A twenty two year old Sri Lankan male presented to the outpatients department of the National Hospital of Sri Lanka complaining of shortness of breath. Noting that the patient was severely emaciated, he was requested to get admitted to a medical ward for further investigations. While in ward his main complaint was recurrent shortness of breath and a bloated feeling that was brought upon by ingestion of food. He also complained of severe constipation and maintained that he had cut down on eating due to this. He did not have symptoms such as pyrexia, symptoms of thyrotoxicosis, bleeding per rectum, chronic diarrhoea and lumps on palpation anywhere in the body. He had no medical history suggestive of chronic infections such as tuberculosis, metabolic disorders such as diabetes, immunodeficiency disorders and primary gastrointestinal disorders such as celiac disease or chronic pancreatitis. There were no inherited organic illnesses in the family, risk behaviors for Human Immunodeficiency Virus (HIV) infection or a history of substance abuse. He was extremely wasted with a body mass index (BMI) of 11.1 kg/m2 (weight 27 kg, height 1.56 m). He did not have any overt signs of micronutrient and vitamin deficiencies. The cardiovascular examination was normal and the blood pressure was 110/70mmHg. The respiratory, abdomen and nervous system examinations did not reveal any clinically significant findings.
He was investigated extensively to identify an organic pathology to explain the emaciation. The haemoglobin was 11.5 g/dl with normal white blood cell and platelet counts. The blood picture was also unremarkable apart from features of iron deficiency. The erythrocyte sedimentation rate was 3mm in first hour and the liver function tests and renal function tests were within normal limits. The fasting blood glucose was 3.3 mmol/l and the serum amylase was 327 U/l. The total serum protein level was 68 g/l with an albumin level of 48 g/l suggesting a more recent cause for weight loss as the protein content was not grossly reduced. The electrolyte profile was normal apart from a hyponatremia (128 meq/l) and there were no significant findings on the chest roentgenogram or the ultrasound scan of abdomen. An upper gastrointestinal endoscopy was arranged and revealed a normal oesophagal, gastric, duodenal and upper jejunal mucosa. Multiple biopsies taken at different sites were within normal histological limits. The HIV screen was negative and the thyroid hormone profile was also normal.
At this point it was noted that the patient was avoiding food. He constantly complained of food causing uncomfortable abdominal distention, epigastric pain and shortness of breath. He was then referred to the University Psychiatry Unit of the National Hospital of Sri Lanka for further assessment for an underlying psychiatric morbidity.
On the initial psychiatric interview it became clear that these recent constellation of symptoms had started three months back after he became constipated following treatment for an infected eczematous rash. He was heavily inconvenienced by the abdominal distension plus the difficulty in passing stools and therefore tried to avoid food to minimize the discomfort. Later, he became preoccupied with the idea of keeping his body free of symptoms by avoiding food. He was having recurrent intrusive fears of ingested food being retained in the body without him being able to defecate due to constipation. This led to secretive disposal of food and resultant weight loss. However, he was not convinced that his beliefs were irrational. His idea of food being retained in the body and accumulating causing discomfort due to the potential inability to defecate, bordered on a delusional thought. Apart from being withdrawn and wasted with a blunt mood, the rest of the mental state examination was normal. Family members have noted that he was withdrawn and smiling to self on occasions over the last 4-5 years. He was unemployed, spent most of his time at home but didn't help out with the daily family chores. He did not have any special interests, hobbies or religious interests. The differential diagnosis at this point included; OCSD with a delusional component, a prodrome of schizophrenia or simple schizophrenia.
A probable diagnosis of a type of OCSD was supported by a history of symptoms suggestive of OCD . For the past two years he had repetitive behaviours such as hand washing due to obsessional thoughts of uncleanliness. Rituals related to hand washing and eating led to significant obsessive slowness sometimes exceeding two hours to complete a meal. In addition to excessive washing, he used to stare at the tap prior to washing as a part of the ritual, sometimes up to an hour. Considering the overall picture it was decided to treat him with cognitive behavioural therapy (CBT) as for OCD instead of starting antipsychotic medication. Because of his poor physical health in ward treatment was necessary. Due to his food refusal he had to be sedated and fed via a nasogastric tube in the first few days. To avoid refeeding syndrome his biochemical parameters including electrolytes were regularly checked. Wernicke's encephalopathy was anticipated and treated with thiamine. As he gradually gained his strength CBT was started early. The behavioural therapy consisted of exposure and response prevention. The exposure consisted of graded refeeding while being encouraged to face the anxiety associated with the obsessive fear of being unable to tolerate meals and constipation. After the initial inpatient stay of two weeks, therapy was carried out at home with the mother being the co-therapist. He was not started on any antipsychotic or anti depressant medications and was managed on CBT alone. At three weeks, his weight increased by 1 kg and after 3 months by 5 kg (BMI 13.1 kg/m2). The average time taken for a meal reduced from 90 minutes to 20 minutes. With less preoccupation about his meals/bowels habits, his social interactions and involvement with other members of the family improved markedly. At six months follow up his improvement continued with further weight gain (BMI 15.8 kg/m2). His interactions with family members and neighbours had also improved. He remained unemployed but was fulfilling his daily household chores and was considering active employment. The excellent response to behavioural therapy within a relatively short time span was surprising but was a vindication of the diagnosis of OCD.