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The Need for Psychiatric Evaluation of Patients with Unexplained ENT

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Journal of Islamabad Medical & Dental College (JIMDC); 2016:5(2):74-76
The Need for Psychiatric Evaluation of Patients with
Unexplained ENT Symptoms
Raja Muahmmad Shoaib1, Tallat Najeeb2, Wajahat Ullah Khan Bangash3
1
Assistant Prof, Dept of Psychiatry, Islamabad Medical and Dental College, Islamabad
2
Associate Prof, Dept of ENT, Islamabad Medical and Dental College, Islamabad
3
Professor, dept of ENT, Islamabad Medical and Dental College, Islamabad
(Shaheed Zulfiqar Ali Bhutto Medical University)
Abstract
Objective: Many psychiatric patients present to other
specialties with physical symptoms and fail to get proper
treatment. This study was conducted to see if psychiatric
disorders presenting with ENT symptoms could be detected
using a simple tool like GHQ-12.
Subject and Methods: This cross-sectional study was
conducted in ENT OPD of Social Security Hospital
Islamabad. A total of 310 patients presented with ENT
symptoms were included in the study. GHQ-12
questionnaire was used to detect psychiatric symptoms in
patients whose symptoms were not explained on ENT
examination and in those with positive ENT symptoms. Chi
square test was applied. p value <0.05 was considered
significant.
Results: Among 310 patients reported in OPD, sixteen
patients were without findings on examination, fifteen tested
positive for psychiatric symptoms and were directed to
psychiatrist. Same number of patients with organic ENT
pathology returned only three positive results.
Conclusion and Implications: GHQ-12 is a useful tool to
detect psychiatric patients. However, more effective tools
need to be used to enhance the accuracy of detection. For that
to happen, doctors at all levels and in all specialties need to
be trained and sensitized. Furthermore, stigma associated
with psychiatric illness has to be addressed effectively.
Key words: Liaison Psychiatry detection, Psychiatric
disorders, Somatic symptoms
Introduction
Psychiatric disorders are on the rise as shown by the various
prevalence studies. Approximately, three-quarters of the
burden of mental illness comes from low and middle-income
countries.1 Stresses and strains of daily life sometimes are
severe with limited availability of advice or help. The
concerned organizations are poorly equipped and less
Corresponding Author:
Dr. Tallat Najeeb
E-mail: tallatnajeeb@yahoo.com
Received: Nov 18th 2015 Accepted: May 16h 2016
74
Original Article
motivated to be of any use to the sufferers. There is an urgent
need to devise mechanisms to ascertain the volume of
psychiatric patients, especially those presenting to non-
psychiatric clinicians.1 Stigma is a major hurdle to help
seeking in people with mental health problems in developing
countries; whereby patients prefer to see non-psychiatric
doctors.2 It seems pertinent that the clinicians attending
patients should be able to suspect, detect and refer, if not treat
Psychiatric symptoms/disorders at an early stage.
There is an alarming increase in the incidence of psychiatric
disorders in Pakistan over the past several years.3 Pakistanfalls
in the category of low and middle income countries where the
literacy rate is also low and we come across many psychiatric
patients presenting with somatic symptoms. Such cases are
also referred to as ‘Somatoform or Somatization’ disorders.4,5
Somatization is defined as multiple, recurrent and frequently
changing physical symptoms usually before the patient is
referred to a psychiatrist. Later, the term 'unexplained somatic
complaints' was introduced to describe patients presenting
with any physical symptom and frequent medical visits in spite
of negative investigations. In primary care, psychological
disorders presenting with physical symptoms may be the only
reason for the appointment with a doctor. It is reported that
patients with anxiety or depression are more than twice as
likely to exhibit multiple unexplained somatic symptoms as
those without anxiety or depression. Psychological disorders
can be masked by physical complaints, such as headache, back
pain, thoracic pain, or digestive troubles, and thus remain un-
recognized.
The absence of somatic illness gives an important indication in
the recognition of a mental disorder. It is suggested that
clinicians are well aware and trained to detect mental disorder
in patients presenting with physical complaints. This study
was thus conducted in patients presenting with unexplained
ENT symptoms. It will be very useful if the clinicians in
general practice and other specialties could be trained and
sensitized to suspect psychiatric disorders and given a tool to
strengthen the suspicions.
Journal of Islamabad Medical & Dental College (JIMDC); 2016:5(2):74-76

