Phebe Tucker, MD

Throughout 12,000 years of human history, pandemics have killed an estimated 300 million to 500 million people, with the bubonic plague decimating an estimated 60% of the European population during the Middle Ages. Despite modern advances in medicine, 

 has caused more than 1 million reported deaths in less than a year. Aside from the death toll, the pandemic has triggered significant emotional, physical, and economic problems around the world. But even in the midst of this crisis, nations have an opportunity to share and learn from each other’s experiences.

The emerging literature measures the impact of various traumatic stressors related to COVID-19, as well as the effects of less severe types of stress exposures. COVID-19 has already led to diverse mental health problems, including anxiety, depression, posttraumatic stress disorder, and other trauma- and stress-related disorders. Different groups have met the qualifying criteria for posttraumatic stress disorder (PTSD) according to DSM-5 as a result of the pandemic: those who have themselves suffered from serious COVID-19 illness and potential death; individuals who, as family members and health care workers, have witnessed others’ suffering and death; individuals who have learned about the death or risk of death of a family member or friend due to the virus; and individuals who have experienced extreme exposure to aversive details (eg, journalists, first responders, medical examiners, and hospital personnel).

Moreover, studies have explored other stressors adding to individuals’ emotional burdens, such as social isolation, unemployment and economic losses, and working from home while caring for children and other family members. Among health care workers, strains include lack of personal protective equipment (PPE), fears of virus exposure, burnout, patients perishing despite heroic efforts to save them, and difficult decisions about which patients should receive limited resources. A few studies have examined posttraumatic stress symptoms (PTSS), as well as anxiety, depression and other symptoms, and substance use in the general population during the pandemic.

More time is needed, of course, to conduct and publish systematic investigations on mental health sequelae, such as formal psychiatric diagnoses. Studies generally have been conducted through diverse internet platforms, which may affect generalizability. Methods and validated rating scales vary.

At the same time, it is not too soon for clinicians to read the emerging literature and base treatments on the latest research. We will explore some representative international studies of various groups affected by COVID-19, as well as protective factors and suggested interventions to help those in need (Figure).

Much of the current research emerges from China, the first country confronted by the pandemic. A 

 in China exposed to COVID-19 found a PTSD incidence of 16.8%, with highest scores in avoidance symptoms.

 Job satisfaction was associated with lower PTSD symptom scores and positive coping. The authors recommended supporting nurses who are having difficulty coping with their work by providing counseling.

A web-based, cross-sectional survey of more than 7000 Chinese individuals in February 2020 found that health care workers had the highest rate of poor sleep, and those aged 35 years or younger had more mood and anxiety symptoms.

 Overall, 35.1% of respondents reported anxiety symptoms, 20.0% depressive symptoms, and 18.2% poor sleep quality.

Other international studies have examined stress responses in health care workers treating patients with COVID-19. A study of 900 health professionals caring for hospitalized patients with COVID-19 in Singapore and India found relatively low symptoms of anxiety (15.7%), depression (10.6%), and stress (5.2%).

 However, among health care workers reporting these issues, more than half had symptoms in the moderate to extremely severe range. In addition, 67% of respondents reported physical symptoms, especially headache, lethargy, anxiety, and insomnia, suggesting somatic expressions of distress. United Kingdom military health care workers were assessed for the effects of inadequate safety equipment on their mental health during the COVID-19 medical response. Those with inadequate equipment had greater odds of having common mental health disorders (2.49), PTSD (2.99), poorer global health (2.09), and emotional problems (1.69).

Only a few studies of mental health problems among patients hospitalized with COVID-19 have been published, with more to come. A study of hospitalized but stable patients found a high prevalence of PTSS (96.2%).

 A chart review of hospitalized patients with COVID-19 in Spain found more than half of the 841 patients hospitalized with COVID-19 had a neurological symptom. Of these, nonspecific neurological symptoms were identified, as well as disorders of consciousness (19.6%), mostly in elderly patients and in those with severe COVID-19 disease; myopathy (3.1%); dysautonomia (2.5%); and other less frequent symptoms.6

Neuropsychiatric symptoms were reported by 19.9% of these patients, including insomnia, anxiety, depression and psychosis; these were not associated with disease severity.

Some studies have drawn inferences based on other severe respiratory viruses. A meta-analysis of long-term clinical outcomes for survivors of adult severe acute respiratory syndrome (SARS) and Middle East Respiratory Syndrome (MERS) who were in the intensive care unit (ICU) revealed PTSD prevalence in 39%, depression in 33%, and anxiety in 30% beyond 6 months after discharge, as well as reduced lung function and reduced exercise capacity.

 Italian experts also concluded that we might anticipate similar outcomes in survivors of COVID-19.8

Acute respiratory distress syndrome (ARDS) in ICU survivors of COVID-19 may occur, with an expected survival rate of approximately 25%. Survivors of ARDS may experience persistent fatigue and poor exercise tolerance, pain and weakness, neurological sequelae, and the psychological effects of prolonged ICU stays, as noted in patients with MERS and SARS. Stressors included immobility, separation from family and friends, prolonged sedation, anxiety about health conditions and survival, and subsequent job loss. The authors emphasized the need to identify PTSD (anticipated in up to 30% of ARDS survivors) and other mental health problems, and to provide appropriate and timely multidisciplinary therapy that should continue after discharge.

 A literature review of studies linking panic disorder with patients who had SARS suggested that aggravation of panic attacks is highly likely in survivors of COVID-19 in the face of prominent respiratory symptoms, as panic may be triggered by fear conditioning to abnormal breathing problems.

 The authors urged monitoring for panic as well as obsessive compulsive disorder, PTSD, and generalized anxiety disorder.

