OF PSYCHIATRIC CAUSES AND ROLE OF AMITRIPTYLINE IN ITS MANAGEMENT.
Kumar Paswan, 2 Ravi Rana, 3Vishal Sinha3,
Resident2. Asstt. Professor3 J.Resident 4
Medical College, Agra
Mass like sensation in throat is a common presenting complaint of an ear, nose
and throat (ENT) outpatient department. Most of the time this symptom had proven
underneath organic cause but some time it is idiopathic and assumed to be
functional. This is than termed as globus hystericus. Various theories assume
that it has some psychological basis and so it is classified under dissociative
Aim & Objectives-
This study was conducted to understand and evaluate various psychological causes
behind the symptom of globus hystericus. It also evaluates the role of
antidepressant (amitriptyline) in the management of globus hystericus.
Subjects with chief complaints of mass like sensation in throat were enrolled
after thorough ENT examination for any possible organic cause. Cases without any
organic cause was evaluated by pre formed sociodemographic profile and various
scales and treated with amitriptyline. Follow-up after defined period for
response was done.
Result and conclusion-
Substantial number of subjects demonstrated psychopathological events and recent
stress. Globus Hystericus was more common in females as compared to males. It
was more common in rural population. Treatment with amitriptyline proved more
effective as compared to placebo group.
Globus Hystericus, ENT, psychological.
Uncomfortable sensation of
mass in the esophagus or upper airway is a common presenting complaint of an
ear, nose and throat (ENT) outpatient department (4.1%) 1. This is a
common sensation demonstrated in a broad range of disorders. Many a times
((60-70%) 2, 3, 4 some organic cause is present behind this type of
symptom. Full ENT examination is performed with detailed investigations;
complete blood cell count, laryngoscopy, barium swallow pharyngoesophagography5
and endoscopy to rule out the possible organic causes. Organic causes of Globus
Hystericus may be motility disorders3, gastro esophageal reflex
disease (23%-68%)6,7,8, cricopharyngeal spasm, strain and fatigue,
Congenital anomaly (web etc), stricture, Post nasal drip (allergy), smoking,
mass, cervical spondylosis, inflammation or infection.
Some time all examinations
and investigations fail to demonstrate any organasity in such causes. Then the
cause is assumed to be psychiatric or psychological. This psychological
uncomfortable sensation of a mass inside throat is known as globus hystericus.
Globus hystericus is sometimes also referred to as Globus pharyngeus (Malcomson,
1968) or pseudodysphagia or conversion dysphasia. Symptoms of globus hystericus
may include aphonia, sensation of a lump in the throat, difficulty in
swallowing, heartburn, and chest pain, sensation of choking, dyspnea,
suffocation and neck pain9. The prevalence of globus hystericus in
all the cases presenting with sensation of a mass in throat is estimated to be
10-15%10. Some books described persistence of globus symptom for a
substantial long period is needed for making diagnosis of globus hystericus i.e.
symptoms must be present for the last three months with symptom onset at least
six months before diagnosis is necessary11.
anxiety, significant life stress13, somatisation, Personality and
obsessional features are some time associated with onset of globus hystericus.
Rarely globus symptom is defective belief of Persistent Personality Disorder and
some time no etiology can be proved. Treatment of globus symptoms is according
to the etiology of the disease in particular patient. Organic causes are treated
accordingly; if the cause is assumed to be psychiatric mostly trial of
antidepressant14 is given. Electroconvulsive therapy14,
psychotherapy/counseling and symptomatic treatment with benzodiazepine are used
in such cases if needed. Roll of antipsychotic drugs and mood stabilizing drugs
in such cases is not established. Speech therapy16/relaxation
techniques, including neck and shoulder exercises, general relaxation
techniques, voice exercises, and voice hygiene have successfully been used to
treat patients with persistent globus symptoms.
Few studies had established
role of tricyclic anti-depressant (i.e. Amitriptyline14) in cases of
globus hystericus but Indian data is lacking. So the study was planned to
evaluate the role of Amitriptyline in Indian globus hystericus patients.
The study was conducted
jointly in the department of psychiatry & ENT in S.N.Medical college Agra. The
study was conducted for duration of two years from October 2010 to October 2012.
