Psychological Distress in Patients having Globus Pharyngeus: A Case-Control Study Anup Acharya,a,c Madan Mohan Singh,b,c Bandana Pokhareld —–————————————————————————————————————————————— ABSTRACT: Introduction: Globus sensation is described as a constant feeling of a lump or foreign body in the throat in absence of pain and dysphagia. It is a common complaint in Ear Nose and Throat clinics. Etiology of this condition remains multifactorial and unclear. Psychiatric disorder has been described as one of the cause of globus. The objective of this study is to evaluate the occurrence of psychological distress in patients complaining of globus sensation in throat coming to our centre. Methods: A case-control study was done. Patients coming to Outpatient of Ear Nose and Throat Department of Lumbini Medical College Teaching Hospital with complain of globus and not having an organic explanation of the condition were included. Age, sex and socio-economic condition matched control group was selected from healthy visitors (patient parties). Validated Nepali version of GHQ-12 was used to assess the psychological distress. Results: Psychological distress was present in 72.69% of the cases and 39.91% in the control group. The difference was statistically significant. Conclusion: Psychological distress was significantly higher in the patients with globus pharyngeus compared to the control group. It was also present in a larger fraction of the control group. The patient who present with Globus should undergo psychiatric evaluation after organic causes have been ruled out. We recommend a national policy to evaluate the population for their psychiatric health. Keywords: case-control study • gastro-esophageal reflux • globus • psychological • stress —————————————————————————————————————————————— ___________________________________________________________________________________ a - Assistant Professor b - Associate Professor and Head c- Department of ENT Head and Neck Surgery Lumbini Medical College Teaching Hospital d - Lecturer (Psychiatric Nursing), College of Nursing Lumbini Medical College Teaching Hospital Corresponding Author: Dr. Anup Acharya e-mail: anupent@gmail.com How to cite this article: Acharya A, Singh MM, Pokharel B. Psychological distress in patients having globus pharyngeus - a case control study. Journal of Lumbini Medical College. 2014;2(2):45-7. doi: 10.22502/jlmc.v2i2.57. ___________________________________________________________________________________ J. Lumbini. Med. Coll. Vol 2, No 2, July-Dec 2014 Original Research Article jlmc.edu.np https://doi.org/10.22502/jlmc.v2i2.57 that it is equally present in both sexes.6 Our record shows that 13% of the Outpatient Department (OPD) patients complained of globus sensation in their throat. Despite history and examination, we cannot find the cause in majority of the patients. Preliminary treatment with anti-reflux medication in these patients, as gastro-esophageal reflux is very common in developing countries,7 does not produce results in many of them. We have started assessment of their psychological distress as a potential cause of globus. General health questionnaire (GHQ) is one of the instruments used to detect psychiatric disorder in the general medical out-patients. It assesses the respondent’s current state and is sensitive to short- term psychiatric disorders. The GHQ -12, the shortest version and commonly used screening tool, has been found to be reliable and well-validated to determine whether an individual is at risk of developing a psychiatric disorder.8-11 METHODS: A case-control study was done by including INTRODUCTION: Globus sensation is described as a constant feeling of a lump or fullness in the throat in absence of pain and dysphagia. The aetiology of globus remains multifactorial and unclear. Gastro- esophageal reflux, pharyngeal inflammation, cricopharyngeal spasm, sinusits and psychogenic factors remain the most common cause of globus.1,2 It is reported to have been experienced by up to 45% of the population.1 Many believe that it is primarily a disease of female,3-5 though other studies suggest 45 J. Lumbini. Med. Coll. Vol 2, No 2, July-Dec 2014 jlmc.edu.np Acharya A. et al. Psychological distress in patients having globus pharyngeus patients who came to OPD of Ear Nose and Throat (ENT) department in Lumbini Medical College (LMC) throughout July 2014 to September 2014 with complain of globus sensation in throat. Thorough history taking and ENT examinations were done. Fiberoptic naso-pharyngo-laryngoscopy was done in all cases. Those patients who had a positive history or clinical finding suggesting any organic condition like gastro-esophageal reflux, pharyngeal inflammation, sinusitis, postnasal