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Globus; Psychiatric comorbidity; Major depressive episode; Addiction; Addiction therapy

Introduction

Globus is characterized by the physical sensation of a lump in the throat which presents as difficulty or discomfort in swallowing. The physical sensation may also present as one of choking or that there is a mass lodged in the esophagus. The disorder may be at times severe or even fatal and is usually reported in young to middle-aged females [1]. Since globus is an uncommon type of a disorder, its exact incidence is unknown however reports suggest that persistent globus accounts for approximately 4% of all referrals to otolaryngologists [2].

Globus has a variable symptom presentation which may include aphonia, sensation of a lump in the throat, difficulty in swallowing, sensation of choking, dyspnea or suffocation. Literature also suggests pain as a presenting symptom [3]. The feeling of mass in the throat has been described variably by different subjects as if irritated by a small hair to the size of a billiard ball [4]. The feeling of lump is usually in the median or paramedian plane and lies more often suprasternal versus at the level of the cricoids [5].

Patients with symptoms of globus usually do not present with hoarseness of voice or weight loss as is observed with cancer. In fact some patients actually demonstrate weight gain [4], a phenomenon possibly explained by increased food intake in an attempt to alleviate symptoms of lump in throat [6]. A mild form of transient “lump in the throat” especially during stressful situations has been experienced by up to 45% of the general population, often in young or middle-aged persons, with an equal distribution among men and women. However, having the disorder implies greater symptom magnitude and duration [7, 8].

According to the DSM-IV, conversion disorder (globus is one of the presentations) symptoms must be of clinical significance to the patient or of social or occupational consequence. Symptoms of globus are not under voluntary control. Finally globus is not a diagnosis of exclusion, a solid investigation to rule out other physical causes of the symptoms must be conducted [9].

In ICD-10, globus is classified in the category of “Other Somatoform Disorders”. In DSM-IV TR, globus is not directly mentioned but by description it is fitting with ‘Conversion Disorder’ with subtype of ‘With Motor Symptom or Deficit’ in Somatoform Disorders. A study done in India by Debnath, Asish, et al. found total psychiatric comorbidity in globus to be 79.25 % [10].

Psychogenic problems have often been thought to cause or trigger the globus sensation. Personality studies have found higher levels of alexithymia, neuroticism, and psychological distress (including anxiety, low mood, and somatic concerns) and lower levels of extraversion in patients presenting with globus.

Since there is paucity of literature regarding the psychiatric comorbidities in globus and as most of the studies were done about personality patterns and traits, rather than specific psychiatric disorders. Hence the study was taken to estimate the patterns of psychiatric comorbidities in these patients.

Material and Methods

The present study was conducted in the Institute of Mental Health and Neurosciences Kashmir which is an associated hospital of Government Medical College, Srinagar and caters to whole Kashmir region, along with some adjoining areas of Jammu and Ladakh, a population of about 12.5 million [11-13]. It was a non-controlled, non-interventional cross sectional; hospital based observational study carried from August 2014 to July 2015 amongst the patients with diagnosis of Globus. This research work was initiated following approval by Institutional Ethical Committee and Board of Research Studies (BORS) of Government Medical College, Srinagar. Diagnosis of globus was made as per ROME III criteria proposed by Clouse and colleagues [14] by the consultant psychiatrist after being vigorously screened for any organic cause. Detailed relevant history, physical and clinical examination of neck, radiological and other investigations (which include x rays of neck, barium swallow, sonography, upper GI endoscopy, nasolarnyngocopy etc.) were done by the concerned consultant before referral for screening of any co morbid psychiatric diagnosis.

Each Patient was informed about the purpose of the interviewing. Informed written consent in locally understandable language was taken from each patient, each was given freedom of choice to accept or refuse participation in the study. Patients with uncontrolled chronic physical illnesses like hypertension, hypothyroidism, diabetes mellitus etc. were excluded from the study. Those not consenting, on corticosteroids or oral contraceptives were also excluded from the study.

All the data of the patients including general description, demographic data was recorded in the semi structured case sheet especially designed for this study. All the cases were evaluated to investigate the psychiatric comorbidity using Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition (DSM-IV) criteria by means of Mini International Neuropsychiatric Interview (MINI, English version 5.0.0) administered by qualified psychiatrist. The choice of MINI as an instrument was based on its high levels of reliability and validity, which have been reported in several studies [15].

The MINI is a structured interview tool, designed to evaluate the presence of psychiatric disorders according to Axis I, of the DSM-IV. A total of 57 patients approached us. Six of these patients either refused to consent or were suffering from chronic physical illnesses and therefore were excluded from the study. As a result of which 51 patients were recruited.

Statistical Analysis

The data about various parameters was entered into Microsoft Excel. Descriptive analysis was carried out with Statistical Package for the Social Sciences version-21 software. The information thus generated was presented in tables as frequencies and percentages.