All consecutive patients who came to ENT OPD with the chief complaint of mass
like feeling in the throat were enrolled in the study after taking informed
consent. The study was longitudinal and double blind with follow up at baseline,
1 week, 2 week and 1 month. All the patients were thoroughly examined and
investigated (Complete blood count, laryngoscopy, barium swallow and endoscopy)
to rule out any organic cause of the symptom at baseline. Subjects were excluded
from the study if any organic cause was detected and treated by the ENT surgeon
for the cause of their symptom maintain their treatment and follow up data.
The follow up schedule was
varying in these subjects according to their illness and treatment. Subjects
without any diagnosable organic cause of their symptoms were included in the
study and assessed by various Psychiatric tools in psychiatry department. The
subjects without any organic cause were randomly (using computer generated
randomization chart) divided into two groups group A and group B. Group A
subjects received Placebo + Clonazepam 0.25 mg BD and group B subjects received
Amitriptyline 25 mg OD + Clonazepam 0.25 mg BD. According to tolerance, response
and prognosis dose was adjusted with time. Follow up was scheduled at 1week,
2week, 1 month and 3 month from the baseline. If no response was there at 1
month supportive Psychotherapy was added and if at 3 months no response was
there treatment modality was changed. In the patients who had responded, they
continued taking treatment for 6 -8 months thereafter. Clonazepam was stopped at
1 week in both the groups.
between 18-65 years.
gave written informed consent?
significant medical illness.
Subjects those were pregnant.
Organic cause of mass like symptom was demonstrated by examination and
Preformed sociodemographic Performa.
Presumptive Stressful Life Events Scale (PSLES)-51 questions.
Hamilton depression rating scale (HAM D)-24 questions.
Hamilton Anxiety rating scale (HAM A) 14 questions.
Standardized Assessment of Personality – Abbreviated (SAPAS) Scale 8
General Health Questionnaire (GHQ-30).
Percent globus symptom improvement from baseline.
Results & Discussion
Total 98 subjects were
enrolled in the study considering inclusion and exclusion criterion. Later 12
subjects were excluded from the mid of the study due to various causes.
Socidemographic variables were accessed by asking various preformed questions.
41% (40 out of 98) subjects were male and 59 % were female and 82% were from
rural and rest from urban background. This distribution is more as compared to
general prevalence Data (Censes 2011) which signifies that it is more common in
females and rural population.
43% subjects demonstrated
recent (within 6 month) significant life stress. 36% subject demonstrated
depression on HAM D score (>7), 12% subjects demonstrated anxiety on HAM A
scoring and 1% had personality on SAPAS scoring (>3).
Out of total 86 subjects
included in the study Placebo group contained 30 subjects and rest 56 were
entitled in treatment group.
Out of 56 subjects of the
treatment group, 60% responded on Amitriptyline and 22% on supportive
psychotherapy and Amitriptyline combination. Rest 18% subjects did not responded
at the end of the study. Most of the responder subjects 82 % started showing
response on various parameters and scale usually at 14 days to 1 month of
treatment. Response attained at 1 month was static in 72% subjects and only rest
28% subjects showed more response thereafter. Most of the subjects 54% were
managed at 25 mg amitriptyline, 36% take 50 mg and in rest 8 % subjects dose was
reduced to 12.5 mg due to side effects.
In placebo group 38 %
subjects showed response at the end of 3 month and rest had same symptoms
persisting thereafter. Response in most of the subjects of this group was
reported at 2-3 months of treatment.
Fisher's Exact Test was
applied to analyze the data. The two-sided P value was < 0.0001, considered
extremely significant. This comparison signifies that high response rate in
treatment group subjects was statistically significant.
Globus Hystericus was more
common in female as compared to males. It was more common in rural population.
Subjects on amitriptyline tolerated it well and response rate was high. Most
subjects responded to amitriptyline monotherapy and only few subjects needed
additive psychotherapy for response. Very few 18% not responded to amitriptyline
Response rate was low in
placebo group and only 38% subjects had shown response. Response in this group
was delayed as compared to response in amitriptyline group.
High level of resent
stressful life situations, depression and anxiety was detected in the patients.
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