Psychological Disorders in Otolaryngology
Ramaswamy Viswanathan
Katarzyna Derlukiewicz
Frank E. Lucente
Numerous symptoms in the otolaryngologic region may reflect an underlying psychological disturbance that either constitutes or modifies the cause of the otolaryngologic disorder. Among these symptoms are dizziness, hearing loss, tinnitus, dyspnea, nasal congestion, dysphagia, hoarseness, headache, defective speech, and cervicofacial pain. The emotional, functional, and social impact of many otorhinolaryngologic disorders also can lead to psychological consequences such as depression, anxiety, anger, and in some instances psychoses. Disorders of communication, both verbal and nonverbal, can be very frustrating to the individual and those around him or her. The therapy of psychosomatic disorders is based on the complex etiology of these diseases. Thus, the physician is obliged to take a careful social and psychological history to ascertain the relative role of psychological problems. When psychological disturbances are uncovered, the physician should determine the extent to which he or she is responsible for their management and the instances in which to seek consultation. The patient may be referred to a psychiatrist, or the physician may simply seek psychiatric advice on how best to treat the patient.
Two groups of disorders are examined in this chapter: primary psychiatric disorders with otolaryngologic manifestations, and primary otolaryngologic problems with psychological manifestations or ramifications.
PRIMARY PSYCHIATRIC DISORDERS
A primary psychiatric disorder with an otolaryngologic presentation may be a frank psychosis, but more commonly it is one of the following disorders: conversion reaction, anxiety disorder, phobic disorder, or hypochondriasis. Conversion reactions have symptoms or deficits that affect voluntary motor or sensory function produced by psychological conflict, but symptom production is not deliberate; that is, the patient is not conscious that he or she is producing the symptoms, unlike malingering. Possible symptoms are deafness, anosmia, and aphonia. Several studies suggest that nonorganic hearing loss is a manifestation of, or reaction to, stress. Data on emotional disturbance in both hearing-impaired and deaf youth in residential treatment facilities indicates a high rate of strong or confirmed indications of sexual abuse.
An example of a psychosomatic disorder is globus hystericus, the sensation of a “globus” in the throat.
Case example: A 24-year-old man suffered from a choking sensation of a lump in his throat in many situations. Medical workup did not reveal any physical abnormalities. In a group therapy session the patient experienced this sensation. Exploration of the verbal communications preceding this event revealed that
the patient must have experienced anger at another group member whom he perceived to be domineering, but the patient did not acknowledge the anger. Instead he had somatized it. This connection was pointed out to the patient. Further exploration revealed that he had unhappy childhood experiences with a domineering father. He could not express any disagreement or anger to his father. During dinner the father would sit at the head of the table and insist that the children gulp down even food they did not like. The patient experienced a choking sensation of a bolus of unwanted food in his throat on these occasions. Later, this experiencing of a globus sensation in his throat had symbolically spread to other situations involving interpersonal dominance, without the patient being aware of it. With this revelation and subsequent assertiveness training, he no longer experienced the globus symptom in his throat, as he learned to assert himself in many situations.
the patient must have experienced anger at another group member whom he perceived to be domineering, but the patient did not acknowledge the anger. Instead he had somatized it. This connection was pointed out to the patient. Further exploration revealed that he had unhappy childhood experiences with a domineering father. He could not express any disagreement or anger to his father. During dinner the father would sit at the head of the table and insist that the children gulp down even food they did not like. The patient experienced a choking sensation of a bolus of unwanted food in his throat on these occasions. Later, this experiencing of a globus sensation in his throat had symbolically spread to other situations involving interpersonal dominance, without the patient being aware of it. With this revelation and subsequent assertiveness training, he no longer experienced the globus symptom in his throat, as he learned to assert himself in many situations.
Aphonia on a psychosomatic basis likewise is due to symbolic transformation and expression of an unconscious conflict; experienced, for example, by a young woman after her first oral-genital sexual relations.
Case example: A 45-year-old woman developed hypophonia after a car accident that did not result in physical injury. In the beginning of the interview, her voice was hardly audible. As the interview progressed, she discussed her sexual affair with her boss, and her anger and fear because lately he started to be interested in a younger woman at the office. She began to cry while discussing it and as the interview progressed her voice became stronger. She regained her voice and agreed to seek further psychiatric treatment.
Dizziness is a common symptom of anxiety, and can also be a source of anxiety. Organic causes of dizziness need to be addressed. In dizziness due to anxiety, the underlying anxiety disorder needs to be evaluated and treated.
Case example: A 55-year-old man presented with complaints of dizziness and a feeling that he was about to pass out in public places. He had to hold on to family members even to cross the street. Medical work-up did not reveal any organic cause and it was determined that he was suffering from an anxiety disorder. Treatment with clonazepam resulted in phenomenal improvement. He was able to independently travel extensively, including situations involving great heights.