Some mental health care advocates believe the general population may be suffering from various levels of vicarious traumatization, although strictly speaking this would not qualify for PTSD’s Criterion A for trauma exposure. Along these lines, in August 2020 the CDC published results of a large US web-based survey of more than 5000 adults (

 in which 40.9% endorsed at least 1 adverse mental or behavioral health problem related to the pandemic. Symptoms of a trauma- and stressor-related disorder were reported by 26.3%, symptoms of anxiety or depression by 30.9%, substance use to cope by 13.3%, and serious consideration of suicide in the prior days by 10.7%. Suicidal ideation was significantly higher for younger respondents aged 18 to 24 years (25.5%), minority groups (Hispanic individuals, 18.6%; Black individuals, 15.1%), nonpaid caregivers for adults (30.7%), and essential workers (21.7%). The authors stressed the need to identify at-risk individuals to develop policies to address health inequities, and to increase resources for identifying mental health problems and offering new treatment options, including telehealth treatments.

In a study of home-quarantined youth in China during the first month of the COVID-19 outbreak, 12.8% had PTSS levels consistent with PTSD, with PTSS and distress associated with negative coping styles.

 Symptom levels were expected to increase with time as quarantine continued. This is important since a formal diagnosis of PTSD requires symptoms to persist for more than a month.

In another online survey conducted early during the Wuhan outbreak, researchers looked at anxiety and depression symptoms (rather than specific PTSS) in relation to social media exposure (SME) to COVID-19 news. The study, which included approximately 5000 adults in China, found high SME was positively associated with higher odds of anxiety and a combination of depression and anxiety, compared with low SME.

 A longitudinal survey of the general population in China during the initial outbreak, and again 4 weeks later, found the mean Impact of Events Scores to be above the cutoff scores for PTSD symptoms at both times, with moderate to severe stress, anxiety, and depression levels.

Results of an Italian cross-sectional, web-based 

 showed a relatively high percentage (29.5%) of PTSS related to the pandemic, suggesting that the pandemic itself could be considered a traumatic event.

 Similarly, an online survey of almost 3500 people in Spain found symptoms of PTSD (15.8%), depression (18.7%), and anxiety (21.6%), with loneliness the strongest predictor of symptoms.

 Other factors associated with these problems were female gender, previous mental health or neurological problems, having physical symptoms similar to those of COVID-19, or having a close relative infected.

Nursing home residents have been particularly vulnerable to poor health outcomes; early in the COVID-19 pandemic many facilities adopted strict lockdown policies. However, social isolation is particularly detrimental to the elderly, who may have increased risk for depression, anxiety, worsening dementia, and even earlier death.

 Given these issues, the Centers for Medicare and Medicaid Services (CMS) recommended safe communal activities for locked-down nursing homes.

In Canada, researchers explored prenatal maternal distress before and during the COVID-19 pandemic.

 Women assessed during the pandemic had higher levels of depression and anxiety, with levels more likely to be clinically significant, compared with women assessed before COVID-19. During the pandemic, dissociative and PTSD symptoms and negative affectivity were also greater, underscoring the need to carefully assess pregnant women to help prevent negative, stress-related outcomes in mothers and infants.

Perhaps not surprisingly, when compared with a control population, psychiatric inpatients in China had more PTSD, anxiety, and depression symptoms; more anger, impulsivity, and worries about health; and intense suicidal ideation.18 Hospitalized psychiatric patients and their mental health caregivers are at high risk for COVID-19 infection, compounding their existing stress. This was noted early in February 2020 in Wuhan, when the virus was diagnosed in at least 50 inpatients with psychiatric disorders and 30 mental health professionals. Factors included lack of protective gear and difficulties isolating.

 Outpatients with psychiatric disorders are also vulnerable to emotional distress during a pandemic. An online survey of more than 2000 outpatients in China discovered that 20.9% of patients with preexisting psychiatric disorders had seen their symptoms get worse during the pandemic.

How can we help individuals whose mental health has been harmed by COVID-19?

To support medical caregivers assigned to the front line during the pandemic, experts advise addressing burnout, as prolonged problems may overlap and lead to acute stress disorder and PTSD.

 Suggestions have ranged from practical measures (such as ensuring adequate PPE, handwashing, and decontamination of surfaces) to developing personnel policies that reassign at-risk medical personnel away from high-risk sites, ensure the safety of their family members, and stress the importance of self-care.

 Also recommended is providing health care workers access to child care services during expanded work hours and school closures. Workers should have adequate rest and breaks, be excused from less-essential tasks, and have regular information and feedback sessions with managers and the community. In many areas, hospitals provide telephone hotline teams trained to provide psychological assistance. Professional organizations offer physician wellness programs to provide free, confidential sessions to deal with burnout, adjustment problems, family issues, and other mental health sequelae.

The increasing numbers of people who were seriously ill with COVID-19 should be assessed for physical symptoms of chronic pain,

 with physical therapy and medications adjusted to avoid opioid dependence. Survivors of ARDS should receive evidence-based medications, cognitive behavioral therapy, and other psychotherapies for PTSD, panic, depression, and other mental disorders.

To combat isolation among locked-down nursing home residents, CMS recommends safe communal activities such as book clubs, movies, bingo, and outdoor family visits (ie, on lawns or in parking lots) with precautions of social distancing and PPE. Some nursing homes have provided live music, parades, therapy animals, recordings and photos of loved ones, physical contact with loved ones through plastic protective barriers, and even physical and occupational therapy sessions held outdoors.

Psychological first aid provided by trained community personnel might help the general population as they experience distress during the COVID-19 pandemic.

 For individuals enduring fallout from personal stressors, experts have recommended expanded use of telehealth to identify and treat mental health conditions, including depression, PTSD and other trauma-related disorders, substance use disorders, and suicidal ideation. Self-help groups, 12-step programs, spiritual and religious services, interest groups, and employee groups working from home are all increasingly using interactive internet-based platforms. And it is essential for societies to provide citizens with assistance for jobs, housing, food, medical care, education, internet connections, and many other basic survival needs.

The current international pandemic and possibly future ones will challenge us and give us the chance to continue to learn and share with other nations, hopefully linking us cooperatively rather than polarizing us.

 is professor and vice chair of education, Department of Psychiatry, University of Oklahoma Health Sciences Center, Oklahoma City. 

is assistant professor and residency training director, Department of Psychiatry, University of Oklahoma Health Sciences Center, Oklahoma City. Authors have no relevant financial conflicts of interest. This article was originally posted on October 5, 2020, and has since been updated.