Subjects and Methods Table 2: Cases presenting with ENT symptoms and
corresponding ENT findings, GHQ-12 scores
This case-control study was carried out in the ‘ENT Out- Presenting ENT findings GHQ-12 Score
Patients Department’ of a tertiary care hospital in Islamabad. symptoms
All the patients (310 in total) coming to one of the consultants Recurrent sore ch ton/sin Negative
in the ENT ‘out-patient department’ in the month of August throat
and September 2014 were selected. Patients, who were not Sore throat ch ton Negative
found to have a finding, explaining their complaints, were Hearing loss snhl Negative
asked to complete the questionnaire. There were 16 such Nasal dns/ all Negative
patients. Same number of patients who had physical findings obstruction
explaining their complaints were also asked to complete the
Nasal dns Negative
questionnaire, as a control. The patients were explained the
obstruction
purpose of the exercise. It had to be explained that refusal to
Pain th goitre Positive
cooperate will not affect the treatment in any way and
completing the questionnaire will also have no effect on the Tinnitus snhl Negative
outcome. The questionnaires were completed on the same day, Pain th phgts/sin Positive
even if the subjects needed help. “General Health Rec snzng all rhnts Negative
Questionnaire version 12 (GHQ-12)” was used to ascertain
Ear discharge perforation Negative
their mental health status at that time. Statistical evaluation of
results was done by using Window SPSS 16 and descriptive Pain ear + perforation Positive
analysis was done. discharge
Ear dis csom/per Negative
Results Headache/ n obs dns/ chronic sin Negative
Score of 4 or above was considered to indicate presence of Headache sinusitis Negative
psychiatric symptoms. Out of 310 patients presenting with Sore throat chronic Negative
somatic symptoms, there were 16 patients (5%) who had tonsillitis
symptoms but no ENT findings. Among these 6 were males
Pain/discharge csom Negative
and 9 were females and their ages ranged from 18-65 years.
ear
Their educational qualifications were from 8th class to Foot note:ch ton=chronic tonsilitis, sin: sinusitis, snhl: sensory neural
Masters; 7 belonged to rural areas whereas 8 from urban hearing loss, dns: deviated nasal septum, all: allergy, phgts:
centers, 8 were married and 7 were unmarried. In the control pharyngitis, all rhnts: allergic rhinitis, csom: chronic supporative otitis
group three tested positive for Psychiatric symptoms. One media, per: perforation
male and two were females with education ranging from
illiterate to Masters. All three were married with 2 coming Discussion
from the city.
Almost all the patients whose complaints were not explained
by physical findings were found positive for psychiatric
Table 1: Cases presenting with ENT symptoms but
symptoms. These were 16 (5%) out of a total of 310 patients
without pathological findings, GHQ-12 scores and this is a very significant number. Nine of these were
Presenting Number of GHQ-12 GHQ-12 ladies and six gentlemen. This is in accordance with the
symptoms patients scores scores
expectations, the ladies are more likely to be diagnosed with
‘Somatoform or Somatization’ disorders.6-8 Haftgoli et al
positive negative
reported somatoform disorder in 15% of their patients.9
Dysphagia 3 3 0 Spitzer et al reported in 9-29% of their patients10 and a Dutch
study mentioned a high number of patients (22%) with
Globus Hystericus 2 2 0
somatoform disorder.11 Psychological depressants are
Aphonia 1 1 0 associated with these disorders; however, these factors are
Pain Throat 2 2 0 associated more so with anxiety and depression than with
Headache 5 5 0 somatoform disorders.
Itchingears 2 1 1 The number of psychiatric disorders has gone up in Pakistan
Discharge ears 1 1 0 as revealed in other studies and the onus of
suspecting/detecting psychiatric symptoms lies with the doctor
attending the patient for non-psychiatric complaints.3 It may
also be due to lack of understanding of the psychological
nature of the problem or inability to effectively express or

75
Journal of Islamabad Medical & Dental College (JIMDC); 2016:5(2):74-76
refusal to accept psychological/psychiatric symptoms as it is
considered a stigma to have or express the same 2,8,12 Patients
are likely to continue seeking physical treatments despite
getting poor results.12-14
Psychiatric disorders also present with physical symptoms in
other specialist clinics and affecting a variety of patient groups
like immigrants and young students.5,7Other studies have
found cases of depression presenting to other clinics instead of
Psychiatry. Besides, physically ill patients can also have co-
existing somatoform disorders.12 Thereby it is evident that
somatic symptom presentation can be varied and complicated.
In order to help understand the phenomenon of somatic
symptoms a multi-ethnic inventory of somatic symptoms has
been developed.15
There is a need to conduct similar studies with a larger patient
population and in patients frequently visiting other specialty
clinics.14 Efforts should be made to develop and use tools
which can pick more cases of Psychiatric disorders.
Alongside, the stigma associated with psychiatric illness,
being a serious hurdle, needs to be addressed. Medical
professionals need to acknowledge and cater to the stigma
associated with psychiatric illness and awareness campaigns
need to be organized to reduce the phenomenon.15,16
These are not just mental processes but complex biological
processes and the available treatment modalities both physical
and psychological are not very effective and can only be
conducted by appropriate professionals.17-19
Recommendations
General practitioners and specialists should be sensitized and
trained to suspect and identify psychiatric patients and patients
with somatoform disorders so that they can be referred to the
psychiatrist. Moreover, studies are needed to investigate the
association psychosocial factors with somatoform disorders as
addressing these factors this will help improve he somatic
complaints of patients.
Conflict of Interest
This study has no conflict of interest as declared by any author.
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