Clinical Kynanthropy: A Case Report of Psychological Manifestation of a Dog Bite

To the editor,

Manifestations of rabies usually start after 1–3 months of exposure. ¹ As the virus begins proliferating in the spinal cord, neuropsychological symptoms can appear. ² The term “zooanthropy” denotes a person’s ability to metamorphose physically into an animal and back again to a human. The term “kynanthropy” was used in ancient Greece for transformation into a dog. ³ The adjective “clinical” was added to distinguish the condition from the actual ability to metamorphose as depicted in classical mythology and demonology. So, “clinical kynanthropy” denotes a person’s belief of transformation to a dog. ⁴ It is a rare variant of delusional misidentification syndrome, particularly reverse inter-metamorphosis, where patients believe they are experiencing transformation or have transformed into an animal. ⁵ An explanation by “two-factor theory” for Capgras syndrome can be extended to kynanthropy, in which the primary factor for delusion formation is a mismatch in the individual’s neural representation of the self. The second factor is contemplated to be an impairment in the belief evaluation system that precludes the delusional explanation to be rejected. ⁶ Here, we present differential diagnosis and management of a case who started grinning, barking, and walking on four legs like a dog two years after a dog bite.

Case Description

A 28-year-old single male, who was average in studies but had dropped out of school after 5th standard due to poverty, currently working in a cloth company as a salesman, was referred from medicine outpatient department (OPD) to psychiatry OPD with complaints of difficulty in swallowing food and fear about dogs. He had been twice bitten by dogs, five years and two years back, following which he had taken a complete course of vaccination. He was apparently alright until two months before the presentation, when, due to the COVID-19-related nationwide lockdown, he read excessively on the internet about dog bites. While going to his native place, he developed a feeling that his tongue is moving like a dog’s and began having repetitive thoughts about converting into a dog. Gradually, his sleep reduced to 1–2 hours/day, and he expressed fear that if he sleeps, he might get up as a dog. He sought repeated reassurance from his family that he hasn’t transformed into a dog, to the extent that they got irritated and asked him to see a doctor. These repetitive thoughts would be present for the whole day, and he would chant God₹s name to get relief from them. Earlier, he also used to check himself in the mirror multiple times, but he had stopped it by the time of the consultation. His uncle informed that he has seen him grinning, barking, and walking like a dog multiple times in the last one month. There was no history of hydrophobia, paralysis, altered-sensorium, persistent sadness or elevation of mood, or substance use. There was no past or family history of any psychiatric, medical, or surgical illness.

His physical examination was within normal limits. On mental status examination, his mood was euthymic, but the affect was anxious. He had repetitive doubts about conversion to a dog and requested for a test to detect that. Somatic obsession and overvalued idea not amounting to delusion were present. Other themes of compulsion were also found, like checking the lock multiple times. On Yale-Brown Obsessive-Compulsive Scale (Y-BOCS), his score was: obsession—12, compulsion—7, and total score—19, indicating moderate obsessive compulsive disorder (OCD). Brown Assessment of Belief Scale (BABS) score was 11 with poor insight. The provisional diagnosis of OCD with poor insight was made according to DSM-5. He was started on fluoxetine 20 mg/day, which was given under his mother’s supervision. After 15 days of treatment, the mother reported improvement in reassurance-seeking behavior, and after one month of treatment, the patient reported improvement in the repetitive doubts. In three months, he was found to sustain the improvement and had improvement in socio-occupational functioning. Also, his Y-BOCS score decreased to 6, and his BABS score reduced to zero with good insight. There were no adverse effects reported. After recovery, he was thankful and attributed the symptoms to stress after reading and watching videos about dog bites.

Discussion

Very few cases have been reported about clinical kynanthropy, and treatment consensus for it is still evolving. Our case posed a diagnostic dilemma and an interesting treatment outcome. The major finding was overvalued idea not amounting to delusion, with elevation in obsessive-compulsive rating scores. No affective component preceding the overvalued idea was identified. Fishbain had reported a similar case with a diagnosis of monosymptomatic hypochondriacal psychosis, wherein the patient had a delusional belief of having contracted rabies. ⁷ However, in our case, the belief was not held with delusional fixity, as the patient was actively seeking reassurances. The presentation was in line with body dysmorphic disorder; however, the preoccupation wasn’t limited to bodily defects. Illness anxiety and somatic symptom disorder could be other differentials, but in this case, the belief wasn’t related to health or acquiring the illness. Ruling out other causes of this presentation and based on psychopathological findings, the patient was diagnosed with OCD with poor insight. He was started only on SSRI, in contrast to previous reports where a combination of antidepressants and neuroleptics were considered, and the patient achieved remission. ⁸

Thus, cases presenting with obsessive-compulsive related disorders with poor insight need rigorous psychopathological analysis, objective assessments, and reliable informants for precise treatment. An adequate trial of SSRI in such cases can prevent superfluous medications and neuroleptic exposure.