 Factors associated with post-traumatic stress disorder of nurses exposed to corona virus disease 2019 in China

2. Huang Y, Zhao N. Mental health burden for the public affected by the COVID-19 outbreak in China: Who will be the high-risk group? 

3. Chew NWS, Lee GKH, Tan BYQ, et al. A multinational, multicentre study on the psychological outcomes and associated physical symptoms amongst healthcare workers during COVID-19 outbreak. 

4. Simms A, Fear NT, Greenberg N. The impact of having inadequate safety equipment on mental health. 

5. Bo HX, Li W, Yang Y, et al. Posttraumatic stress symptoms and attitude toward crisis mental health services among clinically stable patients with COVID-19 in China. 

6. Romero-Sánchez CM, Díaz-Maroto I, Fernández-Díaz E, et al. Neurologic manifestations in hospitalized patients with COVID-19: The ALBACOVID registry. 

7. Ahmed H, Patel K, Greenwood DC, et al. Long-term clinical outcomes in survivors of severe acute respiratory syndrome and Middle East respiratory syndrome coronavirus outbreaks after hospitalization or ICU admission: A systematic review and meta-analysis. 

8. Vittori A, Lerman J, Cascella M, et al. COVID-19 Pandemic acute respiratory distress syndrome survivors: pain after the storm? 

9. Javelot H, Weiner L. Panique et pandémie: revue de la littérature sur les liens entre le trouble panique et l’épidémie à SARS-CoV-2 [Panic and pandemic: Review of the literature on the links between panic disorder and the SARS-CoV-2 epidemic]. 

10. Czeisler MÉ , Lane RI, Petrosky E, et al. Mental Health, Substance Use, and Suicidal Ideation During the COVID-19 Pandemic — United States, June 24–30, 2020. 

11. Liang L, Gao T, Ren H et al. Post-traumatic stress disorder and psychological distress in Chinese youths following the COVID-19 emergency. 

12. Gao J, Zheng P, Jia Y et al. Mental health problems and social media exposure during COVID-19 outbreak. 

13. Wang C, Pan R, Wan X, et al. A longitudinal study on the mental health of general population during the COVID-19 epidemic in China. 

14. Forte G, Favieri F, Tambelli R, Casagrande M. 

COVID-19 Pandemic in the Italian Population: Validation of a Post-Traumatic Stress Disorder Questionnaire and Prevalence of PTSD Symptomatology

15. González-Sanguino C, Ausín B, Castellanos MÁ, et al. Mental health consequences during the initial stage of the 2020 Coronavirus pandemic (COVID-19) in Spain. 

16. Abbasi J. Social isolation—the other COVID-19 threat in nursing homes. 

17. Berthelot N, Lemieux R, Garon‐Bissonnette J, et al. Uptrend in distress and psychiatric symptomatology in pregnant women during the coronavirus disease 2019 pandemic. 

18. Hao F, Tan W, Jiang L, et al. Do psychiatric patients experience more psychiatric symptoms during COVID-19 pandemic and lockdown? A case-control study with service and research implications for immunopsychiatry. 

. 2020;87:100-106.19. Xiang YT, Zhao YJ, Liu ZH, et al. The COVID-19 outbreak and psychiatric hospitals in China: managing challenges through mental health service reform. 

. 2020;16(10):1741-1744. Published 2020 Mar 15.

20. Zhou J, Liu L, Xue P, et al. Mental Health Response to the COVID-19 Outbreak in China. 

21. Restauri N, Sheridan AD. Burnout and Posttraumatic Stress Disorder in the Coronavirus Disease 2019 (COVID-19) Pandemic: Intersection, Impact, and Interventions. 

22. Adams JG, Walls RM. Supporting the Health Care Workforce During the COVID-19 Global Epidemic. 

Articles

The pandemic has triggered an array of emotional, physical, and economic issues but in the midst of this crisis, nations have shared and learned from each other’s experiences.

Post-COVID Stress Disorder: Another Emerging Consequence of the Global Pandemic

Nonsuicidal self-injury to the genitalia, or genital self-mutilation (GSM), is an uncommon form of self-harming behavior seen primarily, but not exclusively, in male patients with psychosis or schizophrenia spectrum disorders. As with any nonsuicidal self-injurious behavior, the severity of GSM 

 Since GSM was first described in the medical literature in 1901, infrequent case reports have been published in both psychiatric and urologic literature. The majority of these cases have been examples of patients exhibiting a single episode of GSM often involving amputation of all or part of the penis and testicles.

In this report, we present a complex and unusual case of repetitive GSM and explore the differential diagnoses and psychodynamic and psychosocial underpinnings, describing the patient’s unfolding presentation while exploring and expanding upon the limited existing literature on the subject.

A 26-year-old man presented to an outpatient mental health clinic with complaints of persistent depressed mood and emotional outbursts. During the interview, “Mr Carr” incidentally disclosed a 13-year history of repetitive, superficial cutting of the ventral aspect of his penis. Adding to the intrigue of this case, he initially denied any history of overt psychotic symptoms.

Mr Carr reported persistent depressed mood, anxiety, outbursts of anger, and increasing social isolation. He recently began taking courses to be trained as an information technology technician and soon after had a physical altercation with a classmate whom he believed was talking about him behind his back. This altercation led him to seek help at the clinic.

Mr Carr described a lifelong history of untreated depression with an aborted suicide attempt at the age of 12 (in which he held a knife to his wrist) and 1 hospitalization at the age of 24 due to suicidal ideation. As an inpatient, he was given an unknown medication, which he discontinued shortly after discharge. Around the time of this hospitalization, he began to feel self-conscious around his friends and family.

