John Ruben Esperanza

Cagayan Valley Medical Center, Philippines

Knockout: A Case Report On Recurrent Self-Harm Through Self-Inflicted Facial Blows In A Filipino Adult With Schizophrenia

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Biography

Dr. John Ruben Apilado Esperanza is a Filipino physician dedicated to advancing mental health and public health in underserved communities. Born and raised in La Union, he completed his nursing degree at the University of Santo Tomas and earned his Doctor of Medicine from the University of the East Ramon Magsaysay Memorial Medical Center. He later pursued a Master’s in Public Health at the University of the Philippines–Manila.

Abstract

Abstract: 

Background: Self-harm is a well-documented complication of schizophrenia, particularly during

periods of active psychosis, affective dysregulation, and functional deterioration. While suicidal

behavior is widely reported, unusual forms of self-injury, such as repetitive self-inflicted facial

trauma, remain underrepresented in the literature, especially in the Philippines and in low-resource

and Asian settings. Psychosis-related motoric self-harm presents unique challenges because behavior

may be driven by hallucinations, delusions, or impulse dyscontrol rather than suicidal intent alone.

Case Presentation: This is a case of a 32-year-old Filipino man with long-standing schizophrenia

and prolonged medication non-adherence who developed recurrent episodes of forceful self-punching

of his face, causing severe facial swelling and repeated emergency consultations. His clinical course

progressed from mood symptoms to persecutory and grandiose delusions, auditory hallucinations,

spiritual preoccupations, and social dysfunction. In the two months preceding admission, his selfinjury

escalated to near-daily episodes. Neuroimaging showed no intracranial pathology. Mental

status examination demonstrated psychomotor retardation, flat affect, persistent delusions, and

impaired impulse control.

Management and Outcome: Immediate safety measures and trauma evaluation were implemented,

followed by initiation of clozapine for treatment-resistant psychosis and high-risk self-harm.

Crucially, care was delivered through a multidisciplinary framework involving psychiatry, nursing,

psychology, social work, and occupational therapy. Family engagement, behavioral monitoring,

psychotherapy, and rehabilitation interventions complemented pharmacologic treatment. The

frequency and intensity of self-harm decreased substantially, emotional stability improved, and partial

insight was achieved.

Conclusion: This case highlights a rare manifestation of psychosis-related self-injury and emphasizes

the importance of early recognition of atypical motoric self-harm. Effective management requires

evidence-based pharmacotherapy, particularly clozapine, alongside coordinated multidisciplinary

care. Detailed case reporting from local settings is essential to inform culturally relevant assessment

and treatment strategies for severe self-harm in schizophrenia.