“Biting like a Dog”- A rare presentation of harm obsessive-compulsive disorder

Dear Editor,

Obsessive-compulsive disorder (OCD) is often a disabling condition consisting of bothersome intrusive thoughts that elicit a feeling of discomfort.[1] Harm OCD is a subtype of OCD in which people either worry that they will harm themselves or someone else by accident or that they will act on an involuntary impulse or urge to harm themselves or others.[2]

A 26-year-old man was taken to the emergency room by his mother after complaining of biting everyone around him and having trouble sleeping for 8 months. History revealed that the patient had recurring urges to bite others around him, causing immense anxiety that could only be eased by biting others. He also had suicidal ideations as a result of his guilt about harming his family members and his inhumane behavior. He tried suicide twice, once by hanging and once by overdosing on prescribed medications. The present episode was triggered by his father’s death in a car accident eight months back, though the patient denies remembering any past painful experience or extreme traumatic memory after his father’s death except for the normal grief that he experienced. For these complaints, the patient was on Cap Fluoxetine 60 mg once daily, Tab Haloperidol 10 mg in divided doses, Tab Sodium Valproate 1000 mg in divided doses, and Tab Clonazepam 1 mg in divided doses, with some improvement in his condition. His symptoms intensified two days back when he went to his cousin’s wedding, and he had to be restrained for the sake of others’ safety. On further enquiry, the mother said that the patient skipped his medications for around 3-4 days before coming to the wedding.

There was a similar episode seven years ago, when he was 19 years old and entered college. Because of his harmful behavior, he had to be escorted home from the hostel. The patient struggled to control his urges and used to cry after biting a person. He withdrew and restricted himself to his room for fear of injuring his loved ones. He was referred to a psychiatrist, who gave Cap Fluoxetine 40 mg per day and Tab Olanzapine 5 mg at night. With further follow-ups and dose increments, the patient gradually improved, but he abruptly stopped taking drugs after a year of treatment. He was symptom-free for a year, but when he had a quarrel in a romantic relationship, symptoms resurfaced. At that moment, the patient was admitted to a psychiatric institute. A battery of blood and radiological tests, including Electroencephelogram (EEG), were normal. The patient had to be sedated and physically restrained at times due to his aggressive biting conduct. He was given six cycles of electro-convulsive therapy (ECT) along with psychotropics and recovered totally in 18 months. He again discontinued medication after 3 years.

There is a family history of dirt and contamination OCD, as well as blasphemous thoughts in the late father. There was no history of Tics, aggression toward people, cruelty to animals, destruction of property, deceitfulness, or serious violations of rules. On physical inspection, there were many bite scars on the patient’s forearms, which he inflicted on himself to refrain from biting others. On Mental Status Examination, the patient was unkempt and restrained with ropes. He was crying, anxious, and trying to bite. He bit his mother’s hand, who was attempting to hold him, and was on trying bite the hospital staff who were handling him. He was acting on obsessional urges to bite people in order to relieve his feelings of anxiety. He had a fair insight into his symptoms. He was given Inj. Haloperidol and Promethazine intramuscularly to alleviate his extreme agitation and later with Inj. Lorazepam 4 mg intravenously. Blood tests, MRI, and an EEG were all repeated and were found to be normal. The patient was given eight cycles of modified ECT along with pharmacological management to minimize his self-harming behavior and suicidality. In a month’s time, the patient’s symptoms improved to the point that he could control his biting behavior to some extent and his suicidal ideations decreased. Lithium could not be started in view of intolerable side effects in the past after lithium initiation. He was discharged on Cap Fluoxetine 60 mg/day, tab Haloperidol 10 mg in divided doses, and tab Clonazepam 0.5 mg at night.

Our patient had recurring urges to bite people, which resulted in serious harm to family members and others close to him. He began to avoid people and developed symptoms of depression, with multiple suicidal attempts. He improved on the combination of Fluoxetine and ECT, with extended time to recovery with each episode. Although harm OCD is not an unusual form of OCD, this presentation of doing harm by biting is unique and distinct.

Author’s contribution

Writing, conceptualisation, data curation, review and editing: A; Review, and editing VPG.

Declaration of patient consent

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

Conflicts of interest

Nil

Funding Statement

Nil.