Abstract
Chief Complaint and Presenting Problem
Z. was a 14-
History of Present Illness
Upon referral, Z.'s mother reported that Z. had appeared as if she had been doing well and seemed to be happy. Mother reported that she was called by the school counselor that day and was told that Z. had been cutting herself with a soda can. Z. confirmed that she had engaged in self injurious behavior at school. She said that she was playing with a soda can when it accidentally cut her finger. She reported that she saw blood that triggered intrusive thoughts of wanting to harm herself with the soda can, and she made several cuts to her arms.
She denied wanting to end her life at that time. Z. explained that since she was ∼7 years old, she had been feeling depressed and experiencing intrusive suicidal thoughts, almost commanding her to end her life. These intrusive thoughts varied between commanding her to cut herself, choke herself, or stab herself. She said that these thoughts are present daily and fluctuated in intensity throughout the day. These thoughts were largely egodystonic, as they were unwanted and causing her much distress.
Z. also reported that these intrusive thoughts led her to attempt suicide on multiple occasions, more times than she was able to recount. She reported that she had never disclosed this information to anyone, not even her family, until the events leading to the current referral. Notably, she did report current suicidal ideation and intent to cut herself. She reported that if she was not hospitalized, she intended to cut deeper than superficially.
In addition to suicidal thoughts, Z. also reported that she had thoughts of “craving human flesh” and had these cannibalistic urges since the age of 12 years. Mother denied any knowledge of Z.'s exposure to cannibalistic experiences such as rituals or being told about them by anyone. Mother was also not aware of any cannibalistic behaviors attempted when Z. was sexually abused. Z. described her cannibalistic urges as mostly triggered by people who she “does not like” or who were “against her.” She reported hypervigilance but no paranoid ideation or delusions. She also reported long-standing perceptual disturbances of occasionally seeing the devil, who she said was her friend, seeing blood currently, seeing dead people, and a naked man.
Z. also had a history of inattentiveness, not formally diagnosed as attention-deficit/hyperactivity disorder. Mother reported that Z.'s teachers had mentioned on multiple occasions that Z. was easily distractible and unable to concentrate, preferring to color instead of participating in the class lesson. Mother reported that she had also struggled to get her to complete her homework since a young age.
There were no past or present symptoms of mania, hypomania, anxiety, disruptive behaviors, or substance abuse.
Psychiatric History
Z. had no formal psychiatric history. Mother reported that when Z. was around 5–6 years old, she had seen a therapist for overt sexual behaviors such as kissing classmates on the mouth and touching them inappropriately. Mother reported that these behaviors began after Z. accidentally saw a pornographic video on her phone. Child Protective Services was reportedly never formally involved with the family at that time.
Developmental History
Mother reported that there were no complications during her pregnancy, including no known exposure to medications or infections. Z. was born full term through normal spontaneous vaginal delivery. Birth weight was 2.948 kg. She had no birth complications and met all normal developmental milestones throughout childhood. She began speaking at 10–12 months, walking at 12 months, and was toilet trained at 24 months. There were no developmental delays.
Educational History
Z. was entering ninth grade. There was no history of suspensions or expulsions.
Social History
Z. was born and raised on a Caribbean Island and had moved to the United States recently. She lived with mother and maternal grandparents. Mother and father separated before Z.'s birth. Father had been minimally involved in Z.'s life and had not attended most birthdays or major holidays. He did not live in the United States; Z. last saw him just before moving.
Z. did have a good relationship with her stepfather, who Z.'s mother married when Z. was 5 years old. She used to refer to him as “dad.” He lived with Z. and mother for 8 years; however, they separated just before Z. and mother's move to the United States.
Mother reported and Z. endorsed a history of sexual abuse. Z. endorsed two distinct sexual abuse events, one at age 7 years and the other at age 12 years, but provided limited details regarding these events. The encounter at age 12 years involved abuse by an adult male relative who was currently deceased. The encounter that occurred at age 7 years involved a 15-year-old teenager at school.
Mother and Z. both denied she used illicit drugs (except for accidentally ingesting a cannabis gummy once), alcohol, or nicotine. Z. did not endorse any current romantic relationship(s) but did indicate she was interested in both males and females.