Mr Carr used to enjoy traveling and meeting new people but is now a loner without lasting friendships. He wanted to work as an information technology technician so that he could work in an isolated environment away from others. His interactions with family, classmates, and strangers on the internet have become more negative, which he attributes to his increasingly pessimistic world view. He endorsed low self-esteem and troublesome interpersonal sensitivity and felt that others are critical of him but admitted that he may be projecting his own feelings about himself onto those around him. He expressed a desire to improve his life and his social skills so that his interactions with others are more positive.

During the interview, Mr Carr was thoughtful, articulate, and had partial insight into his problems. He was attentive and polite to clinicians, and his thought processes were linear, logical, and goal directed. He was fully oriented with depressed affect. He scored 15 on the Patient Health Questionnaire-9 (PHQ-9), which indicated moderately severe depression. He denied current suicidal ideation.

When asked about nonsuicidal self-injury, he reported that since age 13, he has been cutting layers of skin from the ventral side of his penis about 2 to 3 times a year. He did not endorse erotic sensations or emotional relief as motivating these acts. Mr Carr stated all his sexual partners were female and that the cutting of his genitalia did not interfere with his sex life. He has not had any long-term romantic relationships.

Upon questioning, he denied any history of physical or 

. However, he later stated, “My whole life has felt like emotional abuse.” Mr Carr said his family makes him feel inadequate, and they wanted him to be circumcised. He said he was raised Catholic and was of Hispanic and Northern European ancestry. He did not know why he was not circumcised as an infant. An aunt recently asked him, “Why don’t you just have it done and be over with it?” He believes circumcision is not natural; he became visibly upset talking about the subject and declined to answer further questions regarding the cutting of his penis.

Mr Carr did not have a history of mania, 

, or visual hallucinations, and as far as he knows, there was no family history of psychiatric illness. He reported infrequent alcohol and cigarette use and daily marijuana use as self-treatment for his depression and anxiety. He used cocaine and psilocybin each on 1 occasion several years ago; he denied use of other drugs.

Mr Carr was agreeable to medication treatment and was started on 25-mg hydroxyzine and 30-mg duloxetine with instructions to increase the duloxetine dose to 60 mg after 7 days. He was also assigned to meet with a licensed clinical social worker for counseling.

Four days later, Mr Carr called a crisis hotline and reported that he was hearing voices. His psychiatrist was made aware of this call and phoned him to follow up. Mr Carr said he was unsure whether the voices were his neighbors “talking about him” or if the voices were internal. Two weeks later, he called his psychiatrist requesting a higher dose of hydroxyzine to treat his anxiety. When discussing what he was anxious about, he described an earlier event during which he was running errands when he became concerned that the strangers around him did not like him and were calling him names. He also stated that his hotel room was burglarized the night before, and he believed someone was “trying to intimidate [him].” Shortly after these incidents of increasing paranoia, Mr Carr accused his psychiatrist of not caring about him, moved out of state, and was lost to follow-up.

Although it is clear GSM behaviors occur within a spectrum of severity, a limitation of most literature reviews is that few have differentiated between low-intensity and more life-threatening GSM behaviors. The most recent systematic review of the available literature explored this issue directly but also called into question previous reports of the percentage of patients who are psychotic at the time of self-harm.

 sought to compare the psychiatric diagnoses behind 173 cases of GSM and to differentiate between mutilation-only and more extreme cases such as amputation of the penis, castration, or combined amputation and castration. Their review of the literature classified just 12.1% of GSM incidents as mutilation-only cases, whereas 35.8% involved penile amputation, 32.4% were cases of self-castration, and 19.7% were combined amputation/castration cases (

Psychiatric diagnoses were identified in 157 of the 173 cases examined (

). Common psychiatric disorders included schizophrenia spectrum as the most common (49%), followed by substance use (18.5%), personality (15.9%), and gender dysphoric (15.3%). These figures are in stark contrast to other reviews that placed the percentage of schizophrenia spectrum disorders higher, from 77% to 87%.

Veeder and Leo’s analysis found that patients who had a diagnosis of schizophrenia spectrum disorders were more likely to amputate their penises (with or without accompanying castration) than patients with other diagnoses and that castration only was more likely in patients with gender dysphoria. In the cases of mutilation only, 23.8% of patients had a diagnosis of schizophrenia spectrum disorders, 19% had a diagnosis of substance use disorder, 19% had a diagnosis of personality disorder, 9.5% had a diagnosis of depression, 9.5% had a diagnosis of gender dysphoria, and for 14.3%, a diagnosis was unknown or not reported.

Because he was lost to follow-up, many questions regarding Mr Carr’s GSM cannot be answered, and so a wide diagnostic net must be cast to explore the underlying diagnoses that may explain his behavior.

Given Mr Carr’s unfolding psychotic symptoms with auditory hallucinations and persecutory delusions after his visit, and considering the previously mentioned data, it seems most likely that he was experiencing the onset of a schizophrenia spectrum disorder.

 If (conservatively) 49% of patients exhibiting any form of GSM and 23.8% with mutilation-only GSM end up with a diagnosis of a schizophrenia spectrum disorder, then the cutting of his penis may have been Mr Carr’s first presenting sign, preceding the major criteria for any schizophrenia spectrum disorder by many years. Moreover, Mr Carr described himself as a loner, consistent with personality characteristics often noted in patients before the onset of psychosis.

There is at least 1 case in the literature in which a man castrated himself years before the onset of overt psychosis. At the time of the autocastration, this man received a diagnosis of schizotypal personality disorder due to odd beliefs or magical thinking and social withdrawal. Three years later, the patient presented with overt paranoia, disorganized thought, and the diagnosis was schizophrenia.

In addition to schizophreniform disorder, schizophrenia, and schizoaffective disorder, medication-induced psychotic disorder should also be 

in the differential diagnosis because Mr Carr’s psychotic symptoms appeared days after the initiating duloxetine.

 found that mood disorders were not a common diagnosis in the setting of GSM: only 8.9% of cases of any form of GSM and 9.5% of mutilation-only GSM involved patients meeting criteria for major depressive disorder (MDD).

