[Automutilation with indistinct underlying disease--difficulties of care in the community]

Self-mutilation is well-known in various psychiatric diseases and represents a challenge for forensic pathologists as regards the differentiation of accidental versus self-inflicted injuries, especially when a criminal charge is likely to emerge.

A case of extraordinarily severe self-inflicted injuries is presented as well as the related implications concerning clinical and ambulatory care for patients, whose underlying motivation remains unknown.

A 60 year-old worker exhibited an open scull fracture and 14 abdominal wounds with protrusion of small intestine, from which a part of 160 cm length was completely removed beforehand. The patient claimed the wounds having been caused accidentally. When examined by a psychiatrist, disturbances in orientation, unrest and ill concentration were found, but no symptoms related to psychosis, depression or suicidal behaviour.

Although the need for more detailed examination seemed to be clearly evident, the medical authorities did not take action. Consequently, no further psychiatric treatment was initiated. The implications of this case on the background of the literature are discussed.