Polyembolokoilamania with obsessive compulsive and related disorders: A case series

ABSTRACT

Polyembolokoilamania is a condition seen in a medical or surgical emergencies where the person, sometimes repetitively, inserts various foreign bodies through body orifices or skin to obtain gratification often associated with background psychiatric diagnoses. We present three cases where one patient with Obsessive Compulsive Disorder (OCD) presented with urethral polyembolokoilamania, one with Excoriation disorder presented with multiple pin-piercing behavior through the skin and one case of OCD presented with anal polyembolokoilamania. Treatment of the underlying Obsessive-Compulsive and Related Disorders curbed such behaviors successfully in all three cases emphasizing the importance of treating background psychiatric disorders in such conditions.

INTRODUCTION

Polyembolokoilamania has been seen in medical literature for a long time although detailed analysis regarding this behavior is scant as of today.[1] Initially, the term was reserved for the behavior where the person used to insert foreign bodies only through body orifices.[2] Now even foreign body insertion through skin piercing has been included under this terminology.[1] Most of the time such patients are seen as a medical or surgical emergencies due to the imminent risk of fatal consequences.[3]

The foreign bodies that persons use to insert into their bodies have a wide range and variation. They are chiefly common household items including beads, coins, fish bones, pebbles, plastic toys, pins, keys, round stones, marbles, rings, batteries, toothbrushes, bottles, broomsticks, telephone cables, and many more.[1] These can be swallowed, inserted into orifices like the nose, ears, genitalia, rectum, or artificial ostomy sites, or can be forcefully inserted into the subcutaneous tissue piercing the skin.[4]

Multiple reports have mentioned different background motivations for such behavior including auto-erotic paraphilic behavior to obtain sexual gratification[5] or non-pathologic sexual preference,[6] self-injurious behavior,[7] substance intoxication, psychotic or affective disorder,[8] intellectual disability[9] and developmental disorder,[2] malingering and factitious disorder, etc.[10]

It has been seen that the treatment of such behavior is done mostly in the emergency department. There is no consensus to involve psychiatry consultation on a regular basis.[1] Such patients often tend to repeat these behaviors increasing their vulnerability to complications. It has been suggested that mandatory psychiatric management can be helpful to curb this repetitive behavior.[11] Here we present three cases with polyembolokoilamania seeking treatment in the psychiatry department with the background diagnosis of obsessive-compulsive and related disorders, an uncommon psychiatric condition associated with polyembolokoilamania. It was seen that the successful treatment contributed to the limitation of such occurrences.

CASE PRESENTATION

Case 1

The first case was a 30-year-old unmarried Hindu male, educated up to class VI and shopkeeper by profession, from an urban nuclear family of lower middle socio-economic status who was admitted to the psychiatry in-patient department after being transferred from the general surgery where he was treated with suprapubic cystostomy for insertion of a 4 ft long copper wire per urethra which he could not retrieve on his own. History revealed that he started showing symptoms of an obsession with dirt with compulsive washing 15 years back. Out of sheer distress, he used to jump in the nearby pond whenever he even saw something considered dirty to him. In late adolescence, he got preoccupied with intrusive thoughts of explicit sexual content. To cope with the distress, he engaged in multiple sexual behaviors including consensual homosexual and heterosexual intercourse and bestiality. Still, the distress persisted and he was eager to explore further practices. At this point, he got to engage in inserting objects per urethra which were assumed to provide him maximum gratification. He developed repetitive performance of similar nature over the last 10 years throughout which he predominantly inserted plastic straws, broomsticks, matchsticks, and insulated copper wires per urethra to obtain sexual gratification. Apart from this, he used to insert the narrow end of a funnel through his anal opening as well and to pour 1-1.5 L water till feeling a defeating urge which caused sexual gratification to him. There was no history of childhood trauma, bullying or abuse, substance use, or specific psychotic or affective episode.

He was diagnosed provisionally with a case of an obsessive-compulsive disorder and was treated with fluoxetine 80 mg, clomipramine 75 mg, risperidone 1 mg, and cognitive behavioral therapy. Over 6 months, his obsessive symptoms diminished to a large extent, and although the polyembolokoilamanic behaviors were occasionally mentioned afterward, their urge and frequency were diminished.

Case 2

The second case was a 19-year-old unmarried Hindu male, educated up to class X and semi-skilled worker by profession, from a rural nuclear family of lower middle socio-economic status who presented with a history of subcutaneous insertion of multiple small needles over the ventral surface of the left forearm. He was referred to the psychiatry OPD after the removal of all 25 needles in the general surgery department.