 Mr Carr reported a long history of depression and met MDD criteria at the time of his presentation to the clinic. Therefore, MDD with psychotic features should be included in the differential diagnosis.

There is also the possibility that Mr Carr has been suffering with bipolar disorder for many years. He described a time before his hospitalization in which he hitchhiked, traveled through many states, slept on the couches of strangers, and pursued sexual relationships with women he had only just met. Without more information, it is difficult to determine whether this was simply age-appropriate youthful adventurous behavior or hypomanic episodes. The fact that Mr Carr experienced psychosis after starting duloxetine further supports the inclusion of bipolar disorder with psychotic features in the differential diagnosis.

In light of his almost-daily marijuana use, substance use disorder should be considered. Substance use disorders were reported in 19% of individuals with mutilation-only GSM.

 Mr Carr denied any cognitive or other impairment from his marijuana use, but one cannot rule out that marijuana or other possible additives may have exacerbated his paranoia or triggered the auditory hallucinations. Dual diagnosis is not uncommon in patients with psychotic disorders. No urine drug screen was performed to confirm that marijuana was the only substance in his system. Mr Carr stated that he began cutting himself before he began using marijuana, suggesting that marijuana use did not explain his GSM.

When considering a personality disorder (diagnosed in 19% of mutilation-only cases) as an underlying diagnosis, Mr Carr did exhibit some cluster A personality traits such as suspicion of others as found in paranoid or schizotypal personality disorders and a preference for solitary activities as seen in schizoid personality disorder.

 He also had some symptoms of borderline personality disorder with self-mutilating behavior (although not suicidal) and described intense anger and paranoid ideation, which may have been stress related and evolved into psychosis. However, he did not meet DSM-5) criteria for any one disorder. Moreover, these personality traits merge with Mr Carr’s psychotic and mood symptoms.

Of the 4 diagnoses, Veeder and Leo found most commonly in mutilation-only cases, gender dysphoria is the least likely to explain Mr Carr’s case, as he did not describe any dissatisfaction with his gender.

It is very difficult to find examples of patients who have practiced GSM 

. A report from 2002 found only 13 cases of repetitive GSM in the literature. The authors reported that 8 of the 13 cases (61.5%) involved male patients with gender dysphoria and in only 5 of the cases (38.5%) was the patient psychotic at the time. Of these 13 total cases, 46.2% began with low-intensity, nonpermanent forms of mutilation and progressed to more severe acts.

 Although it is a small sample size, this report highlights the importance of asking these patients about gender dysphoria and determining whether their self-harming behavior has evolved in severity over time.

DSM-5 cites nonsuicidal self-injury as a condition warranting further research. While Mr Carr’s behavior does not entirely fit within the proposed criteria for this disorder, it is worth noting here. DSM-5 characterizes 

 as repetitive, shallow but painful injuries to the body surface that commonly produce feelings of relief. Many individuals who practice this behavior report feelings of tension and craving for the mutilation followed by reduced tension and anxiety after the act. Whether Mr Carr felt this pattern of craving followed by relief, we do not know, but it is clear he did not intend to kill himself by GSM.

Case reports on GSM are not only scarce, they are also inconsistent in their documentation of the psychosocial factors underlying these acts. In the case of Mr Carr, one wonders what role the pressure from his family to undergo circumcision played in his GSM or whether his feelings of having been emotionally abused contributed to self-punishing behavior.

Several psychodynamic theories have been proposed regarding GSM. Some have posited that it could be related to Freudian castration anxiety. Thompson and colleagues

 described 2 cases of GSM by 2 young men who had recently lost their fathers, suggesting that an unresolved oedipal complex may have contributed to the GSM. The authors proposed that guilt about an attachment to their mother, ambivalence toward the father, and intense grief might have led to self-punishment by carrying out castration fears.

Findings from another case study of 3 patients suggest that GSM could be related to castration anxiety and unresolved oedipal situations.

 A case study of 2 patients with schizophrenia who carried out a different and extreme form of self-mutilation, self-enucleation, suggested that castration fears and failure to resolve oedipal conflicts, severe guilt, and self-punishment all contributed to these desperate acts.

 Mr Carr did not share specific details about his relationship with his parents other than general feelings of emotional abuse to support unresolved oedipal issues as influencing him.

Other risk factors identified in the literature include feelings of guilt surrounding a sexual conflict, as well as experiences of separation, a recent failure, and a history of self-mutilation (genital and nongenital).

 Unfortunately, the case of Mr Carr, like cases before it, lacks many important details that could contribute to our understanding of this unusual behavior. Questions such as whether he felt guilty about a past sexual encounter or if he was punishing himself for disappointing his family may never be answered. Consistent with the diagnostic complexity of Mr Carr, for 14.3% of mutilation-only GSM cases, a diagnosis was unknown or not reported.

GSM is an infrequent form of nonsuicidal self-injury that occurs within a spectrum of severity. It is very likely that less severe forms of GSM may be both underreported and unpublished. These factors combined with the immense shift in scientific understanding of human sexuality since the first cases were reported has contributed to the clinical mystery of GSM. When facing a case of GSM, clinicians should explore the motivations underlying the self-injury and consider a wide variety of psychiatric diagnoses. Medical treatment should be tailored to the patient’s presentation and underlying diagnosis, and the patient should be closely monitored for recurrence and escalation.

 is a medical student, University of Oklahoma Health Sciences Center, Oklahoma City, OK. 

is Vice Chair of Education, Ungerman Endowed Chair of Psychiatry, Department of Psychiatry and Behavioral Sciences, University of Oklahoma Health Sciences Center. The authors report no conflicts of interest concerning the subject matter of this article.

Male genital self-mutilation: a systematic review of psychiatric disorders and psychosocial factors

2. Catalano G, Catalano MC, Carroll KM. Repetitive male genital self-mutilation: a case report and discussion of possible risk factors. 

