Command Hallucinations and self-amputation of the penis and hand during a first psychotic break

An unusual case is presented of a psychotic young man who experienced command auditory hallucinations which directed him to amputate his right hand and distal penis to atone for a "terrible sexual transgression." The existing literature on genital self-mutilation is reviewed as well as some recent work on factors that might be used to predict an episode of self-mutilation. In patients who are felt to be at extremely high risk, careful monitoring and rapid medication schedules might be effective in preventing such an incident.