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Missing the point: self-inflicted traumatic brain injury in psychosis
  1. Phelan E Maruca-Sullivan1,
  2. Matthew N Goldenberg1,
  3. David C Cone2,
  4. Justine Ciarleglio2
  1. 1Department of Psychiatry, Yale University, New Haven, Connecticut, USA
  2. 2Department of Emergency Medicine, Yale University, New Haven, Connecticut, USA
  1. Correspondence to Dr Phelan E Maruca-Sullivan, phelan.maruca{at}


A 36-year-old man was brought to the emergency department by emergency medical services after being found acting unusually at a gas station with blood on his head and clothing. He presented acutely psychotic and reported that he had a pen in his head. Medical evaluation was notable for a superficial puncture wound to the right temple, and he was medically cleared for psychiatric evaluation. After he developed nausea and headache later that evening, the CT scan revealed a temporal bone fracture, pneumocephalus, intraparenchymal haemorrhage and the presence of a metal pen tip lodged in the brain parenchyma. The full nature of the injury went undiscovered in the emergency department for 16 hours due to the superficial appearance of the injury and his acute psychosis with prominent delusional thought content and disorganisation. He underwent craniotomy with removal of the pen and subsequent hospitalisation for intravenous antibiotics, followed by a prolonged psychiatric hospitalisation for psychosis.

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  • Contributors All authors were involved in direct patient care and clinical decision-making for this case as well as the decision to pursue publication. PEM-S wrote the original manuscript with assistance in drafting from MNG and critical revision by MNG, DCC and JC. All authors gave final approval of the manuscript for publication.

  • Competing interests None declared.

  • Patient consent Obtained.

  • Provenance and peer review Not commissioned; externally peer reviewed.