3. Greilsheimer H. Male genital self-mutilation. 

On background factors of male genital self-mutilation

5. Myers WC, Nguyen M. Autocastration as a presenting sign of incipient schizophrenia. 

6. Preda A, Maclean RW, Mazure CM, Bowers MB. 

Antidepressant-associated mania and psychosis resulting in psychiatric admissions

7. Tomita T, Yasui-Furukori N, Kaneko S. Visual hallucinations during duloxetine treatment in a patient with major depressive disorder. 

8. Thompson JN, Abraham TK. Male genital self mutilation after paternal death. 

9. Money J, DePriest M. Three cases of genital self-surgery and their relationship to transsexualism. 

10. Maclean G, Robertson BM. Self-enucleation and psychosis: report of two cases and discussion. 

This form of nonsuicidal self-injury occurs within a spectrum of severity, and it is very likely that cases are both underreported and unpublished.

Genital Self-Mutilation: A Cutting Conundrum

At precisely 9:02 am on the morning of April 19, 1995, a rental truck filled with explosives was detonated outside the Alfred P. Murrah Federal Building in Oklahoma City (OKC). One third of the building was reduced to rubble, nearby cars were incinerated, and more than 300 nearby buildings were damaged or destroyed. The act of domestic terrorism killed 168 people, including 19 children, and injured hundreds of others. A mere 90 minutes later, a key conspirator was pulled over by authorities, but by then the damage had been done. Until September 11th, this was the worst terrorist attack on US soil.

My story is only one among many accounts by individuals who were touched by the event. Most of us remember where we were when the OKC terrorist bomb shattered our sense of peace in this usually quiet community. The shockwave travelled for miles.

I recall being in my office less than 2 miles away, supervising a resident, when the entire building shook. Having grown up in the San Francisco Bay Area, my immediate thought was that it was an earthquake. But in Oklahoma, that didn’t make sense. More likely a natural gas explosion, I imagined. My resident, who had attended medical school in Kosovo, later told me that she knew exactly what it was.

We wandered to a room with a TV to see if anything unusual had been reported. A local news channel had their weather helicopter hovering over the downtown area. We watched in disbelief and horror. As the smoke parted, we saw the remains of what we later learned was the Alfred P. Murrah Federal Building, with a large section blown away. My thought at the time was that it would not be possible to survive in this structure, whatever had happened to it. As sometimes occurs, a bomb threat was apparently reported at our University of Oklahoma Health Sciences Center campus, and we dutifully left the building. My contact lenses were unbearable due to invisible dust particles in the air.

Many of my memories from that time are spotty. Later in the day I tried to drive downtown to St Anthony’s Hospital, where many of the physically and emotionally wounded survivors were taken. Traffic leaving the city center was so heavy that I couldn’t proceed on the main route. I turned around, rationalizing that I would be of no help at the bombing site given my small stature, and later felt guilty.

Firefighters, police officers, military personnel, doctors and other volunteers reported to the site to search for survivors-grueling work in an unstable structure surrounded by massive debris. Some medical trainees without disaster experience helped the medical examiners sort out human remains. I went to the local Veterans Affairs Medical Center and met with civilians who had been close to the federal building. Countless community members reported to a local church to help-handling donations of food, bottled water, gloves, and other items to aid rescue and recovery workers. Many OKC residents with relatives and friends in the building and surrounding areas wandered around local hospitals to find loved ones.

Back at our outpatient clinic, we tried to reassure the patients who showed up for mental health care. Whatever problems they had were confounded by fear and sadness at the inexplicable loss of human life so close by. For the next days and weeks, we dealt with the additive effects of the bombing on our patients, and our doors and those of numerous mental health professionals were open to survivors, bereaved individuals, and others who were troubled.

Many of our health and mental health professionals were consumed with recovery work-attending to and doing surgeries on broken bones, head injuries, organ damage, and soft-tissue injuries; and assisting those with mental health sequelae. Psychiatrists and psychologists teamed up with clergy and medical examiners to meet with and notify family members of the deaths of their loved ones. In these sessions, the medical examiner started with a statement about identifying the remains of the loved ones, followed by the mental health care professional and clergy member processing the family members’ reactions. I recall feeling very grateful for the clergy, who had far more experience than I had in processing death and grief.

Media coverage of the bombing was intense, and reporters from across the country flooded the airport to chronicle the event. At some point President Clinton visited to express his condolences. Even actors and celebrities visited to show their support and perhaps boost publicity.

Our governor got tough with insurance companies that were slow in compensating for damages to cars and structures due to an act of civil disturbance. The state local workers compensation laws did not cover mental health sequelae without physical injuries. Fortunately, federal workers compensation benefits covered survivors when only mental health diagnoses occurred due to work-related problems.

For weeks and years, we dealt with the aftermath of this event on our community, with people pitching in from all areas of expertise. We were all affected by the tragedy. In addition to the more than 800 injured by the explosion, another 12,000 individuals assisted in extensive rescue efforts, sifting through the destroyed building and surrounding areas for survivors and bodies, caring for those with physical and emotional injuries, transporting and identifying bodies, counseling the bereaved, and performing other duties, many of whom were donating their time. Sadly, there was one fatal injury during the search and rescue operations. In addition to sustaining emotional and physical injuries, many people dealt with unemployment and economic consequences because of barriers to insurance reimbursements and destroyed businesses.

The impact was felt by survivors (adults and children) of direct exposure as well as first responders and family and friends of victims via indirect exposure. Not surprisingly, in a 

of 255 who were directly exposed to the blast, about one-third had a PTSD diagnosis.

 About 80% had witnessed death or injuries, and 77% required medical attention.

Seven years later, 26% still suffered from PTSD while many others had subclinical 

 Moreover, almost 19 years following the event, another study found that 23.2% of directly exposed survivors met threshold criteria for probable PTSD.

 The study also found that survivors had more anxiety and depression symptoms than controls, and higher symptoms were associated with heavy drinking and worse social functioning.

Children who lost close relatives had greater autonomic reactivity than those who lost more distant relatives, with higher levels of grief associated with more reactivity.