Hypochondriasis is preoccupation with the fear of having a serious disease and is based on the person’s misinterpretation of bodily symptoms. Care should be taken not to overlook a real organic illness because of the “noise” from the hypochondriacal symptoms. If adequate medical evaluation and reassurance do not relieve the patient’s anxiety, psychiatric referral should be sought.
Case example: A 45-year-old woman had repeated medical visits because of fear of cancer. She was constantly scanning her body for any blemish or symptom. If she had a headache, she would worry about a tumor in her head. If her mouth was dry or if she noticed what she thought was a discoloration in her mouth, she would worry about oral cancer. If the medical evaluation was negative and the doctor reassured her that she did not have cancer, her emotional relief would last only a brief time. Soon she would worry about cancer at another site or worry that
the doctor might have missed something. She substantially improved on treatment with fluoxetine.
the doctor might have missed something. She substantially improved on treatment with fluoxetine.
Numerous diagnostic modalities are available to aid in assessing the possibility of a psychological cause of otolaryngologic symptoms. Among the tests for psychogenic hearing loss are the Stenger test (for unilateral loss), evoked response audiometry, and delayed feedback audiometry The evaluation of tinnitus and dizziness is more difficult in view of the dearth of tests for the former and the multiplicity of tests for the latter. However, with these and other possibly psychogenic problems, the mere performance of a diagnostic test may have an immediate or subsequent therapeutic effect.
Two observations should be made about the use of the term malingering. There is no doubt that this term may be appropriately applied to instances in which symptoms are consciously produced or reported in the hope of secondary gain. However, the term should not be used in instances in which a patient is not completely aware of the role played by the mind in the production of symptoms. Treatment of patients with symptoms that suggest a psychological cause does not cease with dismissing them, chiding them about their psychological aberration, or referring them elsewhere. The problem should be recognized and dealt with as fully as the situation warrants. The morbidity of imagined diseases is important. They are real psychiatric illnesses that need to be treated.
PSYCHOLOGIC RAMIFICATIONS OF OTOLARYNGOLOGIC DISORDERS THROUGH THE LIFE CYCLE
Infants
The psychological ramifications of primary otolaryngologic disorders can be witnessed throughout the life cycle, extending literally from birth to death. In dealing with a patient with a congenital anomaly, particularly one who needs treatment soon after birth, the physician may be asked to coordinate or participate in a multidisciplinary plan of therapy. The parents, having just confronted the trauma of the birth process itself, are faced with the prospect of raising a child with a disability and the attendant economic and social burdens. Correction of the physical deformity, be it hearing loss, palatal abnormality, or respiratory difficulty does not always resolve parental feelings of guilt or anger. Studies show that mothers whose infants failed a newborn hearing screening had significantly more stress and were consequently at risk for dysfunctional attachment. These feelings may make it difficult for parents to appreciate the intricacies of the medical part of the therapeutic plan. When ancillary psychological and social services are inadequate, otolaryngologists often find themselves called on to act as counselors, confessors, arbiters, and advisers in areas in which they have little formal training. Social support as well as maternal problem-solving skill are the cornerstones of psychosocial intervention on the stress experiences of parents with hearing-impaired children.
Children
When infants enter childhood, they may be susceptible to severe infections of the adenoids and tonsils, which may necessitate
adenotonsillectomy or myringotomy. These procedures often constitute the first hospital experience for a child. If this experience is not well handled, psychological disturbances may result. In explaining the anticipated hospitalization and operative procedure, the physician should be aware of these potential problems. The nature of the disease and recommended therapy must be explained to the patient and the family, using the simplest terms possible. The child should not be left with the notion that removal of the tonsils is a punitive procedure. Furthermore, the problems surrounding administration of a general anesthetic should be anticipated. We emphasize the importance of repeated preoperative explanations in appropriate terms, simplification of the operative setting, and anticipation and direct postoperative handling of any fears that the operative experience may engender. Various psychological abnormalities have been observed after tonsillectomy under general anesthesia, such as fear, anxiety disorders, hostility, or somatization disorders. Many patients who suffer psychologically from the operation have no history of antecedent emotional difficulties.
adenotonsillectomy or myringotomy. These procedures often constitute the first hospital experience for a child. If this experience is not well handled, psychological disturbances may result. In explaining the anticipated hospitalization and operative procedure, the physician should be aware of these potential problems. The nature of the disease and recommended therapy must be explained to the patient and the family, using the simplest terms possible. The child should not be left with the notion that removal of the tonsils is a punitive procedure. Furthermore, the problems surrounding administration of a general anesthetic should be anticipated. We emphasize the importance of repeated preoperative explanations in appropriate terms, simplification of the operative setting, and anticipation and direct postoperative handling of any fears that the operative experience may engender. Various psychological abnormalities have been observed after tonsillectomy under general anesthesia, such as fear, anxiety disorders, hostility, or somatization disorders. Many patients who suffer psychologically from the operation have no history of antecedent emotional difficulties.
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