Family History
Mother endorsed a diagnosis of depression, anxiety, and had experienced thoughts of harming herself when she was a teenager. Mother took antidepressants at that time. Mother's symptoms had since resolved, and she was not currently receiving treatment. There was no other known family history of psychiatric illness, substance use, or suicidality.
Medical History
Mother and Z. denied any medical or surgical history. Z. denied any known allergies, and vaccinations were up to date. Mother and Z. denied any history of traumatic brain injury, seizures, head injuries, or episodes of loss of consciousness. Menarche was at 11 years and menses have been regular since then.
Medication History
Z. did not take any nonpsychiatric medications.
Mental Status Examination
On initial mental status examination, Z. appeared her stated age, was appropriately dressed, and had adequate grooming and hygiene. There were no dysmorphic features. She was calm and cooperative during the interview. She was awake, alert, and oriented to person, location, date, and situation. Z. displayed good eye contact and spoke with spontaneous, clear, comprehensible speech of appropriate volume, rate, and prosody. There was no evidence of psychomotor retardation, psychomotor agitation, or abnormal involuntary movements, and gait was appropriate.
Z. described her mood as “okay.” Her affect was generally constricted, though reactive. Thought process was organized, linear, and goal directed. Thought content consisted of obsession with eating human flesh as well as compulsions of biting herself multiple times per day. She denied suicidal or homicidal ideation. No delusions were elicited. She endorsed intermittent visual hallucinations of a “scary man” but did not appear to be overtly responding to internal stimuli. She exhibited poor/limited insight as well as poor judgment. Attention and concentration were fair. She spoke fluent English and Spanish. Memory was not formally assessed but appeared grossly intact. Fund of knowledge appeared appropriate for the level of education.
Formulation
In summary, Z. was a 14-year-old adolescent girl with no known psychiatric or medical history referred for emergency psychiatric evaluation for self-injurious behavior and intrusive cannibalistic thoughts. Predisposing factors included family history of psychiatric illness, poor coping skills, and reluctance to share emotional experiences with her mother. Precipitating factors included a personal history of childhood sexual abuse within the past 2 years.
Perpetuating factors include lack of treatment for chronic psychiatric symptomatology including her long history of daily suicidal ideation, intrusive thoughts, visual hallucinations, and cannibalistic ideation. Protective factors include adaptive developmental milestones (by history), progress in school, absence of significant medical/surgical disorders, and recent engagement with mental health treatment.
Multi-Axial Diagnoses
Unspecified trauma- and stressor-related disorder
History of sexual abuse in childhood
History of nonsuicidal self-injury
Current nonsuicidal self-injury
History of suicidal behavior
Treatment Course
Z. was admitted involuntarily to a child and adolescent psychiatric unit. On admission, Z. had stable vital signs. Routine laboratories revealed the following abnormalities: total cholesterol, triglycerides, and high-density lipoprotein were mildly elevated. Other laboratories including complete blood count, calculated low-density lipoprotein, hemoglobin A1c, thyroid stimulating hormone, free T4, urinalysis, drugs of abuse screen, and urine pregnancy test were all within normal limits.
Z. was started on aripiprazole 2 mg daily and sertraline 25 mg daily. She was also started on as-needed medications for anxiety (hydroxyzine 25 mg two times a day), sleep (melatonin 3 mg bedtime), and agitation (olanzapine 2.5 mg oral or intramuscular every 8 hours). Z. tolerated initial doses of aripiprazole 2 mg a day and sertraline 25 mg a day. Her mood symptoms gradually improved; however, after a week Z. continued to endorse persistent intrusive cannibalistic thoughts and intermittent visual hallucinations of a “scary man” that almost always happened at night when she was alone.
At this point, differential diagnosis included posttraumatic stress disorder (PTSD) versus a primary psychotic etiology. Since Z. did not display any other signs/symptoms of a primary psychosis such as disorganization, response to internal stimuli, or internal preoccupation, sertraline was titrated up from 25 to 50 mg a day. Over the course of hospitalization, Z. required one dose of hydroxyzine 25 mg for anxiety on admission, and melatonin 3 mg for insomnia on days 2 and 3. She did not require medications for agitation.