drip, chronic tonsillitis, chronic laryngitis, thyroid disorders were excluded from the study. A control group which matched age, sex and socio-economic conditions was selected from the patient parties (visitors) who did not have any medical complains or conditions. Permission was obtained from the ethical committee of LMC. Each participant in both the study and control group was verbally explained about the purpose of the study, instructions for questionnaire, declaration on their anonymity and confidentiality. Verbal consent was taken. The validated Nepali version of GHQ-12 was used for this study.12 Questions were verbally presented one by one to the participants and the responses were registered. The person involved in the interview did not know to which group the participant belonged to. This ensured reduction of bias. GHQ scoring method (0-0-1-1) was adopted for this study. The scores were summed up to get a total which ranged from 0 to 12. A score of 3 or more was considered to be positive for psychological distress. Data was collected in Microsoft Excel 2007™ and was imported to IBM SPSS 21™ for descriptive and inferential statistics. P value less than 0.05 was considered to be statistically significant. RESULTS: There were a total of 238 patients each in the study and the control group. The demographic details of participants in each group are shown in Table 1. Chi-square goodness of fit was calculated Variables Study group Control Male (n) 80 81 Female (n) 158 157 Total (n) 238 238 Mean age (Yrs) 44.55 43.1 SD (Yrs) 5.79 5.38 Table 1: Demographic details of participants comparing the frequency of occurrence of female and male patients having globus in the study group. Significant deviation from the hypothesized value (0.5) was found. Female appeared to be more commonly affected than male (Table 2). Chi-square test of independence was calculated comparing the grading of GHQ-12 scores in study group and controls. It showed a significant relationship; participants in study group were likely to have higher GHQ-12 score than the controls (Table 3). Gender n (%) Female 158 (66.39%) Male 80 (33.61%) Total 238 X2(1)=25.563, P<0.001 Table 2: Sex distribution of patiens having globus in study group Table 3: GHQ-12 scores of two groups Variables Study Group Control GHQ-12 score <3 65 143 ≥ 3 173 95 X2(1)=51.951, P<0.001 DISCUSSION: Globus pharyngeus is likely to occur more frequently in female patients (Table 2). In our study it occurred in about twice than that of male. This finding is in support of several studies.3-5 It may be due to many factors; gender based violence, low or subordinate social status, undervalued domestic work, less pay, expected work as a homemaker and a breadwinner, and difficulty to advance in their careers.13 Psychological distress in study group was significantly higher than that of control (Table 3). This finding support the fact that psychiatric disorder is one of the etiological factor of Globus pharyngeus.1,2 The patient who present with Globus should be evaluated for any organic cause like gastro-esophageal reflux, pharyngeal inflammation, cricopharyngeal spasm, sinusitis, malignancy etc. and if no obvious cause found, should be sent for psychological evaluation. This has become a routine in our centre. A study conducted for evaluation of psychological distress in population similar to 46 J. Lumbini. Med. Coll. Vol 2, No 2, July-Dec 2014 Acharya A. et al. Psychological distress in patients having globus pharyngeus jlmc.edu.np ours, found that distress was present in 37.5% of the general population.11 Comparing findings of our control group with this result, there was no significant difference in the occurrence of psychological distress (X2(1)=0.539, p=0.44). This confirms that our control group represented the general population so far the evaluation of psychological distress is concerned. The authors were aware of the prevalent psychiatric illness in the general population but we did not know it was so common. In Nepal, mental health has been a neglected and overlooked issue for a long time. Most of the people think that suffering from mental illness is the same as being mad, becoming unfit to remain in society and the family. They are the targets of stigma and discrimination to the point where they hesitate to come forward for appropriate treatment.14 The patients in the study group and the participants in the control group who were identified as having psychological distress need further assessment by psychiatrist or psychologist to confirm that they indeed have a psychiatric disorder. They will be in a position to truly recognize what type and what severity of psychiatric disorder do they have. 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