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Monosymptomatic hypochondriacal psychosis complicated by self‐inflicted skin ulceration, skull defect and brain abscess

Self‐inflicted dermatoses are associated with personality disorders and psychoses, including monosymptomatic hypochondriacal psychosis (MHP), which is characterized by a delusion involving a particular hypochondriacal concern. We report an unusual case of MHP with severe mutilation of the skin complicated by a skull defect and brain abscess. The patient was a 66‐year‐old uneducated man who damaged his forehead repeatedly because he believed that a ‘toxic root’ in the forehead was the source of his general ailment. He admitted that the lesions were self‐inflicted. There was no other evidence of psychosis or primary skin disease and MHP was diagnosed. Despite initial favourable response to pimozide, the patient was lost to follow‐up for 4 years, during which he continued to damage his forehead and applied corrosive agents. He was then referred with a personality change and a 6 × 4 cm bony defect in the skull, complicated by herniation and abscess of the left frontal lobe. This case represents one of the most severe examples of self‐mutilation ever reported. The differential diagnosis of dermatitis artefacta and the principles of treating MHP are discussed.