The Man Who Sewed His Mouth and Ears: A Case Report

Some behaviour patterns like cutting nose, penis and ears and causing severe damages are encountered on some psychiatric patients. Although sewing his or another person’s lips as a protesting method was mentioned in media, no publication in medical literature was encountered about this matter. Because of this, we felt the need to publicate this case. Our aim is to be prepared for the cases which are not common in the emergency and to be able to help the patient as quick as possible.


Introduction
Some behaviour patterns like cutting nose, penis and ears and causing severe damages are encountered on some psychiatric patients. Although sewing his or another person's lips as a protesting method was mentioned in media, no publication in medical literature was encountered about this matter. Because of this, we felt the need to publicate this case. Our aim is to be prepared for the cases which are not common in the emergency and to be able to help the patient as quick as possible.
There were several reflections in the media about sewing lips case. The first case is from Iran. Kurdish originated prisoners kept under isolation in Iran Kehrizek Prison protested the Iran Regime because of the rape incidents in prison. One other case is 1090 people in Kyrgyzstan protested the new applications put into action in prisons. Another case is from Russia where an artist protested a court. The last incident is from Turkey in which some people after getting out of the prison protested the governorship in Diyarbakır just because of the unemployment problems. In all cases, the protesters sewed their lips to death fast [1][2][3][4].

Case Presentation
It was observed in the physical examination of the convicted male patient who can speak with a hoarse voice because of the stitch on his lips. He was brought by gendarme with a small piece of paper written: "My jinns imposed speech ban to me and they made me sew my lips unwillingly. Otherwise, they threaten me with my children. I want to meet a psychiatrist urgently". The lips and the both ears of the patient were sewed with a black thread (Figures 1 and 2).
The patient was taken to emergency 3 times only for the stitch on his lips. The gendarme brought him for the fourth time because of his sewing both ears and lips. He was treated by taking out the stitch and dressing the wounds. Some information about the patient was gathered from the juridical documents and prison officers.
It was found out the patient came to the prison 4 years ago due to an injuring usurp and he was treated with the diagnosis of anxiety disorder and anti-social personality disorder. He attempted suicide by hanging himself in a ward where there were at least ten prisoners. (There is hanging mark on his neck). It was prevented with difficulty and he was taken to emergency for these reasons.

Abstract
It is obvious that the case of sewing lips and ears, a form of pathological behavior although not a disruptive behavior is not frequent. Especially the fact that the case was taken from the prison, and brought to emergency accompanied by gendarmes several times, makes the shocking situation even more interesting. This presentation was made to reflect the condition of the convicted patient who sewed both his lips 3 more times with a sewing needle a month ago, seven days ago and 4 days ago and brought to emergency; additionally sewed his ears and brought to emergency for the fourth time writing his wish on a small piece of paper telling that he wanted to see a psychiatrist and whose treatment and examination were done by an emergency specialist and a psychiatrist.
In the psychiatric examination, it was learned the patient was willing to communicate. He managed to give reasonable answers to questions. There was a little increase on his psychomotor activities. He was a 37 year-old farmer who had 2 kids and who had only a primary education. He had blunted affect. He wasn't able to stay in the ward because of the directive voices in his head. He declared he needed to stay in the ward alone. He heard all the words as swearing and he was punished by some people as well as some entities. He also said that some jinns in the form of animals threatened him not to speak and listen to anyone; otherwise they were going to kill his kids. He wanted to protect his children he stitched his lips not to speak anyone and stitched his ears not to hear anyone.
In his family history, he stated that his uncle committed suicide by hanging himself and saying "the birds are calling me"; his father was schizophrenia-diagnosed. When asked from which part of his lips he started sewing, the answer was sometimes from the right part, sometimes from the left part of the upper lip.
The patient stated that he sewed his lips with any colour of thread he could find. He had approximately fifteen pinholes on his upper and lower lips. He tended to suicide with directive auditory and visual hallucination and reference paranoid delirium. As he was imprisoned, he wasn't able to use drugs. The patient who was thought to have a psychotic disorder was injected 10 mg haloperidol intramuscularly and he was sent to a safe psychiatry hospital.

Discussion
There have been many different definitions on self-destructive behaviours so far. The common points among all the definitions are that they are repetitive, done willingly and deliberately, resulted in tissue damage. It can be said that our case is suited to the psychotic behaviours among Favazza's three self-destructive behaviours which are compulsive, typical and psychotic [5].
The cases like sewing one's own lips which we observe as a different type of destructing oneself in our case are mostly regarded as intercultural expression of feelings. The ones, who sew their lips in order to protest something, show their reactions by blocking the nutrition intake organ to the ones who want to continue their superiority. It can be expected in psychotic cases that the patients or his beloved ones might be harmed, damaged or affected emotionally. Thus, the patient who is furious and anxious might react attempted to violence as a reaction to these repetitive threats. Auditory hallucinations giving orders can cause the aggressive behaviours to start [6,7].
In our psychotic case, this kind of behaviour is a way to prevent the voices coming from his inner world, not to answer them and hence making passive defending to world which he does not want to interact. By this means, he may harmonise with the secret natural powers which affect him and he may protect himself his children.
It is stated in medical literatures that increased risk of suicide can be observed among the ones who are self-destructive, moreover these people harm themselves in order to avoid killing themselves [8,9].
As in our case, there can be a relief through sewing lips and ears or strangulation against the oppression created by the person's not being able to adapt the prison.
In many studies, the occurrence of psychiatric disorders is found more common on prisoners than the general society. Bland found the life-long extensity of psychiatric disorders of prisoners two times more than the general society [10]. There are some other studies showing that the extensity of psychotic disorders on prisoners is similar to the general society as well as the ones which are higher than the general society [11][12][13]. Kaya et al. found the extensity of psychiatric disorders, except from somatoform and psychotic disorders, more common than the general society. As the drug use and antisocial personality disorder rate of prisoners are high and the fact that this can ruin the harmony and collaboration, this matter can cause the bias of the health workers. It should not be forgotten that the prison is a stressful environment and stressful living cases increase the disposition to psychopathologic behaviour that the living difficulties in prisons can affect the way of thinking and the capacity of coping and it may cause different psychiatric incidences [14].
In order to evaluate the prisoners effectively and sufficiently the appropriate conditions need to be set. As in this case, although he came to the emergency four times, it can be observed that the patient could not be evaluated sufficiently because of the conviction.
As a result, it is suggested that when these rare cases hard to evaluate in prison conditions come to emergency like the convicted patient who sewed his lips and ears not to hear and talk about his hallucinations, they should be evaluated by psychiatrists so that the patient can have a chance of treatment.