Hemolacria as a Rare Presentation of Dissociative Disorder

Abstract

Hemolacria is a rare manifestation of dissociative disorder. Aim of index report was to present clinical findings in a 13-year old female and explore the socio-cultural meaning associated with this phenomenon. Eclectic psychotherapeutic approach was implemented to address the symptoms. To conclude, physical symptoms presenting in dissociative disorder may be conceptualized in socio-cultural context.

Hemolacria, also referred to as bloody tears,^[1] is a rare clinical phenomenon. Hemolacria has been attributed to a variety of etiological factors, including trauma, infection, inflammation, tumors, and vascular lesions of the eye and orbit. Hematologic diseases, systemic diseases such as exanthematous fever and hypertension, and drugs such as warfarin, heparin, and aspirin may also present with hemolacria.^[1] In few cases, it was considered to be self-inflicted, and factitious disorder was either suspected or established.^[2,3] Some authors have considered hemolacria as a manifestation of hysteria^[4] or dissociative disorders.^[5] With this background, we wish to describe a case of an adolescent female who presented with episodes of hemolacria and to explore the cultural meaning of this phenomenon in the context of dissociative disorders.

Miss X was a 13-year-old, 8^th Class student belonging to a Christian, middle-class family. X was developmentally typical, with difficult temperament, specific learning disability, and history of alcohol dependence in father, conduct disorder in brother, and severe parental discord. She presented in 2017 with episodes of prolonged unresponsiveness with fist-clenching but without any associated features suggestive of epilepsy. X had shown aggressive behavioral outbursts for preceding 2–3 years in the context of academic and psychosocial stressors, with frequent school avoidance and absenteeism. Faith healing rituals provided temporary relief in her symptoms. Further, patient along with parents visited a Church where the statue of Jesus was believed to have had bled tears and to have strong healing powers.

A year later, on three occasions, X had blood in tears preceded by severe tearful and angry outbursts, each time following academic or familial stress. There was no history suggestive of epistaxis, injury, local infection/inflammation, blood dyscrasia, drug intake, systemic illness, relation to headache, or menstruation. History was remarkable in that her father had similar symptoms 3 years back when he had suffered huge financial losses. General physical, ophthalmological, otolaryngological, and systemic examination was unremarkable. Complete blood count, bleeding time, clotting time, prothrombin time, and liver function test were within normal limits. There were no bodily wounds or injuries, and the patient did not have access to any red-colored fluid during or immediately before the episodes. As father was severely stressed when he had similar complaints, parents attributed patient’s symptoms to stress.

On mental state examination, X expressed feelings of inferiority related to her academic performance, and of “being neglected” and “not understood.” Psychological assessments using the Thematic apperception test and Rosenweig picture frustration test revealed a sense of helplessness and despair regarding academics, low self-esteem, anguish over family conflicts, anger towards father, feeling of no control over the situation and poor problem-solving. An eclectic psychotherapeutic approach was implemented. After 3 months of follow-up, dissociative episodes significantly decreased and interpersonal relations improved. For the last 2 years, the patient had no dissociative symptoms and is able to manage stressors effectively.

The index case illustrates a rare but interesting dissociative symptom. Bloody tears have been associated with certain sociocultural and religious beliefs. In Christianity, stigmata are the appearance of bodily wounds, scars, and pain in locations corresponding to the crucifixion wounds of Jesus Christ. Tears of blood have also been reported in this context.^[5] Another belief has been in relation to the weeping statues of Virgin Mary, wherein it was thought that the tears of blood represent her sorrows over the sins of the world and the pain endured in her earthly life.^[6] The Hindi or Urdu idiom “khoon ke aasu rona” is used to express intense psychological distress and anguish. Literally, it means “to be in extreme distress due to an intolerable suffering” or “to be in terrible grief.” Rahman et al.^[7] presented four cases of hemolacria, all in adolescent females, and precipitated by perceived or actual detachment from attachment figure. In our patient, her symptom of bloody tears can be understood from this sociocultural meaning. It was a sign of severe psychological distress due to academic difficulties, family environment, and bullying, for which she was unable to find a solution. This leads to intolerable stress symbolically manifested as hemolacria. With patient developing adaptive skills to cope and regaining a sense of control, the dissociative symptoms abated.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given her consent for images and other clinical information to be reported in the journal. The guardian understands that her names and initials will not be published and due efforts will be made to conceal the patient’s identity, but anonymity cannot be guaranteed.

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Nil.

Conflicts of interest

There are no conflicts of interest.