(PO-161) (PO-161) Outpatient presurgical evaluation of a patient with intentional self-mutilation from xenomelia: The value of preoperative consultation

Background

In consultation-liaison psychiatry, patients are often seen in the inpatient setting, where the primary team has requested assistance with an issue that has arisen. There is considerable interest in the use of anticipatory means of psychiatric intervention to intervene prior to the development of complications. Outpatient presurgical consultation is utilized in several surgical specialities, such as bariatric and epilepsy surgery, as a means of assessing capacity, ability to adhere to recommendations, and prepare the team for any psychiatric complications.

Xenomelia is a disorder complicated by the patient’s desire to remove healthy tissue or to become disabled in the absence of psychosis. It is rare, and not formally recognized in the DSM-5. Patients will often seek surgical removal of limbs, and when denied surgery, may self-mutilate to prompt amputation.

Methods

We present a case of a 45 year old male with a history of impulse control disorder, borderline personality disorder, and xenomelia who presented to the orthopedic surgery department requesting revision of bilateral leg amputations due to infection. He had a longstanding history of wishing he did not have legs and a significant history of trauma, and one year prior, had damaged his legs to the point of needing amputation. It was noted that he had injured healing surgical sites to prompt further amputation when he felt the limb stumps were not short enough. Psychiatry was consulted for presurgical evaluation.

Results

Our evaluation clarified the potential risks with proceeding with surgery, primarily, that the patient was still concerned about the aesthetic appearance of any amputation revision. We requested collateral, allowing us to confirm his psychotherapy participation, and to establish psychiatric care. Bioethics assisted with a behavior contract, which the patient completed prior to surgery. The team held discussions with nursing staff on the orthopedics nursing unit to discuss boundaries and how to approach this patient. He was admitted for surgical revision, completing an uneventful hospital course.

Discussion

In patients with serious mental illness, a preoperative CL evaluation can identify risk factors, ensure appropriate treatment and follow up, and allow for education of nursing and medical staff prior to the development of maladaptive behaviors or complications. We recommend advocating to surgical services to consider preoperative consultation in patients with complex psychiatric histories or medication regimens, or with concern for disruptive behaviors on admission.

Conclusion

Presurgical outpatient evaluation by the CL service can allow for risk stratification, review of treatment, and the ability to prepare medical and nursing staff for psychiatrically complex surgical patients.

References

Yen YC, Huang CK, Tai CM. Psychiatric aspects of bariatric surgery. Curr Opin Psychiatry. 2014;27(5):374-379.

McGeoch PD, Brang D, Song T, et al. Xenomelia: a new right parietal lobe syndrome. J Neurol Neurosurg Psychiatry. 2011 Dec;82(12):1314-9.

Learning Objectives:

To discuss the utility of outpatient presurgical consultation from consultation-liaison psychiatry
To identify components of a presurgical consultation that benefit primary medical and surgical services
To utilize behavior planning strategies for risk mitigation in patients with intentional self-mutilation

Presenting Author(s)

Andrew Coulter, MD, MA
– Associate Staff, Cleveland Clinic Foundation, Cleveland, Ohio, United States

Co-Author(s)

Elias Khawam, MD, DFAPA
– Section Head, Consultation Liaison Psychiatry, Cleveland Clinic, Rocky River, OH, United States