Dr.Mahesh Desai- renouned Psychiatrist of Gujarat share liaison between Psychiatry and ENT problems.

1. By
Dr. Mahesh R. Desai

2. A few firsts
? How many of you feel that Psychiatrists
can be of help in treating ENT problems
? How many of you feel that patients are
not ready to go to Psychiatrists and you
fear losing them
? How many of you feel that their
Psychiatric Patients are demanding and
time consuming and you do not want to
see them again

3. Justification of Subject
 Interface : a point where two systems,
subjects, organizations, etc. meet and interact.
 For e.g. if we see sign and symptoms of
anxiety and tinnitus both seem to be different
and patient would approach both differently.
 But the interface lies in patho-physiology and
cause. It has normal structure but still has
defective functioning.

4. Need for its discussion
 We haven’t invented anything . May be in far
future psyotorhinology is declared as a
specialization branch.
 But the frequent presentation of sufferings of
human and some vacuum created as inability to
give complete cure. this led to the necessity and
gathered us here to achieve the cure.
‘Necessity is mother of invention’

5. Introduction
 The link between ENT disorders and a
patient’s psychology is increasing rapidly due
to more awareness of diseases.
 The patients look for the information on the
disease on the Internet and become
apprehensive, confused and mentally
disturbed unnecessarily.
 Several research studies have established a
strong connection between the interplay of
psychology and it’s manifestation of the ENT
diseases and vice versa.

6. The Conditions in the field between
otorhinolaryngology and psychiatry can be
classified into two :
Psychiatric conditions resulting
from ENT diseases
Interventions and those
expressing themselves as ENT
symptoms
Psychiatric conditions resulting
from ENT diseases
ENT diseases or interventions and
those expressing themselves as
ENT symptoms due to mental
ailment.
Example:
This includes hearing impairment,
dizziness, tinnitus, choked airway,
bad oral breath, stuffy nose,
traumatic interventions and
external nasal deformities.
Example:
This includes exaggerated and
diminished pharyngeal refl ex,
globus hystericus, speech
disorders, vasomotor rhinitis, nose
picking, choked feeling, dizziness
and headache.

7. Statistics
 According to the statistics globally and
seen by me during my practice
approximately 30-40% of patients
presenting with ENT s/s have underlying
psychiatric illness.
 Females out numbers males.

8. This is simple graph presenting the ratio of psychological
disorders among both genders
0
2
4
6
8
10
12
14
No.ofpatients
Psychological Disorders
Male
Female

9. ENT illnesses with psycho-somatic
co-morbidity
 Ear illnesses
 Tinnitus
 Hyperacusis and Phonophobia
 Psychogenic hearing disorder
 Hardness of hearing and deafness
 Morbus Menière
 Vertigo

10. Upper respiratory diseases
 Acute and recidiving infections/
acute rhinitis
 Chronic and allergic rhinitis
 Sick building syndrome
 Disease of pharynx
 Glossodynia/burning mouth syndrome
 Globus pharyngeus
 Dysphagia and phagophobia /oropharyngeal
swallowing disorder.

11. Diseases of Layrnx
 Psychogenic dysphonia and aphonia
 Laryngeal dysfunction- Laryngospasm
and Laryngismus
 Bruxism and temporomandibular
dysfunction
 Dysmorphophobia
 Malign diseases of ENT region

12. Psychological implications of
deafness
 Hard of hearing is usually accompanied by feeling like
isolation, mistrust, paranoid conditions, and depression
which are most pronounced in deaf people. Prevalence
rate being 15-60%.
 Most of studies conclude that the prevalence of affective
disorders in hearing impaired children and adolescent Is
comparable with estimate of normal hearing people.
 Studies suggested that deaf children show greater degree
of impulsivity.
 Delusional disorder is more common in hearing impaired
people.
 Patients who refuse to go for hearing aid, they have
underlying anxiety.

13. Tinnitus
 Tinnitus, buzzing or ringing sounds perceived by the
patients in one or both ears causes a lot of anxiety and
emotional disturbances to the patient and sometimes
disturbs even sleep.
 These patients should be investigated properly to rule
out any neurotological cause especially for unilateral
tinnitus.
 Most of the time, no cause is found and it is termed as
idiopathic.
 Instead of labeling them idiopathic we need to analyze
their history emotionally/socially. This somatic form of
presentation is highly prevalent with co-morbid
depression/anxiety. In that case what we need to treat is
emotional turmoil and not tinnitus.