 Study findings suggest that the enduring physiological effects of trauma may be separate from emotional symptoms in children indirectly exposed, representing a lasting footprint of disaster. For instance, seven years after the incident, children of survivors reported relatively low levels of posttraumatic stress and depressive symptoms, but they had more physiological reactivity than a community comparison group.

First responders seemed to handle the stresses relatively well, which may be partially due to onsite briefings, use of healthy coping techniques (social support and positive reframing), onsite critical stress management, a strong ambiance and sense of community, positive management style, a high educational level, medical experience, and assumption of a professional role.

We, in the field of psychiatry, not only helped in the aftermath, but also used this unfortunate event as a learning opportunity. For instance, Art Rousseau, MD, was among several Oklahoma psychiatrists who took a leadership role in organizing mental health recovery efforts, and he was awarded the American Psychiatric Association’s Bruno Lima Award in Disaster Psychiatry for his work. Betty Pfefferbaum, MD, JD, immersed herself in research on effects of the bombing and recovery efforts, especially among children. Her mentorship inspired me to conduct research on biological after-effects among survivors, and long-term health and mental health sequelae. The expertise and contributions of Carol North, MD, MPE, to disaster research have been invaluable.

The Oklahoma State Department of Health worked with physicians and psychiatrists to study physical and emotional injuries. Our research is indebted to many of the survivors who pledged early on to participate in future research; they were passionate about promoting a better understanding of the effects of terrorism on those directly exposed, to help others in similar situations.

Increasingly our communities are affected by diverse disasters-acts of terrorism, mass shootings, destructive wildfires, colossal storms and other catastrophic events. As a global community, it is essential that we share information about interventions that helped survivors, the bereaved, first responders, caregivers and others-and that we give our support. Healing may take many years.

 is Professor, Arnold and Bess Underman Endowed Chair in Psychiatry, Vice Chair of Education, Department of Psychiatry, University of Oklahoma Health Sciences Center, Oklahoma City, OK.

1. North CS, Nixon SJ, Shariat S, et al. 

Psychiatric disorders among survivors of the Oklahoma City bombing

2. North CS, Pfefferbaum B, Kawasaki A, et al. Psychosocial adjustment of directly exposed survivors 7 years after the Oklahoma City bombing. 

3. Tucker P, Pfefferbaum B, NitiÃ©ma P, et al. Intensely exposed Oklahoma City terrorism survivors: long-term mental health and health needs and posttraumatic growth. 

4. Pfefferbaum B, Tucker P, Jeon-Slaughter H, et al. A pilot study of physiological reactivity in children and maternal figures who lost relatives in a terrorist attack. 

5. Pfefferbaum B, Tucker P, North CS, Jeon-Slaughter H. Physiological reactivity in children of Oklahoma City bombing survivors 7 years postdisaster: a pilot study. 

6. Tucker P, Pfefferbaum B, Doughty DE, et al. Body handlers after terrorism in Oklahoma City: predictors of posttraumatic stress and other symptoms. 

7. Nixon SJ, Schorr J, Boudreaux A, Vincent RD. Perceived effects and recovery in Oklahoma City firefighters. 

Most of us remember where we were when the terrorist bomb shattered our sense of peace in this usually quiet community. The shockwave travelled for miles and across time.

25 Years After the Oklahoma City Bombing

Slideshows

Patients with difficult conditions such as delusional parasitosis tend to resist the notion that a psychiatric problem underlies their symptoms.

5 Techniques to Help Your Patient Accept a Difficult Psychiatric Diagnosis

The recent suicides of two teenaged survivors of the 2018 school shooting at Marjory Stoneman Douglas High School in Parkland, Florida and the father of a child killed in the 2012 Sandy Hook Elementary School shooting raise the question of the interplay and impact of survivor guilt, post-traumatic stress disorder, and traumatic bereavement among survivors and victims’ loved ones after such traumatic events. Alarmingly, these three suicides occurred within a 10-day period. The mother of one shooting survivor who died by suicide shared publicly her daughter’s PTSD and survivor guilt. The father of the young Columbine victim had struggled with prolonged grief over 6 years after his daughter’s death, according to his wife. In addition, suicides have also occurred in the wake of the Columbine and Virginia Tech school shootings.

DSM-5 and its predecessors clarify diagnostic criteria for PTSD, but do not specifically name survivor guilt as an outcome of PTSD or traumatic exposure. PTSD’s criterion D (negative alterations in cognitions and mood associated with trauma) includes persistent distorted cognitions such as blaming oneself or others and persistent negative emotional state such as guilt or shame. Risk for suicidal ideation and attempts in PTSD is clearly discussed in the text, as well as the risk for comorbid depression. DSM-5 differs from previous DSMs, which excluded depression diagnosis for symptoms lasting less than two months after a loved one’s death. Thus, at the clinician’s judgment, major depression can now be diagnosed in the presence of bereavement.

Survivor guilt occurs when individuals believe they have done something wrong in surviving a traumatic event in which others have perished. It has been described among Holocaust survivors and combat veterans as well as by survivors of natural disasters, airplane crashes, acts of terrorism, and mass shootings. While some survivor guilt may be natural, when excessive or prolonged, it can lead to other problems.

Here’s an example of a man who survived the Oklahoma City bombing while working inside the Federal Building. When the blast occurred, he had been turning on a light switch. He developed the irrational belief that his switching on the light had somehow triggered the bomb, although he knew intellectually that this was not the case. He escaped the devastated building with no physical injuries, but many coworkers perished. He did not escape psychic injuries. Along with considerable survivor guilt, he developed PTSD and a substance use disorder, complicating his treatment and recovery, and died a few years later of cardiovascular disease.

Survivor guilt has been described in the psychoanalytic literature. Freud described a broader conceptualization of a more universal guilt that individuals feel when they survive another’s death.

 Hartman recently re-examined Anna Freud’s dreams, exploring the interplay of mourning and survival guilt. Her immediate family escaped the Holocaust but her aunts were lost in Nazi concentration camps. While she never wrote directly about her family’s Holocaust experiences, her grieving was seen to be complicated by survivor guilt, with the possibility that her mourning may have affected her views on trauma and attachment. Anna later worked with child concentration camp survivors although she had a conservative view of altruism.

