Psych Doc Interprets ER Doc's Patient: Blue Balls

I had a 43 year old white male come in for penile pain. He was accompanied by his wife. They seemed like very nice, affluent people.

So I asked him what happened....I wasn't expecting the response I got.

Mr. Blue Balls: "I tried to freeze my penis off 2 days ago by leaving ice packs on it."

Me: "Uhhh...ok. Why did you do that?"

Mr. Blue Balls: "I don't know."

So I proceeded to take a look at the damage. When he dropped his pants. I noticed his testicles were gone. His wife told me that 2 years ago he cut off his testicles HIMSELF. Never said why....always would just say I don't know. She said he was never diagnosed as psychotic or bipolar or schizophrenic. She said he was just diagnosed with being severely depressed. I've seen some really depressed people, and none of them had self mutilated their genitalia!

His penis had 2nd degree burns. It will turn out better than his nuts did. I called our psych team to come out for an eval (team of trained professionals but not physicians). I figured they would deem him a threat to himself and get him admitted to a psych center. Nope. They said he seemed genuinely regretful and set him up with outpatient counseling. Of course, he couldn't tell them why he did it either. So I was left with no choice but to discharge him.


So Psych Doc....what's your interpretation? How much denial is this family in? Should he have been committed?

-ER Doc

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Wow. First off, I hate to question other professionals, but I can't see how this guy didn't get admitted to a psych unit. He meets "Danger to self" criteria more clearly than a lot of the drug overdoses we see. And he's done similar, serious things twice now.

He may or not have been psychotic; however, I would think that if he had been, the evaluating team would have seen it (as would you and the family.) He could have been briefly psychotic, i.e., under the influence of drugs.

My hunch is that this guy has some sexual deviation that is very socially unacceptable. In other words, he probably has urges to commit violent sexual acts. This guy doesn't hate himself; he hates his intrusive, impulsive sexual thoughts. The symbol of the sexual deviance, his own genitalia, have become his enemy.

I have had two male patients that have hinted at things like this. Both of them have intrusive thoughts of molesting kids. One of them admits that when he sees teenage girls at the mall, he visualizes himself raping them. Then he thinks about where he could bury them. Both of them have asked for chemical castration. They both know that these kinds of thoughts are morally and socially unacceptable, which causes them a lot of distress and feelings of shame and guilt. They have problems with depression and anxiety, and both swear they have never acted on these thoughts.

Your patient likely does need some intense outpatient counseling. He may be an outwardly very pleasant, kind, and peaceful person. But the demons are hidden in there. I hope he can afford some good therapy. And I hope that the neighborhood kids stay away from his house.

-Psych Doc