Results

Table 1 shows sociodemographic profile of patients. Majority of patients were females, in the age group of 18 to 45 years, of urban background, were married, housewives by occupation and belonging to lower middle Socioeconomic class. Among the whole sample (N=51), 36 patients (70.588%) had co-morbid psychiatric disorders among which 7 patients (13.72%) had multiple psychiatric comorbidities (Table 2). Table 3 represents the individual co morbid psychiatric diagnosis (Tables 1-3).

Table 1: Sociodemographic profile of patients.

Table 2: Presence or absence of psychiatric comorbidity.

Table 3: Type of psychiatric comorbidity.

Discussion

This is the first study from Kashmir on psychiatric co morbidity of globus. A total of 51 patients were included in our study .The majority of the patients belonged to the middle age groups. Mean age of patients was 39.58 years. Patients with globus tend to be referred to other clinics like ENT, Gastroenterology etc. during the initial stages of the disorder. Even after clearance from above mentioned department’s referral to mental health care are delayed due to barriers to mental health care and concerns about stigma. Since the psychological aspects of the disorder are not addressed in medical facilities, the patients are referred to psychiatric care after a long period of time. Several studies have reported increased numbers of stressful life events preceding symptom onset, suggesting that life stress might be a cofactor in symptom genesis and in exacerbation. Indeed, up to 96% of patients with globus report symptom exacerbation during periods of high emotional intensity.

Females outnumbered males in our study by a ratio of almost 3:1 which is quite similar to the results seen in other studies, thereby showing that the disorder predominantly affects women stating that peak incidence is in middle age , in females who are uneducated and belong to lower socioeconomic class.

Majority of patients with globus are at high risk of having one or more co morbid psychiatric illnesses. In the study done in turkey by Akyüz et al., two thirds (73.3%) of those with globus (conversion) had a co morbid psychiatric illness and hence matches our results of about 70.588%. In India a study done by Debnath, Asish, et al. among a sample of 53 patients, 42 patients (79.25%) had co-morbid psychiatric disorders and 17 patients (32.01%) had multiple diagnoses. But only 16 individuals (30.19%) in the control group had some psychiatric comorbidity. The major psychiatric comorbidities were major depressive disorder, obsessive compulsive personality disorder (16.98 %), undifferentiated somatoform disorder (13.21%), generalized anxiety disorder and panic disorder with agoraphobia (each 9.43%), borderline personality disorder (7.55%), obsessive compulsive disorder and dysthymia (3.77%) and hypochondriasis (1.89%) [16-18].

Major Depressive episode was the most common co morbid disorder in our study as has been reported in several studies. It has been seen that most common co-morbid mood disorder is major depressive disorder (17%-29%) and the results are in unison with our study. Psychiatric disorders are prevalent in medical practice, especially in primary care, where as many as one-third of patients may suffer from one or more current diagnosable psychiatric disorders, especially depressive and anxiety disorders.

However few other studies have reported depressive disorders in more than 50% of the cases which is in contradictory to the results of our results and the reason seems to be the difference in comorbidity of study participants, data collection, sensitivity of screening tool and the geographical differences in the study participants. Mussell et al. [2] found that GI symptoms are significantly associated with depression and anxiety in primary care American patients. A study in India reported major psychiatric disorders found among the patients of globus are major depressive disorder (n=23, 43.4%) which is quite high than the results of our study [10] Anxiety disorders were seen in 15.68% (8) patients. Malik M et al. [18] reported 60% of patients having an anxiety disorder which is very high as compared to other studies. A study conducted in Lahore on dissociative disorder showed 35% of patients to have anxiety symptoms. Similarly Willenger et al in Vienna, Austria found significantly higher scores of anxiety in patients with dissociative disorder. Another study from Turkey showed that 37.2% of the patients had anxiety with dissociative disorder and compared to a control group this association was significant.

Somatoform disorders were the third most common diagnosis in our case study. Reported prevalence rates for all forms of somatoform disorders together vary from 10 to 25% in primary care. Patients with MUS or somatoform disorder report significant decreases in quality of life, impairment in daily functioning, increased high health care utilization, and often undergo medical examinations and treatments unnecessarily[19-21].

Our study had a limitation. We selected cases from a tertiary care specialty center where severe forms of illness are referred; therefore there is a higher chance of associated psychiatric co-morbidities in these patients compared to the ones in the general population or, those presenting to the primary care physicians.

Conclusion

Clinicians in other departments should have a high degree of suspicion about presence of a psychiatric disorder in globus which will lead to early referral and treatment of such cases. It will also lead to decrease in pressure on health care system whereby patients have multiple unnecessary investigations, drain on the economy and wastage of time.

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