Z. was observed as not interacting appropriately with her peers. She discussed human flesh during group therapy sessions and drew disturbing imagery that included pictures with a vampire/blood-like theme. Z. was referred for psychological testing that revealed low self-esteem, feelings of inadequacy, and a distorted body image. Z. spent her time overinvolved in fantasy-like visions to remove herself from the real world. Testing also revealed that Z.'s early childhood sexual trauma as well as social media exposure had resulted in her becoming prematurely sexualized. Z. was diagnosed with a persistent depressive disorder, unspecified trauma- and stressor-related disorder, and child sexual abuse.
Z. showed additional improvement in her symptoms with psychological interventions including supportive therapy, coping skills therapy, and brief trauma-focused therapy. She was continued on aripiprazole 2 mg a day and sertraline 50 mg a day. All her symptoms (daily suicidal ideations, intrusive thoughts, visual hallucinations, and cannibalistic ideation) finally resolved in her third week of admission. Z. was discharged with a plan to follow up with individual psychotherapy and medication in the outpatient clinic.
Discussion
Cannibalistic ideation, the persistent and intrusive thoughts of consuming the flesh of one's own species, is an extremely rare and atypical behavior (Aras, 2021). There is limited information and a paucity of data about cannibalistic ideation in the psychiatric literature, and even less in the pediatric population. This is the first case report, to our knowledge, of an adolescent who initially presented with recurrent thoughts and fantasies related to cannibalism. This case presents both diagnostic and treatment challenges, as such a symptom can represent a complex interplay of psychological, social, and neurobiological factors.
Human cannibalism, though rare, has occurred for thousands of years (Byard, 2023). There are three subtypes of cannibalism: ritualistic, survival/nutritional, and pathological (Byard, 2023; Raymond et al., 2019). The ritualistic subtype refers to cannibalism in the context of religious or spiritual belief systems that require ingestion of another individual in the form of sacrifice or as a form of funerary rites, as seen in tribal groups (Byard, 2023; Raymond et al., 2019). The survival (also termed nutritional or gastronomic) subtype refers to cannibalism in the context of necessity such as in situations of acute starvation (Byard, 2023; Raymond et al., 2019).
Of note, individuals who engage in this type of cannibalism are typically otherwise averse to cannibalism (Raymond et al., 2019). Lastly, the pathological subtype refers to cannibalism in the context of a disorder such as severe mental illness (typically acute psychosis) and/or extreme paraphilias (Byard, 2023; Raymond et al., 2019). Pathological cannibalism may have medicolegal/forensic implications such as in the case that an individual is found to be not guilty by reason of insanity due to a severe mental illness. Although there is not a plethora of examples of these cases, Raymond et al. (2019) describe five cases in which this issue is central.
Of the five cases presented, three ultimately were diagnosed with schizophrenia, two showed signed of mixed personality disorder, and four resulted in the individual being found not criminally responsible in a court of law (Raymond et al., 2019).
Z. was initially referred for self-injurious behavior at school. It has been well established that such behavior may be a solution to unacceptable emotions caused by an inability to adapt to reality (Linehan, 1993). This behavior can serve as a coping mechanism that provides a quick but temporary solution for complex emotions involving, but not limited to, guilt, rejection, sexual thoughts, and hallucinations (Aras, 2021). Z.'s self-injurious behavior may have been a mechanism to provide relief from her intense and disturbing cannibalistic thoughts. Z.'s history of sexual abuse and diagnosis of mood disorder predisposed her to cognitive alterations that may have contributed to the development of cannibalistic ideation.
Traumatic experiences, especially during childhood, can significantly impact an individual's future psychological well-being. A study conducted by Bendall et al. (2013) showed that those with childhood sexual abuse and first episode psychosis had more severe hallucinations and delusions, reported posttraumatic intrusions, and showed selective attention to trauma-related stimuli. This is in accordance with literature that has established that childhood trauma increases the risk for psychosis and impacts its severity (Stanton et al., 2020). In all three cases in which the patients were ultimately diagnosed with schizophrenia, Raymond et al. (2019) found a history of some disturbed childhood experiences.
It is plausible that Z.'s past sexual abuse may have contributed to the development of her symptoms. Traumatic events, especially interpersonal trauma, alter core cognitive schemata in children and adolescents, promoting maladaptive beliefs of self and others leading to distortions of thought that significantly influence the interpretation of internal and external experiences (Misiak et al., 2017). In addition, traumatic events that occur in the caregiving environment further disrupt the development of adaptive emotional regulation strategies in children (Gracie et al., 2007).
