorder compared to nonaggressive ones, indicating particular relevance of septal disruption to aggression in human. [10] Researchers have also found that CSP influences neighboring dense synaptic networks [11] and cause irregularities in the distribution of serotonin (5-HT2A) receptors that may affect the septal regulatory role in the limbic system. [12] In addition, improvement of severe self-mutilation has been reported after limbic leucotomy. [13]

Based on these studies, we hypothesize that limbic dysgenesis may be the reason for aggressive and self-mutilating behavior in our patient. Psychodynamically, self-mutilating behaviors have been termed as "auto aggression." [14] Self-mutilation has an aggressive element, wherein the person, through self-mutilation directs anger inward which enables him or her to feel in control. [15]

Though several line of management have been proposed including clozapine, lithium, and naltrexone and so on, [16] we preferred ECT and chlorpromazine as there have been previous successful treatment of self-mutilating behaviors with ECT [16] and we chose chlorpromazine considering its sedating property which also reduce psychotic aggression. [17]

In our patient, self-mutilating behavior was not secondary to any psychotic process or any affective disturbance; neither it was explainable from mental status examination. It may be argued that CSP, which has been found to be associated with aggression in a different patient population, also might play a role in self-mutilating behavior in our patient with schizophrenia.


   Conclusion Top


We conclude that the self-mutilating behavior in our patient may be an aggressive behavior directed towards self and might be neurobiologically linked to CSP and its relationship with limbic system dysgenesis.

 
   References Top

1.
Sarwar M. The septum pellucidum: Normal and abnormal. AJNR Am J Neuroradiol 1989;10:989-1005.  Back to cited text no. 1
    
2.
Kim KJ, Peterson BS. Cavum septi pellucidi in Tourette syndrome. Biol Psychiatry 2003;54:76-85.  Back to cited text no. 2
    
3.
Trzesniak C, Oliveira IR, Kempton MJ, Galvão-de Almeida A, Chagas MH, Ferrari MC, et al. Are cavum septum pellucidum abnormalities more common in schizophrenia spectrum disorders? A systematic review and meta-analysis. Schizophr Res 2011;125:1-12.  Back to cited text no. 3
    
4.
World Health Organization. The ICD-10 Classification of Mental and Behavioural Diosrders: Diagnsotic Criteria for Research. Geneva: WHO; 1993.  Back to cited text no. 4
    
5.
Breeding LM, Bodensteiner JB, Cowan L, Higgins WL. The cavum septum pellucidum: An MRI study of prevalence and clinical association in a pediatric population. J Neuroimaging 1991;1:115-8.  Back to cited text no. 5
    
6.
Shaw CM, Alvord EC Jr. Cava septi pellucidi et vergae: Their normal and pathogical states. Brain 1969;92:213-23.  Back to cited text no. 6
[PUBMED]    
7.
Nopoulos PC, Giedd JN, Andreasen NC, Rapoport JL. Frequency and severity of enlarged cavum septi pellucidi in childhood-onset schizophrenia. Am J Psychiatry 1998;155:1074-9.  Back to cited text no. 7
    
8.
Trzesniak C, Schaufelberger MS, Duran FL, Santos LC, Rosa PG, McGuire PK, et al. Longitudinal follow-up of cavum septum pellucidum and adhesio interthalamica alterations in first-episode psychosis: A population-based MRI study. Psychol Med 2012;42:2523-34.  Back to cited text no. 8
    
9.
Trimble MR. The limbic system and related anatomical connections. The Psychoses of Epilepsy. New York: Raven Press; 1991. p. 40-64.  Back to cited text no. 9
    
10.
Raine A, Lee L, Yang Y, Colletti P. Neurodevelopmental marker for limbic maldevelopment in antisocial personality disorder and psychopathy. Br J Psychiatry 2010;197:186-92.  Back to cited text no. 10
    
11.
Filipovic B, Kovacevic S, Stojicic M, Prostran M, Filipovic B. Morphological differences among cavum septi pellucidi obtained in patients with schizophrenia and healthy individuals: Forensic implications. A post-mortem study. Psychiatry Clin Neurosci 2005;59:106-8.  Back to cited text no. 11
    
12.
Meyer JH, McMain S, Kennedy SH, Korman L, Brown GM, DaSilva JN, et al. Dysfunctional attitudes and 5-HT2 receptors during depression and self-harm. Am J Psychiatry 2003;160:90-9.  Back to cited text no. 12
    
13.
Price BH, Baral I, Cosgrove GR, Rauch SL, Nierenberg AA, Jenike MA, et al. Improvement in severe self-mutilation following limbic leucotomy: A series of 5 consecutive cases. J Clin Psychiatry 2001;62:925-32.  Back to cited text no. 13
    
14.
Feldman MD. The challenge of self-mutilation: A review. Compr Psychiatry 1988;29:252-69.  Back to cited text no. 14
    
15.
Menninger K. A psychoanalytic study of the significance of self-mutilation. Psychoanal Q 1935;4:408-66.  Back to cited text no. 15
    
16.
Bates WJ, Smeltzer DJ. Electroconvulsive treatment of psychotic self-injurious behavior in a patient with severe mental retardation. Am J Psychiatry 1982;139:1355-6.  Back to cited text no. 16
[PUBMED]    
17.
Adams CE, Awad GA, Rathbone J, Thornley B, Soares-Weiser K. Chlorpromazine versus placebo for schizophrenia. Cochrane Database Syst Rev 2014;1:CD000284.  Back to cited text no. 17
    


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