14.  According to an article published in international
archives of otorhinolaryngology, there is an
important relationship between tinnitus,
hallucinatory phenomena, and depression
based on persistent recall of facts/situations
leading to psychic distress.
 The knowledge of such findings represents a
further step towards the need to adapt the
treatment of this particular subgroup of tinnitus
patients through interdisciplinary team work.

15. A sample of 53 male and female patients with
tinnitus between the age of 13 and 50 years
 More numbers of female were there than males and
majority were in between 30-39 years.
 Middle class and upper middle classes were most
affected.
 Both married and unmarried people were equally.
 The prevalence of psychiatric co-morbidity in these
tinnitus patients follows in descending order:
Major depressive disorder >>>Social Phobia>
Suicide> Panic disorder> Obsessive Compulsive
Disorder> Agoraphobia=Dysthymic disorder =
Generalized-anxiety.

16. Vertigo
 Studies suggest 50% of person who present to
clinics for dizziness have anxiety and reactive
depression with anxiety.
 A review of prevalence of panic was published
by Simon other in ‘98 . They document
prevalence varying 3-41% in dizziness
specialty clinic.
 Psychogenic dizziness or vertigo consists of a
sensation of motion(spinning, rocking, tilting,
levitating disorder. That can be reasonably
attributed to psychiatric disorder. e.g., anxiety,
depression, somatic disease.

17. Simon and associates (1998) reviewed three
explanatory models (hypotheses) regarding the known
association between anxiety (panic) and dizziness
Psychosomatic model Somatopsychic model Network alarm model
a primary psychiatric
disturbance causes dizziness
(psychiatric chicken causes
dizziness egg)
a primary inner ear
disturbance causes anxiety.
(dizziness egg produces
psychiatric chicken which
produces more dizziness
eggs)
renamed variant of
somatopsychic model
Hyperventilation and
hyperarrousal increased
vestibular sensitivity.
Signals from the inner ear are
misinterpreted as signifying
immediate danger, which
increases anxiety. Increased
anxiety increases
misinterpretation.
Conditioning makes it
persistent.
Panic is triggered by a "false
alarm" via afferents to the
locus ceruleus (an area in the
brain), which then triggers a
"neuronal network", including
limbic, midbrain and
prefrontal areas. This
explanation seems to us to
be the "somatopsychic"
model, renamed and
attached to a specific brain
localization

18.  Panic Syndrome:
Situational pattern is major factor that
helps in diagnosis of anxiety.
Examples:
 Vertigo disappears on vacation .
 Mother in law comes and the complain
starts.

19. Differentiation
PPV(phobic postural vertigo) CSD( chronic subjective dizziness)
Triggered Constant
Without any signs Without any medical conditions
E.g., fear of falling without any real fall Lack of other explanation
Persistent > 3 month
Chronic motion sensitivity
Exacerbation with use of vision
PPPD (Persistent Post Perceptual Dizziness) is the replacement acronym for CSD.

20. Headache
 This symptom has many causes including various
ENT diseases.
 It is commonly known that patient’s psychology and
mental factors play an important part in its genesis
and progress and migrainous headache is classical
example.
 Headache is considered as non-specific syndrome
illustrating the concept of pain as an emotion.
 Just as the ‘brain’ can not easily be separated from
the ‘mind’, so as to believe that some pain is
‘physical’ and some ‘emotional’ is a distortion.

21. External nose deformity
 Minor external nasal deformities and
illusion of non existing nasal deformities
especially in young males is used as
scapegoat for underlying mental
disturbance.
 The surgeon should assess and evaluate
psychological, socio-cultural perspective
along with physical manifestations.
 The late stage of cocaine abuse can result
in perforation of nasal septum and difficulty
in breathing.

22. Dysmorphophobia
 It is defined as preoccupation with an imagined defect in
ones physical appearance.
 For example time consuming rituals such as mirror gazing
or constant comparing.
 There was a man named Wolfman who had
preoccupation of imagined defects on his nose.
 There is frequent co-morbidity in BDD especially in
depression, social phobia, OCD and delusional disorder.
 So the doctors need to go through thorough case history
to rule out this in order to avoid irrational surgeries.

