Compulsive Bathing Associated with Cyclical Vomiting Syndrome: A Case Report

Case Report

Mr. V is a 35-year-old gentleman who first presented to the general medicine department with complaints of frequent burping, epigastric burning, and postprandial vomiting. After evaluation, he was diagnosed with Type 2 diabetes mellitus, which was managed conservatively with proton pump inhibitors, antiemetics, and oral hypoglycemic agents. He improved and was symptom-free for a week, following which he developed similar complaints again. Subsequently, during the symptomatic period, each episode of vomiting was followed by bathing in hot water. The bathing gradually became repetitive and ritualistic over time. This would resolve with improvement in the gastric symptoms. He had 15 such episodes of repeated vomiting and ritualistic bathing behavior every 15–30 days, each lasting less than a week. Ten out of those episodes required in-patient care over 12 months. In two of the episodes, ritualistic bathing was so elaborate that he missed his Insulin dosage, and evaluation revealed diabetic ketoacidosis, which was managed with injectable insulin. It was noted that he occasionally induced vomiting by drinking water or by digital stimulation. Over time, he had instances of bathing with boiling water, resulting in burns, blisters, and scab lesions over his neck and lower back. The highest frequency of the vomiting–bathing ritual was 30–35 times per day, lasting from 15 minutes to an hour. After a thorough gastroenterological evaluation revealed no contributory cause, he was referred for psychiatric evaluation.

The detailed assessment revealed the presence of multiple temporally associated workplace and interpersonal stressors. However, no syndromal anxiety, depression, body image disturbances, eating disorders, or substance use was elicited. The repetitiveness of the bathing ritual was associated with ego-dystonicity and distress. Further, the bathing was always preceded by nausea or vomiting, which raised the suspicion of sensory-driven compulsive behavior. These behaviors and recurrent admissions resulted in significant financial burdens, missed workdays, strained interpersonal relationships, and reduced quality of life. The diagnosis of cyclical vomiting syndrome (as per ROME III criteria ³ ) and other OCD (as per International Classification of Diseases, 10th edition ⁴ ) was considered.

After an inadequate response to 75 mg/day of dosulepin with clonazepam 0.75 mg/day, he had a good response to clomipramine (75 mg/day). Individual therapy focusing on coping skills enhancement, distress tolerance techniques, and a sensory-focused approach for dealing with acute anxiety was initiated. Exposure and response prevention were tailored to his repetitive bathing behavior using picture-cue-based and imaginative exposure. There was an improvement in the repetitive bathing behavior and frequency of vomiting episodes.

Discussion

In this report, we have described the rare presentation of OCD in a patient with cyclical vomiting syndrome and the associated diagnostic complexity. Considering the amount of time spent in the symptomatic phase and the degree of dysfunction, our patient could be categorized as a severe variety of cyclical vomiting syndrome. ⁵ The usual time of onset of the emetic phase in our patient was early in the morning, and nausea was the recognizable prodrome, which aligns with earlier observation. ⁵ Even though repeated drinking of large amounts of liquid to relieve the abdominal distress and instances of repeated bathing or showers to relieve nausea have been reported earlier, ⁵ the repetitive, ritualistic, compulsive bathing with hot water resulting in tissue damage in our patient is a contrasting finding. Migraine, though found in 24%–70% of adult patients with cyclical vomiting syndrome, was not present in our patient.^1,5,6

The atypical presentation of OCD here is highlighted by the late age of onset of illness, absence of preceding obsessional thought, as well as the presence of compulsive behavior only during the emetic phase of cyclical vomiting. Clomipramine was considered in our patient, as he was treated along the lines of OCD. However, a confounding factor here could be that diabetic patients with unresolved chronic vomiting are also known to benefit from tricyclic antidepressants. ⁷

Conclusion

The psychiatric comorbidities in cyclical vomiting syndrome extend beyond anxiety and depression. Standard diagnostic interviews will be invaluable in comprehensively assessing patients with cyclical vomiting syndrome. Hence, it is desirable to consider the evaluation of psychiatric comorbidities early in the evaluation of cyclical vomiting syndrome.

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