Survivor guilt has been recognized in combat veterans with PTSD and has been one of 5 factors significantly related to suicide attempts, along with depression, anxiety, severe PTSD, and intense combat guilt as the number one factor.

 Survivor guilt may vary among veterans of different wars. Vietnam veterans had more severe symptoms of PTSD, depression, hostility, survivor guilt, and work impairment as well as earlier onset of alcoholism compared with World War II veterans, although more time had passed since combat experiences for the latter group.

 Hospitalized Nigerian army veterans who had served as peacekeepers in Liberia and Sierra Leon had higher rates of survivor guilt (38%) than PTSD (22%), with survivor guilt associated with avoidance of trauma stimuli and PTSD linked with alcohol and cannabis use.

Traumatic bereavement or grief may occur after a sudden or unexpected death of a loved one if the response is severe or prolonged or interferes with functioning. It differs from survivor guilt in having predominant grief rather than guilt. According to the National Center for PTSD, with traumatic bereavement there is preoccupation with or a longing for the deceased; avoidance or being drawn to reminders of the lost one; feeling bitter, dazed, or angry; seeing the deceased or hearing the loved one’s voice; difficulty with relationships, upsetting memories, or feelings of emptiness.

Other psychiatric, behavioral, or medical problems may also occur with prolonged traumatic grief. Risk factors complicating recovery after witnessing sudden death include survivor guilt, having one’s own life threatened, and being confronted with massive, shocking deaths. For children, having many losses or viewing death is especially difficult. To help the traumatically bereaved individual recover hope and comfort, recommendations include providing information about grief, assessing the bereaved person’s distress while helping solve practical problems, and managing intense feelings.

In light of recent events, mass shootings of youth have become increasingly a concern. What have we learned over the years? Much of the focus has understandably been on PTSD, with some assessments of grief. One year following a 1984 sniper attack at an elementary school, surviving children had more grief symptoms if they were better acquainted with the deceased child and had had more exposure to the violence; grief and PTSD symptoms sometimes presented independently, and at other times they were interconnected.

Four months after a 2007 high school shooting in Finland, half of the girls and a third of boys had posttraumatic distress; intense exposure and female gender increased the risk for PTSD.

 After a 2007 classroom shooting in an Illinois university, an assessment of female undergraduates in a sexual revictimization study found many (42.1%) to be resilient, with 11.9% having probable PTSD acutely and 8 months later.

 More PTSD symptoms at 8 months was associated with higher prior trauma exposure, post-trauma emotional dysregulation, and peritraumatic dissociation.

The impact of school shootings extends far beyond the directly affected school and community. The widespread emotional effects of 69 deaths (average age 19 years) in a 2011 summer camp mass shooting in Norway were revealed in an assessment of over 10,000 Norwegian high school students. One in five respondents knew individuals directly exposed, over 50% felt the event threatened their own or a close one’s lives, and almost 80% had changed views of the world. Higher levels of PTSD symptoms were associated with personal proximity to the events, perceived threat, and being a female or immigrant.

Looking at the widespread effects of mass school shootings, a national US survey of high school students not directly involved in the event was conducted a month before and two months after the 1999 Columbine High School shootings. Results showed that more students felt too unsafe to go to school after the catastrophe, but they were less likely to consider suicide.

So, what can we do to help survivors and family members of school shootings? No studies have systematically studied interventions to help these individuals with specific problems of survival guilt alone. See 

 for recommendations that may be helpful in the immediate aftermath of a community disaster and over time.

Treatments for diagnosed PTSD cited by the National Center for PTSD as having the strongest evidence for efficacy are prolonged exposure, cognitive processing therapy, and eye movement desensitization and reprocessing (EMDR). Four antidepressants with demonstrated effectiveness in adults only are sertraline, paroxetine, fluoxetine, and venlafaxine. Similarly, psychotherapy and some antidepressants may be helpful for children or adolescents who have major depression in the aftermath of mass violence.

Providing a sense of safety and normalcy is important. A recent study of children and teens who presented to an ER in the UK after traumatic incidents were followed for two months. The findings suggest that youths with more PTSD symptoms made more efforts to deliberately process their trauma, as if they perceived that there was something wrong with them. PTSD symptoms were not associated with severity of physical injuries, other life stressors, or social support.

The reactions of caregivers also plays a role in number of PTSD symptoms. More PTSD symptoms were seen in traumatized youths who had families who exaggerated their child’s emotional response or whose parents reported more family over-involvement and accommodation behaviors.

School shootings have taken direct and secondary victims and appear to be increasing. While limiting access to weapons among at-risk youth and monitoring social media for potential threats may help prevent future incidents, as mental health professionals we must deal with the emotional toll on innocent survivors and among youths in general, to restore mental health and a sense of safety.

 is Professor and Vice Chair of Education, Ungerman Endowed Chair, Department of Psychiatry and Behavioral Sciences, University of Oklahoma Health Sciences Center, Oklahoma City, OK. Dr Lastrapes is PGY-1, Department of Psychiatry and Behavioral Sciences, University of Oklahoma Health Sciences Center. She is also an Editorial Board Member for

The impact of school shootings extends far beyond the directly affected school and community. What can we do to help survivors and family members?

Phebe Tucker, MD

Articles

Post-COVID Stress Disorder: Another Emerging Consequence of the Global Pandemic

Genital Self-Mutilation: A Cutting Conundrum

25 Years After the Oklahoma City Bombing

5 Techniques to Help Your Patient Accept a Difficult Psychiatric Diagnosis

The Aftermath of School Shootings

Inflammation, Immune Function, and Schizophrenia: An Overview

The Interface of Dermatology and Psychiatry

Current and Future Treatment Options for Preventing Metabolic Syndrome Due to Atypical Antipsychotics

Introduction: Mental Health Correlates of Trauma

"Re-sensitized" to Violence in the Wake of Newtown