23. Acute and Recidiving Infections/
Acute Rhinitis
 Whether as a doctor or as a patient, we are all
aware of the phenomenon that we catch an
infection a lot quicker when we are under stress
(night watch!). Stress can lead to an increased
occurrence of respiratory.

24. Chronic and Allergic Rhinitis
 Chronic Rhinitis is a common illness. Characteristics
symptoms are a blocked nose, runny nose and frequent
sneezing.
 At first glance, allergic and psychosomatic reactions seem
to have nothing in common.
 Studies into psycho-immunology have shown that allergic
reaction can be curbed with hypnotic suggestion.
 Experimental studies furthermore found out that plasma
histamine concentration rises under pressure.
 Allergies can develop from auto-suggestion and strong
feelings of anxiety let skin react more sensitivity to
potential allergies.

26. Relation between Rhinitis and
Depression
 Despite stark differences in methodologies, the majority of
published studies indicate some type of indistinct relationship
between allergies and anxiety and mood disorders.
 The strength of these associations is difficult to discern,
given the present data.
 There may be a number of allergy-related mediating
variables, such as alterations in immunity/cytokines, the
effect of nasal obstruction on sleep, disturbed cognitive
functioning and genetic overlap.
 Regardless, current evidence indicated that individuals with
allergies appear to be at a higher risk, of an unknown
degree, for developing various types of anxiety and/or
syndromes.

27. Globus Pharyngeus
 Patients suffer from a lump or foreign body sensation
in the throat, sometimes in combination with
increased mucous production and the feeling of
having to clear throat.
 Therapy should start with an instructive talk following
a careful ear, nose and throat examination. If the
symptoms are recent, improvement can often
already be reached quickly.
 Psychosomatic aspects and a conversion disorder
often play a role in oropharyngeal swallowing
disorders, especially if no organic cause could be
found. Women with anxious –hypochondriac
behavior patterns are mostly affected.

28.  Hysterical Aphonia – Sudden,
dramatic loss of speech. One simple
test to clinch the diagnosis is to ask
the patient to write –If she/he can
write easily it is aphonia.

29. Malignancy
 The malignancy growth occurs in ear, nose , throat.
 More commonly in throat cancer, if the patient is found to
refuse the treatment. We need to rule out the fears. Fears
like fear of chemotherapy, surgery, any deformity caused.
 So basically psychiatric intervention could ease the case
for further management.
 The other group of patients is one who don’t have cancer
actually but do have profound fear of cancer.
 So they keep hoping from doctors to doctors.
 We need to educate them about anxiety and further
psychiatric treatment if required.

30. When you should suspect psychiatric
illness or psychological problem?
 ALL YOUR ENT EXAMINATION –WNL FIRST AND FORMOST
 Illness longer than 3 months?
 If you ask anything else, co-morbid many physical complain as
we Asians somatize.
 Sleep/appetite disturbance
 Terminal insomnia.
 Doctor shopping.
 Diffusely specific but specifically vague.
 History of response to anxiolytics and poor response to
conventional treatments.
 Repeat visits. Not happy or satisfied with response.
 NO OBJECTIVE LESION

31. Do’s
 Reassurance and proper scientific explanation like using models like
chemical imbalance or sympathetic, parasmpathetic system.
 How I explain the phenomenon.
 Learning use of SSRI and anxiolytics.
 Dispersible clonazepam
 Life style changes.
 Explain the difference between structural damage and functional
etiology .
 I have examined your ear, nose and throat thoroughly. I do not find
any structural damage and there are chances that this is disorder of
function rather than any damage to structure.’

32. Dont’s
 Please don’t tell them that it is all in your mind. Then giving
long list of medicines.
 Please don’t threaten them that if you don’t behave then I will
send you to psychiatrist.‘
 Writing in illegible words at the corner of a case papers in small
letters ‘Reference to Psychiatrist’. And giving them a long list of
investigations, that is unfair.
 Avoid extensive, costly investigation to rule out rare disorders
and if at all you want to do it, explain the purpose.
 Leaving things to your subordinates giving them printed
instructions rather than that explain the vestibular exercise,
demonstrate them .

