title: Missing the point: self-inflicted traumatic brain injury in psychosis.
abstract: 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.
authors.affiliation: Department of Psychiatry, Yale University, New Haven, Connecticut, USA.
authors.forename: Phelan E
authors.initials: PE
authors.lastname: Maruca-Sullivan
authors.affiliation: Department of Psychiatry, Yale University, New Haven, Connecticut, USA.
authors.forename: Matthew N
authors.initials: MN
authors.lastname: Goldenberg
authors.affiliation: Department of Emergency Medicine, Yale University, New Haven, Connecticut, USA.
authors.forename: David C
authors.initials: DC
authors.lastname: Cone
authors.affiliation: Department of Emergency Medicine, Yale University, New Haven, Connecticut, USA.
authors.forename: Justine
authors.initials: J
authors.lastname: Ciarleglio
mesh_terms: D000208:Acute Disease; D000328:Adult; D001921:Brain / Q000000981:diagnostic imaging; D000070642:Brain Injuries, Traumatic / Q000000981:diagnostic imaging* / Q000523:psychology; D002543:Cerebral Hemorrhage / Q000000981:diagnostic imaging / Q000523:psychology; D020202:Cerebral Hemorrhage, Traumatic / Q000000981:diagnostic imaging / Q000523:psychology; D057210:Delayed Diagnosis; D005547:Foreign Bodies / Q000000981:diagnostic imaging / Q000523:psychology; D020773:Headache Disorders / Q000523:psychology; D006801:Humans; D008297:Male; D011618:Psychotic Disorders / Q000150:complications*; D016728:Self-Injurious Behavior / Q000000981:diagnostic imaging* / Q000523:psychology; D012887:Skull Fractures / Q000000981:diagnostic imaging* / Q000523:psychology; D013701:Temporal Bone / Q000293:injuries; D014057:Tomography, X-Ray Computed; D014950:Wounds, Penetrating / Q000000981:diagnostic imaging* / Q000523:psychology