Cannibalistic ideation may be perceived as somewhat of a self-defense reaction to a supposed threat of physical and/or psychological damage (Raymond et al., 2019). This concept is exhibited in Z. as she reported that most of her cannibalistic thoughts were triggered by people she “did not like” or who were “against her.” In addition, Z's sexual trauma occurred in a familiar environment, increasing the risk of severe cognitive distortions such as cannibalistic ideation.
Trauma exposure often results in a variety of psychiatric disorders (Kessler et al., 2010). Although childhood trauma has been associated with several psychiatric disorders, greater diagnostic complexity has been noted in those presenting with both psychosis and trauma exposure (Stanton et al., 2020). Z.'s cannibalistic ideation and psychotic symptoms (i.e., visual hallucinations) represented a diagnostic dilemma, given that psychotic symptoms typical of schizophrenia occur with a higher-than-expected frequency in PTSD (OConghaile and DeLisi, 2015). In addition, both disorders share common risk factors specific to Z.'s case, such as childhood sexual abuse, comorbid depression, ethnocultural minority status, and psychosocial stressors (OConghaile and DeLisi, 2015).
PTSD with psychotic symptoms and early onset schizophrenia spectrum disorder was both considered in Z.'s differential diagnosis. Symptoms of PTSD can be so severe that they may be characterized by pervasive paranoia and auditory, visual, tactile, and olfactory hallucinations, and in Z.'s case, cravings of human flesh (OConghaile and DeLisi, 2015). However, experiencing a traumatic event or an interaction of trauma with a genetic predisposition for psychosis may also lead to the development of a prodromal onset of a schizophrenia-like illness (Driver et al., 2020).
In early onset schizophrenia, many patients show premorbid disturbances in social, motor, and language domains as well as comorbid mood or anxiety disorders; however, such premorbid disturbances are not diagnostic (Driver et al., 2020). Z's cannibalistic ideation could be an attenuated psychosis syndrome, part of a range of psychiatric symptoms in the period before an initial psychotic episode.
Although Z.'s social media use is unknown, it is important to consider this factor, given its increasing prevalence and possible effects in psychiatric disorders. Individuals with psychosis may be more susceptible to content consumption on social media in comparison with those without psychosis (Berry et al., 2018). In addition, multiple case reports have suggested exacerbation of symptoms associated with severe mental health problems after social media engagement (Berry et al., 2018). Z.'s engagement with social media before referral, especially exposure to violent and graphic media content, may have influenced and contributed to the development of her intrusive and disturbing thoughts.
This case highlights the importance of including psychological assessment in the context of psychiatric evaluation when there is diagnostic complexity. Z.'s psychological testing confirmed diagnoses of persistent depressive disorder, early onset, with mood-incongruent psychotic features; and unspecified trauma- and stressor-related disorder in the context of confirmed child sexual abuse; with other specified schizophrenia spectrum and other psychotic disorders. Attenuated psychosis could not be ruled out.
Z.'s psychopharmacological treatment included a combination of low-dose aripiprazole and sertraline, which led to gradual improvement. Targeted treatment of primary symptoms when diagnostic uncertainty exists is a reasonable approach to complex cases. Selective serotonin reuptake inhibitors are commonly used to treat depressive symptoms in adolescents and used to augment treatment for PTSD. Second-generation antipsychotics are the primary treatment for psychotic disorders in youth (Datta et al., 2020). Second-generation antipsychotics are also effective in the management of PTSD with psychotic features (Compean and Hamner 2019). Long-term follow-up of Z. will be necessary to better understand the nature of her psychopathology and response to treatment.
In summary, cannibalistic ideation represents a highly unusual and rare manifestation of psychopathology. This case emphasizes the importance of comprehensive psychiatric evaluation and individualized treatment in the case of diagnostic uncertainty. Z.'s cannibalistic ideation may have represented a maladaptive attempt at coping with childhood sexual abuse or may have developed as a harbinger of more insidious development of a primary psychotic disorder. Although this case highlights successful treatment of an adolescent with cannibalistic ideation, it is important to acknowledge the limitations.
As a single case report, generalizability is highly limited. Given how rarely cannibalistic ideation is reported in the psychiatric literature, further study is needed to illustrate the connection between this symptom and psychiatric illness to better understand the prevalence, etiology, and treatment outcomes.