37. Anxiolytics
Drug (generic name) Trade Name Equivalent Potency Dosage Range/Day (in mg
oral)
Benzodiazepines
Chlordiazepoxide Librium Long 20 to 100
Equillibrium Long
Diazepam Paxum Long 2 to 60
Vallium Long
Calm doze Long
Calmode Long
Oxazepam Serepax Short 30-120
Alprazolam Zolax Short .5 to 6
Alprax Short
Alzolam Short
Zenex Short
Lorazepalm Larpose Short 5 to 10
Ativan Short
Trapex Short
Clonazeplam Klonopin Long .5 to 10
Nitrazeplam Nitravet Short 5 to 10
Nirosun Short

38. Drug (generic name) Trade Name Equivalent Potency Dosage Range/Day
(in mg oral)
Flupenthixol Fluanxol Long .5 to 3
Risperidone Long .5 to 1
Olanzepine Oliza Long .5 to 5
Trifluperanil Esporine Long 1 to 2.5

39. Summary of therapeutic
method
Pharmacological Interventions
Relaxation methods
 Autogenic training
 Progressive muscle relaxation
 Biofeedback
 Yoga, Qi Gong and Tai Chi
Hypnosis
 Talks as part of psychosomatic- primary health care
 Behavioral therapy

40. Advice to Doctors
 Right at the starting of the first consultation doctor
should ask about acute or chronic stress.
 Besides offering organic forms of treatment,
encouraging patients to learn relaxation methods is
also a sensible approach.
 It’s important for the doctor to empathically
understand the situation, which is seen as
existentially threatening by patient.
 The doctor should immediately clarify the
psychological factor and advise interdisciplinary
treatment to prevent the disorder from becoming
chronic.

41. As Otorhinolaryngologists which possibilities
are open to us for diagnosing psychosomatic
disorders ?
 What seems to be the trouble?
 When did the symptoms first arise, what caused the
trouble , and what coincide with trouble?
 Have there been any drastic changes in your life
recently? Have you had any bad experiences?
 Have you had problems with your ears/ nose before?
 What steps have you taken so far?
 How do you picture your treatment?

42. We psychiatrists are poor cousins of medical
fraternity, divorced from medicine so patients would
rather die, than come to us
In this situation all my esteemed ENT surgeons must learn to
manage the population, other wise the likely scenario would be:
1) Patients going to alternative system of medicine , faith
healers , sooth Sayers and giving our allopathic system
bad name.
2) Repeated unnecessary admission , unnecessary medical
workup, are a burden to health care delivery system , taking
us away from attending more deserving seriously ill patients.
3) Poorly treated or half heartedly treated depression
becoming resistant depression just like resistant T.B.

43. 4) Use of short acting Benzodiazepine sold by chemist
without prescription creating iatrogenic drug
dependence.
5) Undiagnosed or ignored co - morbid psychiatric
illness in surgical patients leading to delayed
recovery ,out of proportion expectations and
sometimes even a medico legal case.
6) Poor communication leading to doctor shopping.
7) Secondary complication of hospitalization like
hospital infection.

44. Prognosis and Outlook: Psychosomatic Disorder
 Prognosis of a psychosomatic disorder depends crucially
on the duration of illness and on the number of already
administered and mostly unsuccessful attempts at
treatment. A psychiatrist co -morbidity such as anxiety or
depression is mostly accompanied by an increased
severity of the disorder and worse prognosis.
 On the part of the otolaryngologist, it is the organ medic’s
opportunity that many patients first come to them with
organic complaints and psychosomatic disorders.
 This gives them the chance to help patients using a
psychosomatic therapy approach and thereby avoid
letting the troubles become chronic.

45. References
 Savistino M, Marioni G, Aita M., ENT Journal
 Simon N M, Pollack M H., Tuby K. S, Stern T A., Dizziness and panic disorder: a review of association
between vestibular dysfunction and anxiety, Annals Clin Psych
 Clouse RE, Lustman PJ, Psychiatric illness and contraction abnormalities of the esophagus. N Engl J
Med. 1983;309:1337-1342
 Decot E., Therapeutic methods for psychosomatic disorders in oto-rhino-laryngology,
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3200998/
 Warninghoff J C, Bayer O, Ferrai U, Strabue A, Co-morbidities of vertiginous diseases, BMC
Neurology, DOI: 10.1186/1471-2377/9/29
 Bisdorff A, Bosser G, Gueguen R, Pernn P, The epidemology of vertigo, dizziness and unsteadiness
and its link to co-morbidities, Frontiers in Neurology, 2013;Vol 04; Article 29
 Indian Journal of Otolaryngology