A 60-year-old female, referred from surgical inpatient department for evaluation by a psychiatrist, was married and uneducated hailing from rural background presenting with inability to swallow and chronic weight loss since the last 3 years. This female has developed nonspecific throat symptoms with inability to swallow and feeling of lump in the throat which gradually prevented her from eating to the extent that she became cachexic, lost 10 kg weight and was hospitalized. Neither the patient nor the informant could recall any stressor preceding the symptoms. During the past 3 years, she was treated by various GPs, ENT surgeons and gastroenterologists and underwent multiple endoscopies and laryngoscopies with normal results. She was initially referred to the surgical outpatient department by a duty medical officer from the emergency department for evaluation of chronic dysphagia, undiagnosed since the last 3 years and was subsequently sent to the psychiatry department for evaluation.
Rapport was established with difficulty since she was hardly talking and appeared very weak and fragile; her only complaint was inability to swallow due to a lump in the throat since the last 3 years. Collateral information revealed that the patient has not been taking meals due to inability to swallow, lost 10 kg of weight, remains alone and aloof, often cries, does not sleep and expresses hopelessness and death wish. However, these depressive symptoms started only 6 months ago. On further enquiry about the past and asking questions pertaining to symptomology of OCD, it was revealed that she washed hands so often that her hands got excoriated, spent more time than required for the daily house hold chores and kept organizing things to the extent of measuring things in order to obtain perfect positioning. The informant being a daughter remembers this behaviour lasting since past 30 years with waxing and waning in the severity of symptoms. However, these symptoms are no longer present. Since last 3 years, she started complaining of the inability to swallow and checking behaviour was noticed. Initially, she was able to swallow with spilling and spitting out and frequently checked in the mirror for any deformity in the neck. Since the last 1 month, she is on fluids which also spill out very often only while drinking fluids, but drooling of saliva is otherwise not reported. Although drooling, coughing, choking, nasal regurgitation and any change in speech quality was not reported, she no longer checks or complains about anything. Patient is a known diabetic on metformin 1000 mg with good glycemic control. No history of any other medical illness. No history of psychiatric illness in the family. Any anankastic trait in the premorbid history could not be elicited due to lack of information. Physical examination revealed no significant findings. Motor, sensory and cranial nerve examination was normal. On mental status examination, she appeared dull, weak and ill groomed; rapport was established with difficulty. Although she expressed hopelessness regarding the cure of her illness, suicidal ideation was not reported; her speech was scant with low tone and affect was blunted with reduced reactivity. The belief of lump in throat and swallowing difficulty was ego-syntonic and at a delusional level with poor insight into the illness. She complained of repeated intrusive thoughts of being strangulated and choked. No other thought and perceptual abnormality was elicited during history taking or mental status examination. The patient cognitive function was intact. Routine investigations were normal including thyroid function test and serum vitamin B12. Neither CT nor MRI brain was done depending on lack of any neurologic deficit on physical examination and financial constraints of patient. The diagnosis of OCD with poor insight and comorbid depression was considered. The Yale Brown Obsessive-Compulsive Scale (Y-BOC Scale) revealed moderate scores (score = 20). Overvalued Idea Scale (OVIS) exhibited higher scores (score = 7) suggestive of poor insight. Becks Depressive Inventory revealed moderately increased (score = 24). Score on the Positive and Negative Syndrome Scale (PANSS) was not suggestive of psychosis although the somatic concerns were at a delusional level. Patient was started on 20 mg fluoxetine which was gradually increased to 60 mg over a period of 4 weeks. At week three, 2 mg risperidone was added. The patient reported appreciable improvement in symptoms in terms of ability to swallow (30–40% as reported by the patient and Y-BOC Scale score). Her depressive symptoms also improved which was revealed in significant reduction in scores of Becks Depression Inventory. Tolerability and adherence to the treatment was good as reported by informants. She was advised sessions for exposure response prevention therapy at week 5 for which she showed low compliance and lost follow-up.