In an interview, he mentioned about similar incident 3 years back when he inserted four needles over the anterolateral right thigh. He acknowledged initiation of indulgence in rubbing, twitching, and picking the facial skin regularly when he developed acne over his face at 13-14 years of age. Gradually he developed a recurrent urge to pick the skin from his hands, forearms, and feet and started spending a significant amount of time in this behavior. He was ashamed of this and tried to stop this several times in vain. He tried inserting needles under the dermal surface for the first time to get rid of the urge. To his astonishment, there was a sense of immense gratification after that attempt. He was secretive regarding this practice and attempted only a few times. He had to visit the hospital twice for the practice and that was when his family members came to know his behavior. He denied any substance use history on regular basis.

He was given a provisional diagnosis of excoriation disorder and treated with fluoxetine which was gradually increased to 100 mg/day. cognitive behavior therapy was administered along with. The skin-picking urge and behavior diminished to a large extent after 4 months.

Case 3

The third case was a 25-year-old unmarried Hindu male, educated up to class XII and businessman by profession, from a rural nuclear family of middle socio-economic status who presented to the General Emergency Department with per-anal fixation of a small glass bottle that could not be retrieved manually. He attributed this to an accidental mishap initially, though on further probing he accepted voluntary enactment of such practice regularly.

After surgical intervention, detailed history was taken at the psychiatry OPD. He was found to be a known patient of obsessive-compulsive disorder for the last 5 years with irregular adherence to treatment. He had a history of obsessive doubt with recurrent checking and ritualistic behavior that started at that time. He was on clomipramine 50 mg daily with little improvement in the OC symptoms. Three years back, he once developed intense constipation for which he was administered a per-rectal enema at a rural hospital. He felt heightened gratification when the enema probe was inserted. He tried to enact the same with a wide array of household items many times while at home and he admitted to feeling a variable levels of gratification each time. He also asserted its effect on reducing the built-up distress that was mounted with his rising obsessive doubts sometimes.

He has treated with fluvoxamine 200 mg daily for the next 2 months with notable improvement in the obsessive-compulsive domain. There was no history of similar incidences since then. He was worked on to maintain adherence to treatment in the future.

DISCUSSION

As shown in case reports published as early as 1897, polyembolokoilamania is a rare type of self-mutilation where foreign objects are inserted into the body.[3] Owing to under-reporting its exact prevalence is largely unknown.[12] The same can be told about gender predilection.[11] We have come across only male patients here, larger sample size is needed to comment on this.

It is reported that accidental insertion is chiefly seen in children, whereas in adolescents and adults, it is mostly due to novelty-seeking behavior, psychiatric disorders, substance influence, or paraphilia when the behavior renders sexual gratification.[1] Sometimes the causes may be conglomerated as seen in our cases where auto-erotic behavior was associated with compulsive acts.[13]

Insertion through the urethra along with auto-eroticism has been most cited in the literature as seen in our first case.[3,5,6,9,11] Sexual gratification through anal polyembolokoilamania as in the third case has also been reported in prior studies.[10,12,14] Subcutaneous insertion is reported to be seen as deliberate self-harm in borderline personality disorder or to attain secondary gain in Munchausen syndrome.[7,10] Here in our second case, he was diagnosed with Excoriation disorder and the behavior had an erotic connotation as well.

Among the psychiatric disorders associated with polyembolokoilamania, obsessive-compulsive and related disorders were seldom mentioned. A case report mentioned one such case where OCD and depression were co-morbid in a case of frontotemporal dementia who exhibited urethral polyembolokoilamania.[15] All three of our cases were diagnosed from this spectrum and followed up with the treatment of OCRD.

There is a dearth of literature regarding long-term management of polyembolokoilamania to avoid the dreadful outcomes.[11] Here we found that such behavior could be curbed to some extent if the background psychiatric disorder is managed adequately. The mainstay of OCRD treatment viz. pharmacotherapy with selective serotonin reuptake inhibitors and cognitive behavior therapy was successful to some extent in all three cases. Prospective studies with proper design will be of paramount importance in this regard.

CONCLUSION

With the help of the cases reported we tried to emphasize the importance of identification of the psychiatric disorders associated with polyembolokoilamania and their prompt and adequate treatment to enhance the patient’s overall outcome.

Declaration of patient consent

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

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.